Carotid Endarterectomy for Asymptomatic Stenosis Based on Duplex Ultrasound Alone Achieves Equivalent Perioperative and Long-Term Outcomes Relative to Advanced Imaging Based Endarterectomy.

BACKGROUND: The purpose of this study is to compare both perioperative as well as long-term outcomes of patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid bifurcation stenosis based on duplex ultrasound in isolation relative to a combination of duplex and more advanced imaging. METHODS: All CEA in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. Exclusions were symptomatic carotid lesion (57,742), lack of imaging documentation (908), lack of advanced imaging status (1,816), simultaneous additional arterial intervention in the carotid, coronary, or peripheral arterial system (n = 4,118), and anatomic high-risk status for CEA (n = 4,071). Included patients were then placed into 1 of 2 cohorts: patients undergoing CEA based on duplex imaging alone (n = 33,437) and those undergoing CEA based on advanced imaging (CTA, MRA, or invasive angiography) with or without duplex (n = 69,715). We performed multivariable analysis for the following outcomes utilizing CEA based on duplex in isolation as 1 of the variables: perioperative neurological ischemic event utilizing binary logistic regression; combined 90-day mortality and neurological ischemic event utilizing binary logistic regression; neurological event in long-term follow-up with date of surgery serving as time zero; time dependent Cox regression analysis; mortality in long-term follow-up utilizing time-dependent Cox regression. RESULTS: Carotid endarterectomy based on duplex alone and CEA based on advanced imaging had essentially equivalent rates of 90-day mortality (0.9% vs. 1.0%, P = 0.108); combined perioperative neurological event and 90-day mortality (2.0% vs. 2.2%, P = 0.042); and, return to the operating room (1.6% vs. 1.7%, P = 0.154). On multivariable analysis CEA based on advanced imaging was noted to have a slightly higher absolute rate of perioperative neurological event without achieving multivariable significance (1.3% vs. 1.2%, adjusted odds ratio 1.11 (0.98-1.25), P = 0.092. CEA based on advanced imaging had a higher rate of neurological event after index hospital admission relative to duplex in isolation (hazard ratio (HR) 1.44 (1.31-1.60), P < 0.001). However, the absolute percentage difference was just 0.5% (1.6% vs. 2.1%). CEA based on duplex alone was associated with a slightly increased risk of mortality in LTFU (HR 1.16 (1.11-1.21), P < 0.001). At 5 years the absolute risk of mortality was less than 1% different between the cohorts. CONCLUSIONS: Performing CEA for asymptomatic bifurcation stenosis based on duplex ultrasound alone is a safe practice which achieves clinically equivalent perioperative and long-term freedom from cerebral ischemia and mortality relative to CEA based on advanced imaging. This has potential implications for health care cost saving as well as avoidance of radiation and iodinated contrast.

A biological reading of a palimpsest.

In the Middle Ages, texts were recorded and preserved on parchment, an animal-derived material. When this resource was scarce, older manuscripts were sometimes recycled to write new manuscripts. In the process, the ancient text was erased, creating what is known as a palimpsest. Here, we explore the potential of peptide mass fingerprinting (PMF), widely applied to identify species, to help reconnect the dispersed leaves of a manuscript and reveal differences in parchment manufacturing. In combination with visual methods, we analyzed a whole palimpsest, the codex AM 795 4to from the Arnamagnæan Collection (Copenhagen, Denmark). We find that both sheep and goat skins were used in this manuscript, and that parchment differed in quality. Notably, the PMF analysis distinguished five groups of folios which match the visual groupings. We conclude that this detailed interrogation of a single mass spectrum can be a promising tool to understand how palimpsest manuscripts were constructed.

Analysis of Return to Play After Modified Broström Lateral Ankle Ligament Reconstruction.

BACKGROUND: Despite marked improvements in stability after lateral ankle ligament repair, many patients do not return to their preinjury activity level. There are few studies addressing athletes' assessment of their ability to return to play after lateral ankle ligament reconstruction for recurrent instability. PURPOSE: To determine the rate of return to the preinjury activity level among physically active patients after the modified Broström procedure (MBP) for recurrent lateral ankle instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included were patients who had undergone a primary MBP by a single surgeon over a 6-year period and had a minimum 24 months of follow-up. A telephone questionnaire was conducted to ascertain the patient's ability to return to sport and/or work activity at final follow-up. Activity levels were evaluated utilizing the Tegner activity score. Outcome scores and other measured variables were compared between patients who returned to their preinjury level and those who did not. The reasons for failing to return were also documented. RESULTS: Of the 59 patients who met the inclusion criteria, 41 (69%; 20 men and 21 women) participated in the telephone interview. Results indicated that 22 (54%) returned to their prior level of activity (returners). The mean age of returners was 27.2 years; for nonreturners, the mean age was 27.1 years. Most patients (36/41; 88%) were satisfied with surgery and the overall outcome. Of the 19 nonreturners, 7 (37%) noted ankle-related reasons for not returning (pain: 57%; residual instability: 29%; decreased range of motion: 14%), and 12 (63%) cited non-ankle-related reasons. The mean preinjury and postoperative Tegner score for returners was 6.8. Moreover, 7 of 14 (50%) high-level athletes with preinjury Tegner scores ≥8 returned to their preinjury activity level. For high-level athletes who did not return to their previous level, the mean postoperative Tegner score was 6.6, and only 1 (7%) cited an ankle-related reason for not returning. CONCLUSION: A high patient satisfaction rate was reported after the MBP for recurrent lateral ankle instability. The majority of patients who did not return to their preinjury level cited a non-ankle-related factor as the reason for not returning to sport. This was especially true for the higher level athletes.

Forgotten books: The application of unseen species models to the survival of culture.

The study of ancient cultures is hindered by the incomplete survival of material artifacts, so we commonly underestimate the diversity of cultural production in historic societies. To correct this survivorship bias, we applied unseen species models from ecology to gauge the loss of narratives from medieval Europe, such as the romances about King Arthur. The estimates obtained are compatible with the scant historic evidence. In addition to events such as library fires, we identified the original evenness of cultural populations as an overlooked factor in these assemblages' stability in the face of immaterial loss. We link the elevated evenness in island literatures to analogous accounts of ecological and cultural diversity in insular communities. These analyses call for a wider application of these methods across the heritage sciences.

Catastrophic Thinking and Pain Alleviation After Lower Extremity Surgery.

OBJECTIVES: Requests for opioid pain medication more than a few weeks after surgery are associated with greater symptoms of depression and cognitive biases regarding pain such as worst-case thinking and fear of painful movement. We sought factors associated with patient desire for more opioid medication and satisfaction with pain alleviation at suture removal after lower extremity surgery. DESIGN: Cross sectional study. SETTING: Enrollment occurred at 1 of 4 orthopaedic offices in an urban setting. PATIENTS/PARTICIPANTS: At suture removal after lower extremity surgery, 134 patients completed questionnaires measuring catastrophic thinking, ability to reach goals and continue normal activities in spite of pain, symptoms of depression, and magnitude of physical limitations. MAIN OUTCOME MEASUREMENTS: Psychological factors associated with questionnaire-reported patient desire for another opioid prescription, satisfaction with postoperative pain alleviation, and the self-reported number of pills remaining from original opioid prescription. RESULTS: In logistic regression, smoking and greater catastrophic thinking were independently associated with desire for opioid refill (R2 = 0.20). Lower satisfaction with pain alleviation was associated with greater catastrophic thinking (R2 = 0.19). The size of surgery (large vs. medium/small procedure) was not associated with pain alleviation or satisfaction with pain alleviation. CONCLUSIONS: The association between unhelpful cognitive bias regarding pain and request for more opioids reinforces the importance of diagnosing and addressing common misconceptions regarding pain in efforts to help people get comfortable. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With Patient Satisfaction Measured Using a Guttman-Type Scale.

Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (ß: -0.03; 95% CI: -0.05 to -0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters' degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of -0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.

Adverse Childhood Experiences Are Not Associated With Patient-reported Outcome Measures in Patients With Musculoskeletal Illness.

BACKGROUND: Adverse childhood experiences (ACEs) affect adult mental health and tend to contribute to greater symptoms of depression and more frequent suicide attempts. Given the relationship between symptoms of depression and patient-reported outcomes (PROs), adversity in childhood might be associated with PROs in patients seeking care for musculoskeletal problems, but it is not clear whether in fact there is such an association among patients seeking care in an outpatient, upper extremity orthopaedic practice. QUESTIONS/PURPOSES: (1) Are ACE scores independently associated with variation in physical limitations measured among patients seen by an orthopaedic surgeon? (2) Are ACE scores independently associated with variations in pain intensity? (3) What factors are associated with ACE scores when treated as a continuous variable or as a categorical variable? METHODS: We prospectively enrolled 143 adult patients visiting one of seven participating orthopaedic surgeons at three private and one academic orthopaedic surgery offices in a large urban area. We recorded their demographics and measured ACEs (using a validated 10-item binary questionnaire that measured physical, emotional, and sexual abuse in the first 18 years of life), magnitude of physical limitations, pain intensity, symptoms of depression, catastrophic thinking, and health anxiety. There were 143 patients with a mean age of 51 years, 62 (43%) of whom were men. In addition, 112 (78%) presented with a specific diagnosis and most (n = 79 [55%]) had upper extremity symptoms. We created one logistic and three linear regression models to test whether age, gender, race, marital status, having children, level of education, work status, insurance type, comorbidities, body mass index, smoking, site of symptoms, type of diagnosis, symptoms of depression, catastrophic thinking, and health anxiety were independently associated with (1) the magnitude of limitations; (2) pain intensity; (3) ACE scores on the continuum; and (4) ACE scores categorized (< 3 or ≥ 3). We calculated a priori that to detect a medium effect size with 90% statistical power and α set at 0.05, a sample of 136 patients was needed for a regression with five predictors if ACEs would account for ≥ 5% of the variability in physical function, and our complete model would account for 15% of the overall variability. To account for 5% incomplete responses, we enrolled 143 patients. RESULTS: We found no association between ACE scores and the magnitude of physical limitations measured by Patient-Reported Outcomes Measurement Information System Physical Function (p = 0.67; adjusted R = 0.55). ACE scores were not independently associated with pain intensity (Pearson correlation [r] = 0.11; p = 0.18). Greater ACE scores were independently associated with diagnosed mental comorbidities both when analyzed on the continuum (regression coefficient [ß] = 1.1; 95% confidence interval [CI], 0.32-1.9; standard error [SE] 0.41; p = 0.006) and categorized (odds ratio [OR], 3.3; 95% CI, 1.2-9.2; SE 1.7; p = 0.024), but not with greater levels of health anxiety (OR, 1.1; 95% CI, 0.90-1.3; SE 0.096; p = 0.44, C statistic = 0.71), symptoms of depression (ACE < 3 mean ± SD = 0.73 ± 1.4; ACE ≥ 3 = 1.0 ± 1.4; p = 0.29) or catastrophic thinking (ACE < 3 = 3.6 ± 3.5; ACE ≥ 3 = 4.9 ± 5.1; p = 0.88). CONCLUSIONS: ACEs may not contribute to greater pain intensity or magnitude of physical limitations unless they are accompanied by greater health anxiety or less effective coping strategies. Adverse events can contribute to anxiety and depression, but perhaps they sometimes lead to development of resilience and effective coping strategies. Future research might address whether ACEs affect symptoms and limitations in younger adult patients and patients with more severe musculoskeletal pathology such as major traumatic injuries. LEVEL OF EVIDENCE: Level II, prognostic study.

Arthroscopic transosseous bony bankart repair.

Restoration of glenoid bony integrity is critical to minimizing the risk of recurrence and re-creating normal kinematics in the setting of anterior glenohumeral instability. We present an arthroscopic suture anchor-based technique for treating large bony Bankart fractures in which the fragment is secured to the intact glenoid using mattress sutures placed through the bony fragment and augmented with soft-tissue repair proximal and distal to the bony lesion. This straightforward technique has led to excellent fragment reduction and good outcomes in our experience.

Medial malleolar screw versus tension-band plate hemiepiphysiodesis for ankle valgus in the skeletally immature.

BACKGROUND: Ankle valgus is frequently encountered in skeletally immature patients in association with a variety of musculoskeletal disorders. Guided growth with temporary medial malleolar transphyseal screw (MMS) hemiepiphysiodesis is an established surgical treatment capable of correcting the angular deformity, but is often complicated by symptomatic screw head prominence and difficult hardware removal. Tension-band plate (TBP) hemiepiphysiodesis has recently been advocated as an alternative; however, the relative efficacy of these 2 techniques has not been directly investigated. Thus, the purpose of this study was to compare MMS and TBP in treatment of pediatric ankle valgus deformity. METHODS: Medical records and radiographs of all patients undergoing distal tibial medial hemiepiphysiodesis for ankle valgus between January 1, 2005 and November 1, 2010 at a pediatric orthopaedic specialty hospital were retrospectively reviewed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured. Patient age, sex, underlying diagnosis, concurrent surgical procedures, surgical and postoperative complications, and the presence or absence of symptomatic hardware complaints were documented. RESULTS: Sixty ankles in 42 patients met the inclusion criteria, with adequate radiographs and minimum postoperative follow-up of 12 months (mean: 34 mo). Thirty-five ankles were treated with MMS, and 25 with TBP. Good mean correction of the tibiotalar angle was achieved in both groups (MMS: pre-77.1 degrees to post-87.8 degrees over 25.2 mo; TBP: pre-81.3 to post-87.6 over 20.0 mo). The mean rate of correction was faster in ankles treated with MMS than TBP, but differences did not reach statistical significance (0.55 vs. 0.36 degrees/mo, respectively; P=0.057). Complications included 6 hardware-related surgical complications in MMS ankles (17.1%) and 1 in TBP ankles (4.0%). The incidence of symptomatic hardware complaints was low in both groups (MMS, 5.7%; TBP, 0%). CONCLUSIONS: Both MMS and TBP techniques can result in successful correction of ankle valgus in the growing child. Although the rate of deformity correction may be faster with MMS, TBP seems to be associated with fewer hardware-related complications. This information may aid the clinician in selecting the surgical option most appropriate for each individual patient. LEVEL OF EVIDENCE: Level II-retrospective study.

Correction and recurrence of ankle valgus in skeletally immature patients with multiple hereditary exostoses.

BACKGROUND: Ankle valgus is encountered in children with a variety of congenital musculoskeletal disorders, including multiple hereditary exostoses (MHE). Guided growth with temporary distal tibial medial hemiepiphysiodesis (DTMH) may correct the deformity; however, exostoses about the ankle commonly observed in MHE patients may hinder correction and increase the risk of recurrence. Thus, the purpose of this study was to review the outcomes of DTMH in treatment of ankle valgus in MHE versus other diagnosis (non-MHE). METHODS: Medical records and radiographs of patients undergoing DTMH for ankle valgus between January 1, 2005, and November 1, 2010, at a single pediatric orthopedic hospital were retrospectively analyzed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured. RESULTS: Fifty-eight ankles in 41 patients met inclusion criteria, with minimum follow-up of 12 months (mean, 34 months). Mean age was 10 years (range, 4-14 years). MHE was the most common underlying diagnosis (19 ankles, 33%). The rate of tibiotalar angle correction (mean ± standard deviation) with hardware in place was 0.37 ± 0.28 deg/mo in MHE ankles and 0.51 ± 0.42 deg/mo in non-MHE ankles (P = .161). Following hardware removal, the rate of recurrence was faster in MHE (0.29 ± 0.25 deg/mo) compared with non-MHE ankles (0.12 ± 0.19 deg/mo) (P = .059), and more total recurrent valgus deformity was observed in MHE (7.8 ± 8.2 degrees) than non-MHE ankles (3.4 ± 4.6 degrees) (P = .08) over a similar follow-up period (mean 23.4 vs 23.6 months, respectively), with differences approaching statistical significance. CONCLUSION: MHE is a common cause of ankle valgus in children. Guided growth interventions in this population can be successful but require special consideration given the potential for relatively gradual deformity correction and rapid recurrence following hardware removal in the skeletally immature. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Marrow stimulation improves meniscal healing at early endpoints in a rabbit meniscal injury model.

PURPOSE: To critically evaluate the effect of marrow stimulation (MS) on the extent of healing and the local biological environment after meniscal injury in ligamentously stable knees in a rabbit model. METHODS: A reproducible 1.5-mm cylindrical defect was created in the avascular portion of the anterior horn of the medial meniscus bilaterally in 18 New Zealand White rabbits (36 knees). In right knees (MS knees), a 2.4-mm Steinman pin was drilled into the apex of the femoral intercondylar notch and marrow contents were observed spilling into the joint. Left knees served as controls. Rabbits were killed in 3 groups (n = 6 rabbits each) at 1, 4, and 12 weeks with meniscal harvest and blinded histomorphometric and histologic evaluation using an established 3-component tissue quality score (range, 0 to 6). One-week specimens were also evaluated for the presence of proregenerative cytokines using immunohistochemistry. RESULTS: The mean proportion of the avascular zone defect bridged by reparative tissue was greater in MS knees than in controls at each endpoint (1 week, 55% v 30%, P = .02; 4 weeks, 71% v 53%, P = .047; 12 weeks, 96% v 77%, P = .16). Similarly, there was a consistent trend toward superior tissue quality scores in knees treated with MS compared with controls (1 week, 1.8 v 0.3, P = .03; 4 weeks, 4.3 v 2.8, P = .08; 12 weeks, 5.9 v 4.5, P = .21). No statistically significant differences, however, were observed at the 12-week endpoint. Increased staining for insulin-like growth factor I, transforming growth factor-ß, and platelet-derived growth factor was observed in regenerated tissue, compared with native meniscal tissue, in all specimens at 1 week. Staining density for all growth factors was similar, however, in reparative tissue of MS and control knees. CONCLUSIONS: The results of this study suggest that marrow stimulation leads to modest improvements in quality and quantity of reparative tissue bridging a meniscal defect, particularly during the early recovery period. CLINICAL RELEVANCE: Clinical evaluation of marrow stimulation techniques designed to enhance healing in isolated meniscus repair surgery may be indicated.

Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study.

PURPOSE: To evaluate knee stability after anterior cruciate ligament (ACL) reconstruction using 2 modern clinically relevant single-bundle constructs. METHODS: Two arthroscopic ACL reconstructions were performed on 6 fresh-frozen human cadaveric knees using bone-patellar tendon-bone autografts. The tibial tunnel was centered in the anatomic tibial footprint. The femoral tunnel was reamed through the anteromedial (AM) portal and centered alternately in either the AM portion of the femoral footprint (center-AM) or the center of the femoral footprint (center-center). Two external loading conditions were applied: (1) a 134-N anterior tibial load and (2) a 10-Nm valgus load combined with a 5-Nm internal tibial torque. Resulting kinematics were determined under 4 conditions: (1) ACL intact, (2) ACL deficient, (3) center-AM reconstruction, and (4) center-center reconstruction. RESULTS: In response to anterior tibial loading, anterior translation was similar in the ACL-intact knee and the 2 reconstructions at 0° to 60° of flexion but was greater in the reconstructed specimens at 90°. In response to the complex rotatory load, internal tibial rotation (ITR) at 30° of flexion was slightly greater in center-AM knees compared with ACL-intact knees (11.0° ± 0.6° v 10.5° ± 0.6°, P = .03). At other angles tested, ITR in both reconstructions was similar to the ACL-intact knee (P > .05). When we compared the 2 reconstruction alternatives, however, center-center knees exhibited greater resistance to ITR at all angles (P < .05). CONCLUSION: Anatomic single-bundle ACL reconstruction performed with the femoral tunnel placed through the AM portal restores translational and rotational knee stability to an extent that closely approximates the ACL-intact condition. When compared with the AM femoral tunnel position, a femoral tunnel positioned in the anatomic center of the femoral origin of the ACL may further improve rotatory stability without sacrificing anterior stability. CLINICAL RELEVANCE: This study provides additional biomechanical evidence in support of anatomic single-bundle ACL reconstruction with tunnels positioned in the center of the femoral and tibial footprints.

Implantation of allogenic synovial stem cells promotes meniscal regeneration in a rabbit meniscal defect model.

BACKGROUND: Indications for surgical meniscal repair are limited, and failure rates remain high. Thus, new ways to augment repair and stimulate meniscal regeneration are needed. Mesenchymal stem cells are multipotent cells present in mature individuals and accessible from peripheral connective tissue sites, including synovium. The purpose of this study was to quantitatively evaluate the effect of implantation of synovial tissue-derived mesenchymal stem cells on meniscal regeneration in a rabbit model of partial meniscectomy. METHODS: Synovial mesenchymal stem cells were harvested from the knee of one New Zealand White rabbit, expanded in culture, and labeled with a fluorescent marker. A reproducible 1.5-mm cylindrical defect was created in the avascular portion of the anterior horn of the medial meniscus bilaterally in fifteen additional rabbits. Allogenic synovial mesenchymal stem cells suspended in phosphate-buffered saline solution were implanted into the right knees, and phosphate-buffered saline solution alone was placed in the left knees. Meniscal regeneration was evaluated histologically at four, twelve, and twenty-four weeks for (1) quantity and (2) quality (with use of an established three-component scoring system). A similar procedure was performed in four additional rabbits with use of green fluorescent protein-positive synovial mesenchymal stem cells for the purpose of tracking progeny following implantation. RESULTS: The quantity of regenerated tissue in the group that had implantation of synovial mesenchymal stem cells was greater at all end points, reaching significance at four and twelve weeks (p < 0.05). Tissue quality scores were also superior in knees treated with mesenchymal stem cells compared with controls at all end points, achieving significance at twelve and twenty-four weeks (3.8 versus 2.8 at four weeks [p = 0.29], 5.7 versus 1.7 at twelve weeks [p = 0.008], and 6.0 versus 3.9 at twenty-four weeks [p = 0.021]). Implanted cells adhered to meniscal defects and were observed in the regenerated tissue, where they differentiated into type-I and II collagen-expressing cells, at up to twenty-four weeks. CONCLUSIONS: Synovial mesenchymal stem cells adhere to sites of meniscal injury, differentiate into cells resembling meniscal fibrochondrocytes, and enhance both quality and quantity of meniscal regeneration.

Does greater knee flexion increase patient function and satisfaction after total knee arthroplasty?

The purpose of this study was to determine whether high flexion leads to improved benefits in patient satisfaction, perception, and function after total knee arthroplasty (TKA). Data were collected on 122 primary TKAs. Patients completed a Total Knee Function Questionnaire. Knees were classified as low (≤ 110°), mid (111°-130°), or high flexion (>130°). Correlation between knee flexion and satisfaction was not statistically significant. Increased knee flexion had a significant positive association with achievement of expectations, restoration of a "normal" knee, and functional improvement. In conclusion, although the degree of postoperative knee flexion did not affect patient satisfaction, it did influence fulfillment of expectations, functional ability, and knee perception. This suggests that increased knee flexion, particularly more than 130°, may lead to improved outcomes after TKA.