n Feature Article

Prospective Assessment of Sleep Quality

Before and After Primary Total Joint
Replacement
Blaine T. Manning, BS; Sean M. Kearns, BS; Daniel D. Bohl, MD, MPH; Tori Edmiston, MD;
Scott M. Sporer, MD; Brett R. Levine, MD, MS

abstract tional recovery following TJA.2 As such,

lowering the incidence of sleep disturbance
has the potential to decrease pain and en-
Sleep disruption is a common, yet rarely addressed, complaint among patients hance a patient’s mental status during day-
who have undergone total joint arthroplasty (TJA). This study assessed sleep time hours after TJA, which may improve
quality before and after primary TJA. A total of 105 patients who underwent functional outcomes and hasten postop-
primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) prospec- erative recovery.3 Inversely, persistent sleep
tively completed questionnaires during the preoperative, early postoperative, disturbance after TJA may increase pain and
and late postoperative periods. The survey included the Epworth Sleepiness jeopardize the postoperative course while
Scale, current sleeping habits, and patient perspectives of sleep quality and straining the physician–patient relationship.
duration. In the early postoperative period (4.7±2.0 weeks), patients reported The impact of sleep quality on post-
significant increases in sleep disturbance as denoted by increased length of operative functioning and recovery ne-
time to fall asleep (P=.006) and mean nightly awakenings (P=.002) compared cessitates its optimization, especially in
with the preoperative baseline. At late postoperative follow-up (40.8±19.5 the context of exponentially increasing
weeks), patients’ sleep quality subsequently improved above the preoperative
baseline. Approximately 40% of patients tried a new sleeping method postop- The authors are from the Department of Or-
eratively, the most common being new pillow placement. No significant dif- thopaedic Surgery, Rush University Medical Cen-
ter, Chicago, Illinois.
ferences in pre- or postoperative sleeping trends were noted between THA and
Mr Manning, Mr Kearns, Dr Bohl, and Dr
TKA patients. These findings suggest transient sleep disturbance is common in Edmiston have no relevant financial relation-
the early postoperative period, with subsequent improvement by 10-month ships to disclose. Dr Sporer is a paid consultant
follow-up after a primary TJA. Given the growing importance of patient sat- for DJO Orthopaedics, Pacira, Smith & Nephew,
Zimmer, Pixarbio, and Osteoremedies and has re-
isfaction in health care systems, orthopedic surgeons must manage patients’
ceived research support from Stryker, Zimmer, and
expectations while working with them to optimize sleep quality after TJA. A Pacira. Dr Levine is a paid consultant for Link,
multimodal approach with preoperative counseling, early postoperative sleep Zimmer, Janssen Pharmaceuticals, and Human
modifications, and possibly preemptive use of medications may improve tran- Kinetics and has received research support from
Zimmer, Biomet, and Antelon.
sient sleep disturbance among TJA patients. [Orthopedics. 201x; xx(x):xx-xx.]
Correspondence should be addressed to: Brett
R. Levine, MD, MS, Department of Orthopaedic
Surgery, Rush University Medical Center, 1611 W

S
leep disruption is a common, yet of-
ten ignored, problem among patients
before and after total joint arthro-
plasty (TJA), with a postoperative preva-
lence as high as 50%.1 Postoperative sleep
disturbance is often reciprocal to night pain
and remains a mediator in the relationship
between early postoperative pain and func-
Harrison St, Ste 300, Chicago, IL 60612 (blaine.
manning08@gmail.com).
Received: January 21, 2017; Accepted: Feb-
ruary 27, 2017.
doi: 10.3928/01477447-20170411-01

MONTH/MONTH 201x | Volume XX • Number X 1

n Feature Article
Table 1
Patient Demographics
(N=105)
Demographic Value
Sex, No. (%)
Male 43 (41)
Female 62 (59)
Age, mean±SD, y 62.5±11.7
Current tobacco use, 8 (7.6)
No. (%)
Surgery, No. (%)
Primary TKA 62 (59)
Primary THA 43 (41)
Abbreviations: THA, total hip
arthroplasty; TKA, total knee
arthroplasty.
demand for TJA and an evolving health
care landscape. By 2030, total hip arthro-
plasty (THA) utilization is projected to
nearly triple from 2005 levels to almost
600,000 cases per year.4 Demand for to-
tal knee arthroplasty (TKA) is also ex-
pected to increase more than 650% from
2005 levels to nearly 3.5 million cases
annually.4 The use of patient satisfaction
and outcome measures in reimbursement
systems also continues to intensify. Sleep
quality remains an important determinant
of postoperative pain and functional re-
covery, both of which can impact such
outcome measures and patients’ experi-
ence. This paradigm shift toward a “pay-
for-performance” system underlines the
importance of optimizing all aspects of
TJA patients’ postoperative course, in-
cluding sleep quality. Although previous
studies have revealed sleep disturbance
in the weeks and early months following
TKA,2,5-7 studies that prospectively assess
preoperative, early postoperative, and late
postoperative sleep quality after primary
THA and TKA are lacking.
The purposes of this study were to pro-
spectively assess the incidence and dura-
tion of postoperative sleep disturbance
after TJA and to determine the incidence
2 Copyright © SLACK Incorporated
and types of new sleeping methods em-
ployed by TJA patients to alleviate these
effects.
Materials and Methods
Following institutional review board
approval, patients scheduled for THA
or TKA to be performed by 2 surgeons
(S.M.S., B.R.L.) were approached for en-
rollment during their preoperative clinic
appointment by means of convenience
sampling. The study was conducted in
an outpatient clinic office at a single aca-
demic medical center located in an urban
setting.
Study surveys were administered
during 3 discreet time periods. The first
section was administered during the pa-
tient’s preoperative clinic appointment at
the time of enrollment. Questionnaires
included demographics and medical his-
tory, current sleeping habits, the Epworth
Sleepiness Scale (ESS), and perspectives
on the association between sleep qual-
ity, joint replacement, and daily activi-
ties. The ESS is a standardized, validated
questionnaire used to assess daytime
sleepiness. It consists of 8 questions that
ask respondents to rate, on a 4-point scale,
their typical chance of falling asleep or
dozing off while engaged in various dai-
ly activities. Epworth Sleepiness Scale
scores range from 0 to 24 (sum of 8 item
scores, 0-3), with a higher score indicat-
ing a greater propensity for daytime sleep-
iness. The second and third sections were
administered during the first (2-3 weeks)
and second (4-8 weeks) postoperative
clinic appointments, respectively. All
clinic appointments followed the authors’
routine pathways and standard-of-care
protocols. For enrolled patients who did
not return for one of their postoperative
clinic appointments, results were attained
by phone or mail during the appropriate
follow-up period. The second and third
survey sections were virtually identical to
the first section, other than questions be-
ing modified to reflect the postoperative
phase.
Statistical analyses were conduct-
ed with Stata version 13.1 software
(StataCorp LLP, College Station, Texas).
Responses were compared between time
points using the signed-rank test (for con-
tinuous variables) or McNemar’s test (for
binary variables). Responses were com-
pared between THA and TKA patients us-
ing the Wilcoxon rank-sum test (for con-
tinuous variables) or Pearson’s chi-square
test (for binary variables). The level of
significance was set at P<.05.
Results
Table 1 contains respondents’ demo-
graphic data. There was a slight major-
ity of female participants (59% female
vs 41% male). The mean±SD patient age
was 62.5±11.7 years. Most participants
underwent primary TKA (59% primary
TKA vs 41% primary THA).
Table 2 includes responses from the
preoperative, early postoperative (4.7±2.0
weeks), and late postoperative (40.8±19.5
weeks) periods. Patients reported sig-
nificant increases in length of time to
fall asleep during the early postoperative
period (P=.006). Mean nightly awak-
enings increased early postoperatively
(P=.002) and decreased late postopera-
tively (P<.001) compared with preop-
erative baseline. The overall percentage
of patients expressing a desire for better
sleep quality decreased from 70.2% at
preoperative baseline to 44.7% late post-
operatively (P<.001). Patients expressing
a desire for longer sleep duration also
decreased from 59.1% preoperatively to
41.2% late postoperatively (P<.001). Use
of sleep medications and ESS scores did
not change significantly after TJA com-
pared with preoperative values. Overall
pre- or postoperative responses did not
differ significantly between THA and
TKA patients (Table 3).
Table 4 details new methods used by
patients to improve sleep postoperatively.
Nearly 40% of patients reported trying a
new sleeping method, with the most com-
mon being new pillow placement (~33%
 n Feature Article

of patients). Overall use of a new sleeping

method did not differ between THA and Table 2
TKA patients in the early (P=.800) or late
Patient Responses at Preoperative, Early Postoperative, and Late
(P=.766) postoperative periods.
Postoperative Visits
Discussion Early Late
Postoperativea Postoperativeb
Total joint arthroplasty is one of the
most commonly performed procedures Sleep-Related Factor Preoperative Value Pc Value Pc
and offers substantial functional and
Mean time to fall asleep, min 15.8 18.1 .006 14.7 .288
symptomatic improvement for osteoar-
Mean nightly sleep duration, h 6.4 6.2 .267 6.6 .085
thritis patients. Although osteoarthritis pa-
Mean nightly awakenings, No. 2.5 2.9 .002 1.9 <.001
tients often experience diminished sleep
quality, there are few studies examining Patients wishing for better sleep 70.2% 63.8% .289 44.7% <.001
quality
patients’ sleep quality after orthopedic
Patients wishing for longer sleep 59.1% 61.5% .590 41.2% <.001
surgery, especially primary TJA.8-10 The duration
purpose of the current study was to pro-
Sleep qualityd 3.3 3.2 .449 3.6 .002
spectively evaluate sleep disturbance in
Impact of sleep difficulties on 2.0 2.0 .762 1.7 .004
the preoperative, early postoperative, and daily livingd
late postoperative periods among primary Current sleep medication use 22.9% 19.1% .285 25.2% .655
TJA patients.
Current antidepressant use 18.1% 17.3% 1.000 22.6% .317
Prior to surgery, the majority of pa-
Epworth Sleepiness Scale score 5.8 6.0 .876 5.7 .411
tients expressed a desire for improved
a
sleep quality (70.2% of patients) and dura- At 4.7±2.0 weeks.
b
At 40.8±19.5 weeks.
tion (59.1% of patients). Suboptimal sleep c
P values compared with preoperative value.
d
quality in osteoarthritis patients may be As reported on 1–5 scale.
secondary to increased night pain, a com-
plication that has been well documented
in previous studies.7,11,12 In the early operative days 5 to 9.5,15 Worsening sleep of TJA patients.6,7,16 In one study of 34
postoperative period (4.7±2.0 weeks), pa- quality early after TJA may be the result primary TKA patients, sleep quality con-
tients’ sleep quality decreased as time to of limited postoperative functioning be- tinued improving until 6 months after sur-
fall asleep and number of nighttime awak- cause patients often take several months gery.7 On the basis of the current findings
enings both increased significantly from to recover. and those from previous studies, primary
preoperative baseline (Table 2). Interest- Although sleep disturbance increased THA and TKA patients should be advised
ingly, these increases occurred despite no in the early postoperative period, sleep to anticipate increased disturbances in
significant difference in total sleep dura- quality eventually improved (40.8±19.5 sleep in the immediate postoperative pe-
tion, patient satisfaction with sleep qual- weeks) to supersede the preoperative riod, with subsequent improvement over
ity or duration, or ESS scores compared baseline. Patients reported significantly baseline by 10 months postoperatively.
with preoperative baseline. It is possible fewer nighttime awakenings (P<.001) and This study had several potential limi-
that patients’ satisfaction with their sleep improved satisfaction with sleep quality tations. First, participants were patients
quality and duration did not change be- (P<.001) and duration (P<.001) in the late of 2 orthopedic surgeons at one private
cause they anticipated sleep disturbance postoperative period (Table 2). Many pa- practice in an urban setting. As such, the
(nighttime awakenings and increased time tients also reported a new sleeping method findings may not represent patients in
to fall asleep) immediately after their TJA. after surgery, the most common technique other orthopedic practices or geographic
Suboptimal quality of sleep after both being new pillow placement. It is possible regions. Second, all patients were pri-
THA and TKA has been established in that by optimizing positioning of the op- mary unilateral TKA and THA patients.
previous studies.13,14 The duration of post- erative extremity with a pillow, patients Although there were no significant differ-
operative sleep disturbance after TKA has were able to minimize nighttime pain. Re- ences in preoperative baseline or postop-
been suggested to be 6 weeks,7 although gardless, the current study’s results from erative sleep disturbance between these
rapid eye movement sleep and daytime the late postoperative period are similar THA and TKA patients, the findings may
sleepiness may normalize as early as post- to those from other studies of both types not be applicable to patients undergo-

MONTH/MONTH 201x | Volume XX • Number X 3

n Feature Article

Table 3
No Significant Difference Between Total Hip Arthroplasty and Total Knee Arthroplasty Patient
Responses
Preoperative Early Postoperativea Late Postoperativeb
Sleep-Related Factor THA TKA P THA TKA Pc THA TKA Pc
Mean time to fall asleep, min 16.4 15.4 .559 16.7 19.2 .206 15.0 14.5 .732
Mean nightly sleep duration, h 6.2 6.5 .854 6.4 6.0 .130 6.5 6.6 .330
Mean nightly awakenings, No. 2.7 2.3 .223 2.8 3.0 .465 1.8 1.9 .387
Patients wishing for better sleep quality 76.7% 65.6% .220 58.1% 67.7% .314 51.2% 40.0% .261
Patients wishing for longer sleep duration 67.4% 53.2% .145 58.1% 63.9% .550 51.2% 33.9% .080
Sleep qualityd 3.2 3.4 .074 3.3 3.2 .708 3.5 3.7 .260
Impact of sleep difficulties on daily livingd 2.1 1.9 .112 2.0 2.0 .904 1.8 1.7 .545
Current sleep medication use 18.6% 25.8% .387 18.6% 19.4% .923 25.6% 25.0% .947
Current antidepressant use 11.6% 22.6% .152 11.6% 21.3% .199 16.3% 27.1% .196
Epworth Sleepiness Scale score 6.3 5.4 .229 6.2 5.8 .778 6.5 5.1 .065
Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty.
a
At 4.7±2.0 weeks.
b
At 40.8±19.5 weeks.
c
P values compared with preoperative value.
d
As reported on 1–5 scale.

ing bilateral or revision TJA. Finally, the

authors did not evaluate additional func-
Table 4
tional or pain scales (eg, Knee Society
Score, Short Form 36) at narrow, multiple New Sleeping Techniques Since Previous Visita
postoperative intervals. Although these Early Postoperativeb Late Postoperativec
may have provided further insight into the Patient Response THA TKA P THA TKA P
etiology and course of sleep disturbance, New method used 39.5% 37.1% .800 18.6% 21.0% .766
the authors thought this would be outside New/different use of pillow 32.6% 33.9% .888 14.0% 15.3% .855
the scope of their small prospective study. New sleeping position 11.6% 12.9% .845 4.7% 11.9% .205
Future studies could attempt to acquire New sleeping medication 4.7% 0.00% .086 2.3% 3.4% .753
additional functional and pain scales at
Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty.
multiple postoperative intervals as well as a
Stratified by THA vs TKA. Methods not mutually exclusive.
employ a multimodal approach to manage b
At 4.7±2.0 weeks.
c
At 40.8±19.5 weeks.
sleep dysfunction. Extremity position,
medical prophylaxis, and preoperative
counseling should be assessed to further
minimize postoperative sleep disturbance postoperative period with subsequent im- early postoperative sleep modifications
after a THA or TKA. Further investiga- provement above preoperative baseline at may improve transient sleep disturbance
tions from more geographically diverse 10 months after primary THA and TKA. following TJA.
populations would better aid in making Given the increasing role of patient satis-
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