The impact of individualized care after artificial knee replacement surgery for patients with valgus deformity of the knee^†

This study used a quasi-randomized controlled trial design. The Ethical Review Board of The Second Affiliated Hospital of the Nanjing University of Chinese Medicine approved the study (2014-441). Written informed consent was obtained from the participant before inclusion.

Based on the calculation results of sample size described in previous studies,¹⁰ the sample size required for this test was estimated. From March 2014 to March 2018, 76 patients (39 males and 37 females) with an average age of 67.8 years (53–82 years) were treated in our hospital; In 35 cases left knee and in 41 cases right knee was operated on. The body mass index was 22.5–27.9 kg/m² (mean 25.9 kg/m²). Etiology: in 46 cases of osteoarthritis, in 10 cases of rheumatoid arthritis, and in 20 cases of traumatic arthritis. The main clinical symptoms were severe knee joint pain and severe pain during weight-bearing. Seventy-six patients were divided into a treatment group (n = 37) and a control group (n = 39) according to the parity of the last number of the ID card number. There were no significant differences in sex, age, occupation, educational level, stage of the disease, marital status, and surgical scheme between the two groups (P < 0.05).

All the operations were performed by the same group of surgeions. The anterior median incision was made to remove the internal and external meniscus and anterior cruciate ligament, the knee flexion was 90, and the location, reaming and osteotomy was performed. After an osteotomy, the residual osteophyte around the joint was removed and the lateral soft tissue of the contracture was released step by step, and the rectangular space was obtained by extending the joint at the narrow part of the osteotomy space. The tibia and femur pros-thesis were fixed with bone cement, and polyethylene liner was installed after ensuring the balance of flexion and extension space and soft tissue. After prosthesis replacement and fixation, the joint capsule and soft tissue around the knee joint were injected with “cocktail” analgesics.”¹¹ The patellar was checked, a drainage tube was placed in the incision, then the incision was sutured layer by layer, and then bandage it was applied under pressure.

The average tourniquet time was 85 min (75–110 min) and the mean hospitalization days were 5–7 days. All the incisions healed in the first stage without infection and skin necrosis, and complications occurred in 13 cases after the operation, and the operation was successful in all the patients, with an average tourniquet time of 85 min and an average hospitalization of 5–7 days. Among them, six cases developed symptomatic deep venous thrombosis of the lower extremity, four cases showed swelling of the lower extremity after the operation, and mild deep venous thrombosis of the lower extremity was diagnosed by ultrasound Doppler examination. After thrombolytic therapy, one case developed quadriceps extensor knee weakness 3 months after the operation. The patient had a history of 15 years before operation, poor strength of quadriceps femoris, and poor execution of exercise after the operation. All of them were given intensive functional exercises. The symptoms were improved during the recent follow-up. The patients were followed up for 3–48 months (mean 30 months), and the results of the final follow up showed that the knee joint had normal force line, good joint prosthesis position, no loosening and osteolysis, and normal patellar trajectory. The results of the final follow-up showed that the knee joint was in a normal position, and the patella trajectory was normal in the last follow-up.

The control group received routine care as follows: pre-operative preparation and guidance, keeping the ward quiet and tidy, and give current medical treatment after the operation; when the patient complained of pain, the nurse reported the syndrome to the doctor and gave an analgesic treatment according to the condition. After the implementation, the nurse observed and recorded the pain relief. The nurse carried out the doctor's orders and observed the effect of pain relief. Individualized care included: (1)

Interactive nursing care: Focusing on understanding the basic situation of the patient through general interactive conversation familiar with the basic information of the patient and his family and sociocultural background, the psychological concerns of the patient in this hospital, as far as possible can build mutual trust to alleviate the patient's anxiety feeling.

The pain degree, the range of motion of joint, muscle strength, and stability of the two groups of patients were evaluated by the knee joint function score of American Special Surgical Hospital [Hospital for special surgery (HSS)]. The recovery of the two groups of patients was compared. Pittsburgh sleep quality index (PSQI) was used to assess the postoperative sleep status. The table is composed of 19 topics and can be divided into 7 parts: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disorders, hypnotic drug use, and effects on daytime function. Each part was evaluated by 0, 1, 2, and 3 grades. The cumulative score of each part was the total score of PSQI. The higher the score, the worse the quality of sleep. According to PSQI score ≤3 points, 4–7 points, and >8 points, the sleep quality was divided into three groups: good, medium, and poor.

Data were analyzed using IBM SPSS 19.0. Independent-Samples t-test was used to analyze continuous quantitative data, Pearson χ² test was used to analyze categorical variable data, and statistical significance was determined at P < 0.05.

TKA is the first choice for the treatment of osteoarthritis, joint pain, flexion contracture, valgus deformity, and so on.^12,13 It can relieve pain and reconstruct the function of the knee joint. Pain is considered to be the most common complication after TKA, and local tissue trauma is the main cause of pain after TKA.^14,15 In the past, the nerve blocking method was used to control pain, and because of incomplete obturator nerve block, the clinical effect was not obvious. Recently, some researchers have adopted the technique of total joint analgesia, which has also achieved good results. In this group, intraoperative “cocktail” analgesia, combined with intra-articular indwelling catheter analgesia, was used to control pain 24 h after the operation. Kerr found that this analgesic method was simple, effective, and without side effects.¹⁶ Fischer confirmed that high-dose intra-articular “cocktail” can significantly alleviate pain after TKA, improve patient satisfaction, and have no side effects such as muscle weakness.¹⁷ In recent years, due to the change of medical model, inpatients pay more attention to perioperative care and hope to achieve a good perioperative process through individualized nursing.¹⁸ However, most of the patients undergoing TKA surgery are elderly patients so they have a slow sensory response, large surgical stimulation, and poor psychological endurance. At the same time, some patients do not have a high educational level and poor compliance with TKA, and some of them have a low educational level and poor compliance with TKA.^19,20 The purpose of the operation and the implementation of postoperative rehabilitation exercises could not be understood. Table 1 shows that although HSS scores improved in both groups after knee arthroplasty, individualized care was more effective in promoting patient recovery. Table 2 shows that there was no significant difference in sleep quality between the two groups before operation (P > 0.05). Table 3 shows that the sleep quality of the treatment group was significantly better than that of the control group (P < 0.01), which indicated that standardized nursing intervention after the operation could significantly improve the sleep quality of the patients after operation. The patients were followed up for an average of 30 months after the operation. The general status was excellent in 40 cases, good in 8 cases, and moderate in 2 cases. All patients were able to walk up and down the stairs independently, could completely self-care, and some patients could even participate in mountaineering.