Clinical Rheumatology

, Volume 28, Issue 9, pp 1083–1089 | Cite as

Effect of comorbidity on quality of life of male veterans with prevalent primary total knee arthroplasty

  • Jasvinder A. Singh
Brief Report


This is a study of the impact of specific and overall comorbidity on health-related quality of life (HRQoL) in men with primary total knee arthroplasty (TKA). In a population-based sample of male veterans who responded to a cross-sectional survey using the validated short-form 36 for veterans (SF-36 V) and had undergone primary TKA prior to survey, eight SF-36 V domain and two summary scores (physical and mental component (PCS and MCS) summary) were compared using multivariable-adjusted multiple linear regressions between patients with and without five comorbidities—chronic obstructive pulmonary disease (COPD)/asthma, diabetes, depression, hypertension, and heart disease. Analyses were adjusted for age, five comorbidities, and time since TKA. Two hundred ninety-three male patients constituted the analytic set with mean (SD) age of 70.3 (8.8) years; 97% were Caucasian and mean (SD) duration since TKA was 2.1 (0.7) years. COPD/asthma was associated with significantly lower adjusted MCS (mean ± standard error of mean, 47.1 ± 0.7 vs. 43.1 ± 1.2; p ≤ 0.001) and PCS (30.1 ± 0.6 vs. 27.7 ± 1.0; p < 0.05), depression with significantly lower MCS (48.9 ± 0.7 vs. 37.6 ± 1.2; p ≤ 0.001) but not PCS, hypertension with significantly lower MCS (47.0 ± 0.7 vs. 44.3 ± 1.0; p < 0.05) but not PCS, and heart disease with significantly lower MCS (47.4 ± 0.8 vs. 44.2 ± 0.9; p ≤ 0.001) and PCS (30.5 ± 0.7 vs. 28.1 ± 0.8; p < 0.05). Diabetes was not associated with lower MCS or PCS. The overall number of comorbidities was associated with lower MCS and PCS (p ≤ 0.001 for both). Medical and psychiatric comorbidity impacts physical and mental/emotional HRQoL in patients with primary TKA. The impact differs by comorbidity. Higher comorbidity load negatively impacts both physical and mental/emotional HRQoL.


Comorbidity Health-related quality of life HRQoL Knee arthroplasty Quality of life Total knee arthroplasty 



This project was supported by an NIH CTSA Award 1 KL2 RR024151-01 (Mayo Clinic Center for Clinical and Translational Research).



Key messages

1. Higher comorbidity is associated with worse physical and mental/emotional HRQoL in primary TKA patients.

2. COPD/asthma and heart disease impact physical and mental/emotional HRQoL in primary TKA patients.

3. Depression and hypertension impact mental/emotional but not physical HRQoL in primary TKA patients.


  1. 1.
    Kane RL, Saleh KJ, Wilt TJ, Bershadsky B (2005) The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 87:1719–1724PubMedCrossRefGoogle Scholar
  2. 2.
    Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME (2001) The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med 161:454–460PubMedCrossRefGoogle Scholar
  3. 3.
    Lingard EA, Katz JN, Wright EA, Sledge CB (2004) Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am 86-A:2179–2186PubMedGoogle Scholar
  4. 4.
    Wasielewski RC, Weed H, Prezioso C, Nicholson C, Puri RD (1998) Patient comorbidity: relationship to outcomes of total knee arthroplasty. Clin Orthop Relat Res 356:85–92Google Scholar
  5. 5.
    Rajgopal V, Bourne RB, Chesworth BM, MacDonald SJ, McCalden RW, Rorabeck CH (2008) The impact of morbid obesity on patient outcomes after total knee arthroplasty. J Arthroplast 23:795–800CrossRefGoogle Scholar
  6. 6.
    Fisher DA, Dierckman B, Watts MR, Davis K (2007) Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J Arthroplast 22:39–42CrossRefGoogle Scholar
  7. 7.
    Fitzgerald JD, Orav EJ, Lee TH et al (2004) Patient quality of life during the 12 months following joint replacement surgery. Arthritis Rheum 51:100–109PubMedCrossRefGoogle Scholar
  8. 8.
    Fortin PR, Clarke AE, Joseph L et al (1999) Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum 42:1722–1728PubMedCrossRefGoogle Scholar
  9. 9.
    Naylor JM, Harmer AR, Heard RC (2008) Severe other joint disease and obesity independently influence recovery after joint replacement surgery: an observational study. Aust J Physiother 54:57–64PubMedGoogle Scholar
  10. 10.
    Hawker G, Wright J, Coyte P et al (1998) Health-related quality of life after knee replacement. J Bone Joint Surg Am 80:163–173PubMedGoogle Scholar
  11. 11.
    Jones CA, Voaklander DC, Suarez-Alma ME (2003) Determinants of function after total knee arthroplasty. Phys Ther 83:696–706PubMedGoogle Scholar
  12. 12.
    Kennedy DM, Hanna SE, Stratford PW, Wessel J, Gollish JD (2006) Preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty. J Arthroplast 21:559–566CrossRefGoogle Scholar
  13. 13.
    Nunez M, Nunez E, Segur JM et al (2007) Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement. Osteoarthr Cartil 15:258–265PubMedCrossRefGoogle Scholar
  14. 14.
    Gandhi R, de Beer J, Leone J, Petruccelli D, Winemaker M, Adili A (2006) Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplast 21:46–52CrossRefGoogle Scholar
  15. 15.
    Papagelopoulos PJ, Idusuyi OB, Wallrichs SL, Morrey BF (1996) Long term outcome and survivorship analysis of primary total knee arthroplasty in patients with diabetes mellitus. Clin Orthop Relat Res 330:124–132PubMedCrossRefGoogle Scholar
  16. 16.
    Meding JB, Reddleman K, Keating ME et al (2003) Total knee replacement in patients with diabetes mellitus. Clin Orthop Relat Res 416:208–216Google Scholar
  17. 17.
    Ayers DC, Franklin PD, Ploutz-Snyder R, Boisvert CB (2005) Total knee replacement outcome and coexisting physical and emotional illness. Clin Orthop Relat Res 440:157–161PubMedCrossRefGoogle Scholar
  18. 18.
    Moon HK, Han CD, Yang IH, Cha BS (2008) Factors affecting outcome after total knee arthroplasty in patients with diabetes mellitus. Yonsei Med J 49:129–137PubMedCrossRefGoogle Scholar
  19. 19.
    Brander V, Gondek S, Martin E, Stulberg SD (2007) Pain and depression influence outcome 5 years after knee replacement surgery. Clin Orthop Relat Res 464:21–26PubMedGoogle Scholar
  20. 20.
    Singh JA, Sloan JA (2008) Health-related quality of life in veterans with prevalent total knee arthroplasty and total hip arthroplasty. Rheumatology (Oxford) 47:1826–1831CrossRefGoogle Scholar
  21. 21.
    Singh JA, Borowsky SJ, Nugent S et al (2005) Health-related quality of life, functional impairment, and healthcare utilization by veterans: veterans' quality of life study. J Am Geriatr Soc 53:108–113PubMedCrossRefGoogle Scholar
  22. 22.
    Singh JA, Murdoch M (2007) Effect of health-related quality of life on women and men's Veterans Affairs (VA) health care utilization and mortality. J Gen Intern Med 22:1260–1267PubMedCrossRefGoogle Scholar
  23. 23.
    Singh JA, Nelson DB, Fink HA, Nichol KL (2005) Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the veterans arthritis quality of life study. Semin Arthritis Rheum 34:755–765PubMedCrossRefGoogle Scholar
  24. 24.
    Singh JA, Strand V (2009) Health care utilization in patients with spondyloarthropathies. Rheumatology (Oxford) 48:272–276CrossRefGoogle Scholar
  25. 25.
    Kazis L, Skinner K, Rogers W et al (1998) Health status of veterans: physical and mental component summary scores (sf-36v). 1998 national survey of ambulatory care patients. Executive report. Bedford, Massachusetts: Center for Health Quality, Outcomes, and Economic Research, Bedford VAMC; 1998: Department of Veterans Affairs, Veterans Health Administration, Office of Performance and Quality, Washington, D.C.Google Scholar
  26. 26.
    Kazis LE, Miller DR, Clark J et al (1998) Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med 158:626–632PubMedCrossRefGoogle Scholar
  27. 27.
    Kazis LE, Ren XS, Lee A et al (1999) Health status in VA patients: results from the Veterans Health Study. Am J Med Qual 14:28–38PubMedCrossRefGoogle Scholar
  28. 28.
    Kosinski M, Keller SD, Ware JE Jr, Hatoum HT, Kong SX (1999) The sf-36 health survey as a generic outcome measure in clinical trials of patients with osteoarthritis and rheumatoid arthritis: relative validity of scales in relation to clinical measures of arthritis severity. Med Care 37:MS23–MS39PubMedCrossRefGoogle Scholar
  29. 29.
    Kvien TK, Kaasa S, Smedstad LM (1998) Performance of the Norwegian sf-36 health survey in patients with rheumatoid arthritis. II. A comparison of the sf-36 with disease-specific measures. J Clin Epidemiol 51:1077–1086PubMedCrossRefGoogle Scholar
  30. 30.
    Tuttleman M, Pillemer SR, Tilley BC et al (1997) A cross sectional assessment of health status instruments in patients with rheumatoid arthritis participating in a clinical trial. Minocycline in Rheumatoid Arthritis Trial Group. J Rheumatol 24:1910–1915PubMedGoogle Scholar
  31. 31.
    Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-form health survey (sf-36). I. Conceptual framework and item selection. Med Care 30:473–483PubMedCrossRefGoogle Scholar
  32. 32.
    Ware JE, Kosinski M, Dewey J (2000) How to score version two of the sf-36 health survey, 3rd edn. QualityMetric, LincolnGoogle Scholar
  33. 33.
    Kashner TM (1998) Agreement between administrative files and written medical records: a case of the Department of Veterans Affairs. Med Care 36:1324–1336PubMedCrossRefGoogle Scholar
  34. 34.
    Szeto HC, Coleman RK, Gholami P, Hoffman BB, Goldstein MK (2002) Accuracy of computerized outpatient diagnoses in a Veterans Affairs general medicine clinic. Am J Manag Care 8:37–43PubMedGoogle Scholar
  35. 35.
    Petersen LA, Wright S, Normand SL, Daley J (1999) Positive predictive value of the diagnosis of acute myocardial infarction in an administrative database. J Gen Intern Med 14:555–558PubMedCrossRefGoogle Scholar
  36. 36.
    Strand V, Singh JA (2007) Improved health-related quality of life with effective disease-modifying antirheumatic drugs: evidence from randomized controlled trials. Am J Manag Care 13(Suppl 9):S237–S251PubMedGoogle Scholar
  37. 37.
    Strand V (2004) Longer term benefits of treating rheumatoid arthritis: assessment of radiographic damage and physical function in clinical trials. Clin Exp Rheumatol 22:S57–S64PubMedGoogle Scholar
  38. 38.
    Strand V, Crawford B (2005) Improvement in health-related quality of life in patients with SLE following sustained reductions in anti-dsDNA antibodies. Expert Review of Pharmacoeconomics & Outcomes Research 5:317–326CrossRefGoogle Scholar
  39. 39.
    Strand V, Kelman A (2004) Outcome measures in osteoarthritis: randomized controlled trials. Curr Rheumatol Rep 6:20–30PubMedCrossRefGoogle Scholar
  40. 40.
    Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM (2000) Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Arch Intern Med 160:3252–3257PubMedCrossRefGoogle Scholar
  41. 41.
    Windisch W, Freidel K, Schucher B et al (2003) Evaluation of health-related quality of life using the MOS 36-item short-form health status survey in patients receiving noninvasive positive pressure ventilation. Intensive Care Med 29:615–621PubMedCrossRefGoogle Scholar
  42. 42.
    Lingard EA, Riddle DL (2007) Impact of psychological distress on pain and function following knee arthroplasty. J Bone Joint Surg Am 89:1161–1169PubMedCrossRefGoogle Scholar
  43. 43.
    Mancuso CA, Salvati EA, Johanson NA, Peterson MG, Charlson ME (1997) Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 12:387–396PubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2009

Authors and Affiliations

  1. 1.Rheumatology Section, Medicine ServiceMinneapolis VA Medical CenterMinneapolisUSA
  2. 2.Division of Rheumatology, Department of MedicineUniversity of MinnesotaMinneapolisUSA
  3. 3.Departments of Health Sciences and Orthopedic SurgeryMayo Clinic School of MedicineRochesterUSA

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