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Table 1 Expectations and experiences of total knee replacement in older adults

From: Decision-making regarding total knee replacement surgery: A qualitative meta-synthesis

Methods & Concepts Sanders et al. 2004 Toye et al. 2006 Woolhead et al. 2002 Hudak et al. 2002 Figaro et al. 2004
Sample 27 patients with hip/knee pain & disability. 18 participants with knee osteoarthritis listed for TKR. 25 patients on a waiting list for TKR. 17 patients who were potential for TJA (hip or knee) – but did not want the procedure. 94 black people aged 50 – 89 with knee osteoarthritis.
Data Collection In-depth interviews. Semi-structured interviews. In-depth Interviews. In-depth interviews. Semi-structured interviews.
Setting Survey was used to identify a sample of participants in Somerset, UK. Patients listed for TKR at a specialist orthopedic hospital in UK. Patients sampled from 3 orthopedic surgeon's waiting list in UK. Participants recruited from an initial survey, conducted in Toronto, Canada. Participants were recruited from a church or senior centre in northern Manhattan, USA.
Concepts      
Experience of pain Most had experienced pain and disability for one or more decades. Participants found it difficult to describe their pain – also reported functional loss. Crippling and severe pain and limited mobility was identified. _____ ____
Perception of health professionals role Did not want to bother the GP with their symptoms. Doctor was seen as the expert. Believed the surgeon was the expert. Patients relied on the doctor to help them make a decision about surgery. Doctors were seen as the gatekeepers to TKR surgery.
Expectation of treatment Participants assumed they would not be considered as appropriate candidates for surgery because of their age. Most participants felt that TKR surgery was the only cure. Participants accepted that there should be a waiting list for TKR, but felt several other factors really determine who gets TKR (i.e. weight & age). Participants believed they needed to be in constant pain and unable to move before they would consider surgery. Most patients expressed the belief that their body should remain intact and they did not want surgery.
Expectation of condition Participants perceived their symptoms as associated with normal aging. Participants believed their OA would only get worse _____ Participants had the expectation of pain with age. OA was natural, inevitable, a sign of aging or deterioration.
Social Context & social support ______ A person's social network was an important factor in constructing the need for TKR. _____ Participants often drew on lay sources of TJA information. ______
Comparison with others ____ ____ Believed that there are people worse off than them and they should have priority for surgery. Participants believed that there are people worse off than them. Patients believed the economic status of blacks & whites was the reason black people did not have TKR.
Coping strategies Relied on over the counter medications and exercise to relieve pain. ______ ____ _____ Belief in god was important with regard to the outcome of surgery.
Second order Interpretation Patients viewed their symptoms as a natural part of aging, and were reluctant to seek care or have surgery. Patients make decisions about surgery based on their perception of symptoms, and depending on their life environment. Patients have the perception that "there are probably people worse off" and they should have priority for surgery. "The taken for granted assumption that one needs to be in constant pain and virtually unable to move before seriously considering surgery". Participants had negative perceptions of TKR, because of the risks they associated with surgery.
Methods & Concepts Marcinowski et al. 2005 Sjoling et al. 2004 Showalter et al. 2000 Woolhead et al. 2005 Clark et al. 2004
Sample 9 patients who had TKR – but had been waiting for up to 2 years. 9 patients after TKR, 9 patients on waiting list for hip replacement. 5 TJA patients and their spouses after surgery. 25 patients 3 months before TKR – 10 interviewed 6 months after TKR. 17 patients who were potential for TJA (hip or knee) – but they did not want the procedure.
Data Collection Un-structured interviews Un-structured Interviews. 1 focus group – to discuss their needs prior to and following TJA surgery. In-depth interviews. In-depth interviews.
Setting Participants were contacted with a letter after surgery in a hospital in New Zealand. Participants were recruited at a hospital in Sweden. Participants recruited by telephone (were already scheduled for follow up visit) in USA. Patients sampled from 3 orthopedic surgeon's waiting list in UK. Participants recruited from an initial survey, conducted in Toronto, Canada.
Concepts      
Experience of pain Living in constant pain & hurting with everyday activities. Pain is described as dreadful and extremely disabling. Still felt extreme pain after surgery. Still had continued pain and immobility after surgery Participants viewed their pain as bad, but not "'bad enough" for surgery.
Perception of health professionals role Had a powerful faith in health professionals. Needed to establish a trusting relationship with the doctor. Nurses and physicians were acknowledged as important sources of information & support. Participants did not criticise the surgeon or the surgery. Participants wanted more information from their health care provider.
Expectation of treatment Some viewed surgery as the only way to carry on leading a normal life. ______ Believed they would be back to normal (walking, dancing) at 56 weeks. Patients acknowledged that TKR was major surgery and it was natural to feel pain. Participants were concerned about the efficacy of TKR surgery.
Expectation of condition ______ ______ _____ ______ Participants perceived pain as natural, expected with old age.
Social Context & social support Participants revealed that "accepting help" was a condition necessary to maintaining independence in the long run. Having a sense of underlying support (friends & family) helped preserve continuity. Spousal support was important during the recovery process. Participant's perception of outcome was related to certain situations in their life (i.e. moving from a lonely neighbourhood). Patients drew on lay sources of information.
Comparison with others _____ _____ _____ Felt the outcome was good when they compared themselves to others worse off than them. Relied on accounts from others who had undergone TJA surgery
Coping strategies Having faith and a positive attitude (stoicism) allowed participants to endure the pain. Respondents preserve the sense of living a full life by contending with what they could do. Participants had to make adjustments to their home (putting on socks, going to bathroom) to cope after surgery. _____ Participants 'accommodated' the pain, by making adjustments and coping.
Second order Interpretation Determination, optimism, and trust sustained participants through the entire TKJA process. Participants "put their trust in surgery to alleviate their suffering, but find it hard to live in the uncertainty inflicted by the indeterminate waiting time". "Preparing spouses for the role changes that occur following surgery could help patients and spouses establish realistic expectations of the recovery process". The TKR outcome was viewed positively or negatively when viewed in relation to the participant's life context or environment. "Symptoms and information sources were the two main factors influencing patient decision making".