Hope for a new knee: a qualitative study on decision-making process for total knee replacement in Taiwanese women

doi:10.21203/rs.3.rs-2006990/v1

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Research Article

Hope for a new knee: a qualitative study on decision-making process for total knee replacement in Taiwanese women

https://doi.org/10.21203/rs.3.rs-2006990/v1

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Background: Total knee replacement (TKR) can alleviate knee osteoarthritis (OA) effectively. Many women undergo TKR; however, research on women’s decision-making process remains scant. This study aimed to explore the decision-making process for undergoing TKR among Taiwanese women.

Methods: A qualitative approach was used. Through purposive sampling, a total of 20 women aged > 40 years with knee OA undergoing TKR were recruited from a teaching hospital of Northern Taiwan. Data were collected 3–5 days and 6–8 weeks after TKR through in-depth interviews, observation, and field records and analyzed with constant comparative analysis.

Results: “Hope for a new knee,” the core theme for TKR-related decision-making, comprised three stages (including six themes): before decision (impacts of pain and seeking nonsurgical methods), decision (intrinsic and extrinsic motivation), and after decision (assessing physical function and achieving the golden phase of rehabilitation).

Conclusion: Women expected to have a new life after undergoing TKR. Impacts of pain and concern of becoming a burden on the family were main factors influencing the Taiwanese women’s decision for a TKR. These women strove to overcome difficulties related to post-TKR rehabilitation. An individual teaching programs and psychological support for women is imperative. The findings of women’s values and preferences for a TKR surgery will be helpful to develop an interventional decision support for shared decision-making.

Total knee replacement

osteoarthritis

decision-making process

qualitative study

Degenerative joint disease has been increasing in the rapidly aging population worldwide ^{(1, 2)}. Osteoarthritis (OA) is one of the most common forms of degenerative arthritis ⁽³⁾, which is a leading cause of disability and source of societal cost in older adults ⁽²⁾. OA is mainly characterized by pain and limited joint movement ⁽³⁾. In the US, approximately 58.5 million people (23.7% of the total population) have arthritis (most of whom have OA), and approximately 25.7 million (43.9%) of whom have daily activity limitation ⁽⁴⁾. The knee is the most common site of osteoarthritis, followed by the hand and hip The findings of women’s values and preferences for TKR surgery will be helpful to develop an interventional decision support for shared decision-making. Knee OA has been listed as a serious disease ⁽³⁾. Knee is a main joint that bears high levels of activity and weight and can affect the patient’s life considerably ⁽¹⁾. Knee OA pathogenesis involves pathological changes in the whole joint, including cartilage wear, osteophyte formation, and synovial inflammation, all leading to pain, stiffness, swelling, and loss of normal joint function ^{(2, 5)}. Because the disease progresses relatively slowly, knee OA can be treated in a progressive manner, with the focus on reducing joint pain and stiffness, maintaining, and improving joint mobility, reducing limb disability, and improving the quality of life ⁽⁶⁾.

Total knee replacement (TKR) is the most cost-effective treatment for the medical care of patients with advanced joint diseases because it can ameliorate joint pain and disability, improving the patients’ quality of life ⁽³⁾. In 2018, TKR accounted for the second most common surgery in the US; a total of 715,230 patients underwent this surgery, the majority (61%) of whom were female ⁽⁷⁾. Postoperative satisfaction for TKR were determined mainly by postoperative function recovery and pain relief, ranges between 80% and 100% ⁽⁸⁾. A systematic review identified and assessed factors affecting patient satisfaction following TKR ⁽⁹⁾: A history of mental health problems was the most frequently reported factor affecting patient satisfaction, followed by the use of a mobile bearing insert, patellar resurfacing, severe preoperative radiological degenerative change, no low back pain, normal body mass index (BMI), no to less postoperative pain, good physical function postoperatively, improvement in range of motion, and preoperative expectations being met. In another systematic review, postoperative patient-reported functional outcome was the most commonly reported predictor for satisfaction, whereas preoperative anxiety and depression were the most common preoperative predictor for dissatisfaction ⁽⁸⁾. The decision-making surgery is a complicated process, motivation and confidence during the difficult and tedious postoperative rehabilitation phase are essential for ensuring compliance with rehabilitation ^{(10, 11)}.

In Taiwan, approximately 3.1 million people had knee OA in 2020, accounting for 13% of the total population ⁽¹²⁾. Approximately 30,000 people received TKR annually, most of them whom were female (73%); of them, most were elderly (56%), but the number of middle-aged women undergoing TKR has been increasing gradually (17%) ⁽¹³⁾. Many quantitative studies have explored joint function, pain, quality of life, and satisfaction (8, 14–18), whereas most qualitative studies focused on exploring OA experience (19–24), and decision-making process of TKR (25–27). However, none of Taiwanese studies have addressed the experience of decision-making process from the preoperative to postoperative period. To redress this gap, the present study aimed to explore Taiwanese women’s decision-making process for undergoing TKR, particularly middle-aged and elderly women.

Study design

A qualitative approach was used to explore the decision-making process for TKR among middle-aged and elderly women.

Study setting and participants

Using purposing sampling, the participants from the orthopedic ward of a teaching hospital in Northern Taiwan were recruited in this study. In 2018, 338 people underwent TKR in this hospital. Of them, 76% were women, of whom 67% and 9% were elderly and middle-aged, respectively; a proportion similar to the 2020 statistic from the Statistics Department of the Ministry of Health and Welfare of Taiwan ⁽¹³⁾. Eligible women who (1) were aged > 40 years, (2) received primary TKR (3) and could communicate in Chinese and Taiwanese, were invited to participate in this study; women who (1) received a diagnosis of a mental disorder, (2) had dementia, (3) received bilateral TKR, and (4) received TKR revision were excluded.

Data collection

Data were collected through in-depth interviews, observations, and field records. The one-on-one and face-to-face interviews were conducted from September 2020 to May 2021. The data were collected twice for each patient. Each interview was completely recorded on digital audio. During the interview, in addition to verbal communication, the patients’ expressions and intonation were observed to obtain information. After each interview, a summary of the interview was recorded, and a reflection was written. Data collection and analysis were performed simultaneously; data analysis was performed immediately after data collection was completed from the first interviewee. When the data reached saturation (i.e., when no new data were obtained), data collection was stopped. Each interview was transcribed verbatim in Chinese from the digital audio recording soon after the interview. After all the interviews were transcribed, the author verified the transcripts by listening to each recording repeatedly. With the aid of two bilingual teachers, the interview transcripts were translated from Chinese to English.

Data collection procedures

This study was commenced after approval of the research ethics committee of the study hospital. Before data collection, the attending physician and the head nurse of the orthopedic ward were informed in advance. After identifying the eligible patients, the researcher explained the study purpose and procedures and obtained written consent. The first interview was held 3–5 days after TKR, at about 10 AM or 2 PM (i.e., after the interviewees took painkillers). Face-to-face interviews and recordings were conducted in a quiet space in the ward. A semi-structured interview guide was adopted. The interview questions were phrased as follows: “Please tell me about your illness….” Each interview lasted approximately 60 min. The second interview was conducted in a quiet corner of the Outpatient Department of Orthopedics 6–8 weeks after TKR. The interview questions were phrased as follows: “Please talk about the situation after returning home….” Each interview lasted approximately 30 min.

Data analysis and study rigor

Data analysis was based on the constant comparative analysis method of grounded theory, involving the process of open coding, axial coding, and selective coding ^{(28, 29)}. In the process of data analysis, computer processing system and software (including MS Word and Excel) were used to sort data files, continually compare, and classify data, assess the meaning of the interviewees, and combine all the text for sorting and summarization. The rigor of this study was evaluated according to four criteria of Lincoln and Guba (1985) ⁽³⁰⁾. Credibility: The data sources included interviews, observations, and field recordings, and this triangular audit aided in establishing the credibility of the current data. Using a peer review strategy, the research team met regularly to analyze and discuss the content of the research findings. In addition, the author, with 18 years of clinical nursing experience in orthopedics, assisted the participating women in sharing their real thoughts. Dependability: To establish consistency, the research team wrote interview and reflection journals immediately after each interview, read the interviews repeatedly to ensure correctness, and analyzed and recorded the decoding process and study results. Confirmability: This study used a triangular audit strategy to reduce the impact of research bias, including continuous review of the participants’ verbatim manuscripts, field records, and the author’s personal reflection journal. Transferability: The methods and findings of this study are described in detail, and these descriptions may help other researchers explore TKR in women in other contexts.

Ethical considerations

Ethical approval

was obtained from the Institutional Review Board of the National Taiwan University Hospital (No.202009031RIVA) and National Taipei University of Nursing and Health Sciences. The participants were required to provide informed consent prior to the study commencement. For anonymization of the interview data, each participant was identified by alphabetical codes (A, B, C, etc.). The data, encrypted for 6 years, are stored in the author’s personal computer.

In total, 20 women participated in the study; their demographic characteristics are presented in Table 1.

Table 1

Demographic characteristics of participants’ women (N = 20)
Characteristics	Number	%
Age group (years)
55–59	1	5
60–64	4	20
65–69	6	30
70–74	4	20
75–79	2	10
80–84	3	15
Education (highest level achieved)
Illiteracy	4	20
Elementary school	8	40
Junior high school	2	10
High school	6	30
Occupation
Retired	10	50
None	2	10
Housewife	4	20
Working	4	20
Marital status
Married	8	40
Widowed	10	50
Single	2	10

Core theme: hope for a new knee

“Hope for a new knee” was the core theme of the journey of middle-aged and elderly Taiwanese women undergoing TKR. The core theme was formed based on three stages, each including two themes: before decision (impacts of pain and seeking nonsurgical methods), decision to undergo decision (intrinsic and extrinsic motivation), and after decision (assessing physical function and achieving the golden phase of rehabilitation); these themes contained 17 categories (Table 2).

Table 2

Categories and theme synthesized to the core theme “Hope for a new knee”
Core theme	Theme		Categories
Hope for a new knee	Before decision	Impact of pain	− Limited mobility
			− Inability to handle work demands − Interruption in daily social activities
			− Sleep disturbances
		Seeking nonsurgical methods	− Compliance with conservative therapy
		Seeking nonsurgical methods	− Trying alternatives
	Decision	Intrinsic motivation	− Weighing TKR’s advantages
			− Concern of becoming a burden on the family
			− Worry about body image change
		Extrinsic motivation	− Physician’s advice
			− Encouragement from relatives and friends
			− Influence of other patients
	After decision	Assessing physical function	− Heaviness in legs
		Assessing physical function	− Difficulty in increasing range of motion over knee
		Achieving the golden phase of rehabilitation	− Exercising according to the rehabilitation plan
			− Striving toward the benchmark
			− Developing a home rehabilitation plan

Before decision

After being diagnosed as having knee OA, the included women decided to undergo TKR from 7 months to 12 years. During this period, women were affected by pain and sought nonsurgical methods.

Impacts of pain

In the included women, knee OA caused stiffness, swelling, deformation and pain in the knee joint and affected their knee function, resulting in limited mobility, inability to handle work demands, interruption of daily social activities, and sleep disturbances. These discomforts led to exhaustion.

Limited mobility: All the women reported mobility limitations due to knee OA pain; they included limping, weakness, inability to walk long distances, difficulty moving up and down stairs, difficulty using squat toilets, immobility of feet due to temporarily locked knee joints, and even the possibility of falling.

H-66: Before surgery, the pain was very intense when I lied down on my side. Sometimes when I walked around, I seemed to get stuck, and I couldn't walk. It was very strange. I was most afraid of crossing the long main roads, even those with traffic lights. I was very afraid of walking in the middle of the road. I am afraid of getting stuck in the middle of the road because my knees get stuck, and I can't walk.

I-15: (My left foot) was numb and weak. I remembered that when I was about to get on the bus, I forgot that (the left foot) should be the first to go up, and I couldn't get (on the bus). When I fell, everyone was startled, and the driver was also startled.

Inability to handle work demands: Among the working women, enduring knee OA pain during work affected the quality of their work, and as a result, they became gradually overwhelmed with the workload.

A-26: I plant some garlic, and I’d ask the workers to plant more. My feet couldn't do anything, and most of the planting was done by others.

F-32: I’d get off work (working as the owner of a breakfast shop) very early. Because of the pain in my feet, I couldn’t stand for a long time.

Interruption in daily social activities: The pain also affected the women’s daily social activities considerably. The women were less likely to socialize daily because of the pain.

G-19: When I didn't have any pain in my feet, I’d go to the park near my house to do gymnastics every morning at six o'clock. Now, because of the pain, I haven't been there for a long time. One day I went to the park, and a man in his 80s who also did gymnastics asked me, “Why I didn’t come?” I said, “My feet were hurting.”

L-32: The people in the community … I’d go out with the people in the community. But after my feet started hurting … I didn’t want to go. Because I didn’t want to go, it was better to stay at home.

Sleep disturbances: The pain occurred during the day and the night. When pain occurred at night, the women’s sleep quality was affected, resulting in insomnia, sleep disruption, and poor night sleep.

A-12: When I sleep at night, I felt sore. I often couldn't fall asleep. If I was sore, I’d move a little and then a little more, and it became less sore. My feet became more and more sore. If I couldn't fall asleep, I moved, lifted, and turned my feet.

O-02: Well, the pain became worse (before the operation), and I couldn't sleep.

Seeking nonsurgical methods

The women sought various nonsurgical conservative treatments or alternative treatments to relieve pain and improve quality of life, instead of undergoing surgery.

Compliance with conservative therapy: When the women sought treatment, they visited various locations to seek care ranging from primary clinics to medical centers. They also followed their medical practitioner’s advice to receive conservative treatment, including oral anti-inflammatory pain relievers, rehabilitation, intraarticular steroid or hyaluronic acid injection, autologous platelet proliferative therapy (PRP), high-concentration glucose injection, and joint hydrarthrosis fluid extraction.

A-08: Since last year, I have visited many doctors. I accepted the doctors’ recommendations for injecting steroids and hyaluronic acid and taking painkillers and anti-inflammatory drugs.

L-05: I also went to visit a lot of doctors. I couldn't get a hyaluronic acid treatment, so I went to pump water (draining fluid from the joint cavity). But the more (fluid) they drew out, the more uncomfortable it became. I got that procedure done more than a dozen times. I used to get it done every week. Then (one day) I couldn't draw (anymore), and I felt that this was not the way to go.

Trying alternatives: When the knee pain was unbearable, most of the women thought of undergoing alternative treatments first. In most cases, medical professionals do not recommend TKR immediately after knee OA diagnosis considering the fear of surgery the patient may have or other similar factors but may recommend alternative treatments first, such as Chinese herbal medicine, osteopathy, massage (Tui na), acupuncture, consumption of healthy foods (e.g., turmeric and collagen), over-the-counter medicines, and pain-relief patches.

A-07: Some people say that taking herbal medicines can effectively treat bone spurs. I tried it, but it was no good.

B-10: I didn't see any orthopedic surgeon after the orthopedic surgeon suggested TKR. If the pain was a little bit painful in the early days, I quickly went to visit Kung Fu Clinic and applied the herbal medicine on it.

F-02: I first sought acupuncture and then I saw (that) Chinese medicine … takes a. while [referring to each treatment] if you want to continue getting good treatment effects.

Decision

The women’s decision to undergo TKR was determined by two factors: intrinsic motivation and extrinsic motivation.

Intrinsic motivation

Intrinsic motivation refers to the inner forces that drive a woman's decision to undergo TKR, including weighing TKR’s advantages, concern of becoming a burden on the family and worry about body image change.

Weighing TKR’s advantages: Eventually, the women felt that the nonsurgical conservative treatments were ineffective, and they could no longer tolerate the pain and disability caused by it. The women began considering the benefits of undergoing TKR, such as improved knee function, discontinuation of ongoing medication, and planning for post-TKR living arrangements.

M-70: I think the surgery should be done once and for all. Don't make the left foot bad because the right foot is bad: I found that my left foot had started deforming because I thought I was using it to compensate (for my right foot’s disability). So, I think my knee is needed to be perform surgery (Improve knee function)

G-06: I would take painkillers, but I was afraid that the painkillers would damage my kidneys if I took them for a long time. I didn't take the painkillers all the time … and I couldn’t bear the pain. So, I thought it’d be better to have surgery because I had been taking the painkillers all the time. Painkillers, taking too much will damage the kidneys. (Stop continuous medication)

F-42: …because I feel that my responsibilities have been fulfilled, and I don't need children in my life. Why do I work so hard? I want to live my own life leisurely. I can’t spend it every day like this, anyway. After (TKR) and retiring, you can play everywhere. (Planning for postsurgical living arrangements)

Concern of becoming a burden on the family: The women were independent, and most of them were family caregivers. Many problems due to knee OA made the women worry that if they underwent TKR, they may become a burden on their family.

C-15: Look at (that 80-year-old patient with limited mobility) who can’t walk … I just think who is going to help me? Who’s going to pull me away? If you don’t get the surgery, you can’t go at home. Today’s society is independent. It’s not like before.

D-84: I don’t want to trouble others. I don’t want to bother others at home. My husband died very early, and I took care of all three children by myself. It’s very hard. I just take care of myself and want to get better as soon as possible. Now, I don’t want to bother anyone else.

Worry about body image change: Women were very concerned about the deformed appearance of the affected limb and the limping of the gait caused by knee OA. The women wanted to have normal appearance and limb function after TKR; therefore, they decided to undergo TKR.

B-16: My foot was crooked, but I hadn't had surgery yet. Usually, the older the children are, the better they walk. We old people are getting worse and worse! It's mainly because my foot was crooked that I took the initiative to have the surgery. Although others said, “It's fine if you can walk; so why do you need the surgery?” I still want to have the surgery; my feet are crooked when I walk, and if I wear shorter pants, I feel that the crookedness is obvious, it doesn't look good … it’s ugly."

R-15: Before walking with my husband, I usually walked ahead of him, and I just walked … (meaning walked very fast). Before surgery, when I walked … I lagged. My husband walks very slowly, and (still) I lagged…. The feeling of walking was very uncomfortable. I kind of walked dragging my legs, a girl staggers while walking. At that time, I felt…. I am a person who loves beauty very much, and that feeling is so…. That my feet are deformed is really undignified.

Extrinsic motivation

The influence of external factors on the women’s decision to undergo TKR involved physician’s advice, encouragement from relatives and friends, and influence of other patients.

Physician’s advice: Some women sought the advice of different physicians to confirm whether they required TKR. In one case, an orthopedic physician asked their patient to obtain an X-ray of the affected knee and explained the severity of her knee's degeneration and indicated that TKR was the only treatment available.

D-60: The doctor said, “If you have surgery, you will be able to climb mountains … you can’t walk until your knee is worn to the end.” When I came to (the doctor with) the X-rays that day, the doctor said, “You need to have (TKR).”

J-06: I saw two or three doctors who said that I need surgery, so I decided to have surgery. I just need surgery, and there is no way I couldn’t get it.

Encouragement from relatives and friends: Some women did not realize that they required TKR or were unwilling to undergo TKR; nevertheless, encouragement from relatives and friends drove them to decide to undergo TKR.

H-11: A neighbor also said, “The older you get and the more you delay, the slower your recovery will be. Don't delay it any longer.” He said, “You should just go for the surgery.”

N-19: At first, I agreed to get the surgery; then, my daughter-in-law … daughter and son said, “Mom, you have to get the surgery; otherwise, you won’t be able to stand it.”

Influence of other patients: Women inquired about the experience of patients who had undergone TKR. Most of these patients were relatives, friends, and neighbors the women knew well; these patients played a major role in the women’s decision to undergo TKR.

O-11: (The other patients) said that the surgery was good, and they had already advised me to have the surgery. The patient next door to me said that the surgery would be fine. But I didn't dare … I was worried about the surgery. It seemed to be very painful. He said, “It will be fine for 2 days. You don't dare to go for surgery?”

R-14: My mother was on bedrest for a long time. At that time, she had atrophy of her feet. She couldn’t get up and had to lie in the bed. That situation would … give me a vigilance. Maybe one day, I will be like this, so what should I do? No way, I must have the surgery.

After decision

After TKR, the women assessed their knee function and achieved the golden phase of post-TKR rehabilitation to ensure that the operated knee could return to normal function.

Assessing physical function

The acute adverse effects in the early post-TKR stages included knee joint pain, swelling, and stiffness; these increased discomfort and distress among the women and affected their activities.

Heaviness in the legs: The women described how the affected limb felt in the early postoperative period; some stated that their leg felt as if it was heavy, rock-like, wooden, or even dead.

G-30: After the operation, my body felt as if life was worse than death. It was very painful. I kept pressing on (referring patient controlled intravenous analgesia) but it was still very painful. I couldn’t straighten my feet or lift them up; it was just pain. At that time, I felt my whole foot, It was very heavy, too heavy.”

N-34: It was very heavy at the beginning, at the time of surgery, and during the period of anesthesia [from the start of use after the operation (referring patient controlled epidural analgesia) to the time of removal]. The foot was very uncomfortable, like a stone, from this side to the lower body side (left side), buttocks to the bottom of the left foot; the toes were numb, and the rest, I don’t know … I didn’t feel the flesh.”

Difficulty in increasing range of motion over knee: post-TKR joint mobility exercises included knee flexion and extension as well as straight leg raise. However, postoperative pain, swelling, and stiffness made it more difficult for the women to move their joints.

E-42: On the first day after the surgery, I thought I could lift it very high, but now, I can’t even lift it. Didn't you tell me to do this exercise? [referring to the right foot that has not been operated] It was almost the same. It was not ok on the third day, and it was the hardest to lift the foot.

N-33: Using continuous passive motion (CPM), it was very uncomfortable to do 90°. I don't want to do this. I think 80° was fine, not 90°. It was very tight at the beginning (after surgery), very painful, very painful.

Achieving the golden phase of rehabilitation

Through the guidance of the medical staff, reminders from relatives and friends, and reflection on the negative experiences of patients who underwent TKR, the women realized that if they did not undergo rehabilitation as soon as possible, they might not be able to restore their normal functions in the future. Therefore, the women actively practiced knee flexion, extension, straight leg raise, and walking out of bed when tolerable.

Exercising according to the rehabilitation plan: Independent or with the assistance of others, the women performed post-TKR rehabilitation step by step to achieve the maximum rehabilitation effect.

C-69: My daughter took pictures of the six exercises that my (physiotherapist) taught me. When I'm not sure, I'll look at it myself. And my daughter will help me set the time for the exercise. For example, I must do 6 times a day, and I need 10 reps for 1 exercise. I practice according to the rehabilitation chart. For example, if the mobile phone prompts me to change to the next exercise, I will follow the prompt on the mobile phone.

J-26: Whatever my daughter asks me to do, I just do it. My daughter even showed me the information on how to rehabilitate, and my daughter guides me when I do it.

Striving toward the benchmark: Women expected to have improved knee function after receiving TKR and then return to daily life or work. They therefore set various goals to achieve restored knee joint function.

M-65: Because of my current workplace, I only took 3 months off. So, I need to become functional enough to go back to work as soon as possible. At least I try something … that would help me recover as soon as possible. (Benchmark: Return to the workplace)

N-40: I have to get well [referring to sitting and walking] before I can go back home as soon as possible. I was not used to living (at the hospital). It doesn’t matter if I don’t (bend my knees) 90°. I’m 84 years old. What am I afraid of? I can walk, I can sit, I can. (Benchmark: Sit and walk)

Developing a home rehabilitation plan: Before leaving the hospital, the women considered the problems and difficulties encountered in their rehabilitation, and they received reminders from the medical staff and family members after they left the hospital. The women created a plan to facilitate rehabilitation at home after discharge.

M-41: Because I still did not get (90° of knee flexion) and Dr. X asked me to get discharged … I rented this (CPM) and went home. It could help me bend the knee every day; it made it easier to bend. I couldn’t bend at an angle like that (myself).

T-25: I went back and worried about my feet, so I'll just rehabilitate like this. My husband would tell me to walk a little harder at (home).

This study used a qualitative approach to elicit the decision-making process for TKR among middle-aged and elderly women in Taiwan at three stages: before decision, decision, and after decision.

Before decision

Pain caused by knee OA and the related movement restriction was noted among all women in this study; pain affected the women’s work, social interaction, and sleep. The current results are consistent with those reported previously: knee OA progressively worsens over time; pain is always present and occur at any time ^{(2, 11, 31)}. Pain limits the patients’ mobility and independence ^{(10, 11, 22)} and even leads to deterioration of the contralateral knee joint ⁽¹¹⁾. The affected knee becomes locked up without warning ^{(10, 31)}, increasing fall risks ^{(31, 32)}. Pain originally from structural damage can interfere with daily activities, social interaction ^{(22, 23)}, work, and sleep ⁽²²⁾. The current results also indicated that the women could not squat down to use a squat toilet—commonly used in Taiwan—or stand after squatting down.

Complementary and alternative medicine (CAM) is another method for Taiwanese or Chinese women to seek for treating various conditions; in recent years, its use has also become popular in Western societies ⁽³³⁾. The women in the current study sought alternative treatments to relieve pain, avoid long-term use of painkillers, and delay surgery. This result is consistent with previous findings related to the use of adjunctive and alternative therapies in the United States, United Kingdom, and France ^(34–36). Compared with Western women, who mostly opt for a combination of alternative and adjuvant therapies for pain relief ⁽³³⁾, the women in the current study tended to consider alternative therapies as their first option for pain relief. In the current study, when their physician recommended TKR, the women sought alternative therapeutic options due to fear of surgery. These options included acupuncture, osteopathy, massage (Tuina), Chinese herbal medicine, healthy foods, nonprescription of pain relievers, and pain-relief patches ^(34–36). Moreover, Taiwanese women tend to adopt alternative therapies more frequently than do European women or than do Taiwanese men ⁽³⁷⁾. The women in the current study considered undergoing surgery only after the alternative therapeutic options appeared to be ineffective.

Decision

In the current study, women finally decided to undergo TKA surgery. A systematic review identified four domains that affected the patients’ decision to undergo TKR, including personal factors, external factors, information sources and preferences towards outcome prediction⁽³⁸⁾. Our study has similar findings, Women’s preferences for a TKR influencing by intrinsic and extrinsic motivation. Intrinsic motivation including weighing TKR’s advantages, concern of becoming a burden on the family and worry about body image change. Extrinsic motivation including physician’s advice, encouragement from relatives and friends and influence of other patients. The concern of becoming a burden on family members was the major intrinsic motivation factor influencing the women’s decision to undergo TKR in the current study. The women had been independent all their life, with many of them even serving as family caregivers. Women were concerned that if they did not undergo surgery, they may become a burden on their family in the future. These findings were consistent with those reported previously: women’s desire to have an independent life and fulfill their caregiver responsibilities were the key factors in their decision for undergoing surgery ^{(25, 39, 40)}. By contrast, a study reported that Taiwanese men opt surgery only to regain their mobility and not lose their autonomy (25). Influence of other patients was a major extrinsic motivation affecting the women’s decision to undergo TKR in the current study. Specifically, the women asked close relatives or neighbors who had undergone TKR regarding their surgical experience. This result is consistent with that reported previously ^{(27, 41, 42)}: Positive experiences of fellow TKR patients increases motivation and confidence among women with knee OA to undergo TKR ^{(27, 41, 42)}. However, these women may ignore negative experiences shared by other patients ⁽²⁷⁾. This can be considered an optimistic bias, where better outcomes are imagined through positive patient evaluations without any adjustments for worse surgical outcomes ⁽⁴¹⁾. The women in the current study considered that the negative experiences among TKR patients resulted from the patients’ personal factors (e.g., not being active during rehabilitation and undergoing bilateral TKR once). This result was inconsistent with that of a previous study, where negative TKR patient experience was a factor hindering the patients’ decision to undergo surgery ⁽⁴³⁾.

After decision

Bandura’s self-efficacy theory indicates that self-efficacy is an individual’s belief or willingness to perform or complete an activity, which can be achieved through achievement performance, surrogate experience, verbal persuasion, emotional and physical motivation ⁽⁴⁴⁾. In the early postsurgical period, the Taiwanese women in the current study experienced physical pain and hampered daily activities and walking ability. This result was consistent with that of previous studies: pain is a common complaint after TKR ^{(45, 46)} and pain and swelling limit post-TKR rehabilitation performance (10, 47). Despite the pain and discomfort, women strive to perform rehabilitation activities ⁽⁴⁸⁾. As such, Taiwanese women in the current study strove to achieve their customized post-TKR rehabilitation goals. Similarly, studies have shown that patients strive to perform rehabilitation activities to regain their mobility and independence as soon as possible ^{(10, 49, 50)}. These findings were consistent with those reported in two systematic reviews: functional outcome and pain relief are major determinants of satisfaction ⁽⁸⁾.

Bandura’s social cognitive theory emphasizes that human behavior is determined by the interaction of the individual, the environment, and the behavior itself ⁽⁵¹⁾. In the current study, an elderly women considered the ability to sit and walk as her rehabilitation goal; therefore, for her, achieving a < 90° of knee flexion was acceptable. However, the rehabilitation goal of the working women was to restore knee joint function immediately and flex the knee to 130°. For the women who were caregivers for others, the rehabilitation goal was to resume their activities of daily living.

Limitations

Due to time constraints, 20 participants from one medical center in Northern Taiwan were included in this study. Therefore, the current results may not be applicable to all women in Taiwan. The long-term results could not be inferred because all our data were collected at 6–8 weeks after TKR. Future studies with follow-up durations of 3 or 6 months or up to 1 year are thus needed. Moreover, the study population comprised merely women; therefore, further research exploring the TKR decision-making process of male patients in Taiwan and comparing them with the current results is needed. Despites these, the results of the current study based on one-on-one in-depth interviews may aid clinicians in understanding the decision-making process of middle-aged and elderly women undergoing TKR. The finding of women’s values and preferences for TKR will be helpful to develop an interventional decision support for shared decision-making.

Taiwanese women expected to have a new life after undergoing TKR. The impacts of knee OA pain and concerns of becoming a burden on the family were critical factors influencing the women’s decision to undergo TKR. The women strove to overcome any difficulties during rehabilitation after TKR. Health-care providers should listen to and encourage women describing their journey of receiving TKR with an open mind and provide individualized teaching program and psychological support for women. Encouragement women establish a self-management to meet individual woman’s rehabilitation goal is needed.

Ethics approval and consent to participate

This study obtained ethical approval from National Taipei University of Nursing and Health Sciences and Institutional Review Board of the National Taiwan University Hospital (No.202009031RIVA). All methods were carried out in accordance with relevant guidelines and regulations of Belmont Report and Declaration of Helsinki. Prior to commencement, participants gave written informed consent for participation.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Competing interests

The authors declare that they have no competing interest.

Funding

No funding was received for the study.

Authors’ contributions
CHH contributed to the research design and methods development, writing original draft, undertook recruitment, conducted the interviews, undertook data analysis, and led the preparation of the transcripts. CTW contributed to the research design and methods development, participants recruitment, and data analysis contributed to the research design and methods development and data analysis. YYC contributed to the research design data analysis and original manuscript writing. SWC contributed to the research design and methods development, supervision, data analysis, writing -original draft writing and writing - review & editing. All authors reviewed the final version of manuscript.

Acknowledgments

We sincerely thank the 20 middle-aged and elderly women who participated in the study.

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No competing interests reported.

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Hope for a new knee: a qualitative study on decision-making process for total knee replacement in Taiwanese women

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Introduction

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Core theme: hope for a new knee

Before decision

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After decision

Discussion

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After decision

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