Total Knee Arthroplasty due to Knee Osteoarthritis: Risk Factors for Persistent Postsurgical Pain

Effects of Isometric Quadriceps Muscle Exercise with Visual and Auditory Feedback at 1 Year after Total Knee Arthroplasty

OBJECTIVE

To examine the effect of isometric quadriceps exercises with visual and auditory feedback after total knee arthroplasty (TKA).

METHODS

The sample included 41 patients from our previous study who could be followed up for 1 year after TKA. Patients in the intervention group performed isometric quadriceps exercises with visual and auditory feedback using the quadriceps training machine from the 2nd to the 14th day after TKA, whereas those in the control group underwent standard postoperative rehabilitation (without visual or auditory feedback during isometric quadriceps exercises) in the hospital. Patients were evaluated for pain intensity, timed up and go test (TUG) score, 10-m gait speed, 6-minute walking distance (6MWD), and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score 1 year after TKA. Additionally, exercise habits and responses to the International Physical Activity Questionnaire (IPAQ) were investigated.

RESULTS

Pain intensity was significantly lower in the intervention group than in the control group. Greater improvements in the TUG test scores, 10-m gait speed, 6MWD, and WOMAC scores were observed in the intervention group. Walking activity, as recorded by the IPAQ, and the proportion of patients with exercise habits were significantly higher in the intervention group than in the control group.

CONCLUSIONS

These results suggest that performing isometric quadriceps exercise with visual and auditory feedback using the quadriceps training machine has good effects, such as pain reduction, physical function improvement, exercise tolerance, and increased physical activity at 1 year after TKA.

Education level has an effect on the recovery of total knee arthroplasty: a retrospective study

OBJECTIVE

This study aimed to observe the relationship between education level and outcomes after total knee arthroplasty (TKA).

METHODS

One thousand two hundred sixty four patients after TKA in our hospital from April 2016 to April 2020 were reviewed. These patients were divided into 4 groups (A who were illiterate, B who had elementary school degree, C who had junior high school degree, D who had senior high school degree or higher) by the educational level, which was blinded to the observers. The postoperative outcomes of KSS score, pain, joint extension and flexion function were observed 1 year after discharged from hospital.

RESULTS

Among 1253 patients met the inclusion criteria, the average age was 68.63 years, the average body mass was 57.73 kg. There are no distinctions among 4 groups one day after the surgery. However, the outcomes of the follow up were that, the KSS score was: 77.84 ± 10.635; 80.70 ± 8.956; 87.92 ± 8.123;91.27 ± 8.262, with significant differences (P < 0.05). The mean VAS scores were: 1.97 ± 1.60; 2.07 ± 1.66; 1.197 ± 1.5265, 1.044 ± 1.4662. Patients in Group C and D had significantly less pain than that in Group A and B (P < 0.05). The knee flexion range of motion (ROM) was: 91.21 ± 11.69°; 91.77 ± 11.95°; 102.12 ± 11.38°; 109.96 ± 10.64°, Group D performed best, with significant differences (P < 0.05). The knee extension ROM were: - 2.41 ± 4.49°; - 0.91 ± 2.82°; - 0.83 ± 2.87°; - 0.35 ± 1.60°, with significant difference between Group D and the others (P < 0.05).

CONCLUSION

Education level affects the outcomes such as VAS score, KSS score, the extension and flexion ROM of the knee after TKA. The patients with higher education level have better outcomes.

Different Prevalence of Neuropathic Pain and Risk Factors in Patients with Knee Osteoarthritis at Stages of Outpatient, Awaiting and after Total Knee Arthroplasty

Objective

Neuropathic pain (NP) plays an important role in patients with knee osteoarthritis (KOA). However, the prevalence of NP at different treatment stages including outpatient, awaiting and after total knee arthroplasty (TKA) have not been compared. The understanding of this issue and identify risk factors can help physicians develop individualized strategies to manage the pain of KOA. Therefore, the aim of the study is to investigate the prevalence and risk factors of NP at different treatment stages of KOA.

Methods

Patients diagnosed as KOA between August 2016 and August 2020 were enrolled in this cross‐sectional study and divided into three groups according to treatment stage, including outpatient stage, awaiting TKA stage (pre‐TKA) and after TKA stage (post‐TKA). A numeric rating scale (NRS) and PainDETECT questionnaire were used to evaluate nociceptive pain and NP. Patient demographics, radiological assessments using Kellgren–Lawrence (K‐L) grade, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were analyzed. Data analysis and statistics were processed using SPSS 20.0 and examined by ANOVA with/without Bonferroni correction or Kruskal–Wallis test. A chi‐square test was used to determine cross‐table data and calculate the odds ratio (OR) value.

Results

Of the 921 patients, the prevalence of possible and likely NP was 17.5% (56/320) and 2.5% (8/320) in the pre‐TKA group compared with 3.4% (8/233) and 0.4% (1/233) in the outpatient group and 1.4% (5/368) and 0.5% (2/368) in the post‐TKA group, respectively. In the pre‐TKA group, higher NRS (NRS >3; OR = 10.65, 95% CI: 3.25–34.92, P < 0.001) and WOMAC pain score (score > 10; OR = 4.88, 95% CI: 2.38–10.01, P < 0.001) conferred an increased risk of unclear pain. Age, gender, BMI and K‐L grade showed no significant differences among the unlikely, possible and likely NP groups.

Conclusion

Prevalence of NP is different at stages of out‐patient, awaiting and after TKA in patients with KOA. Patients awaiting TKA have the highest prevalence of NP compared with patients in outpatient and post‐TKA groups. In the patients waiting for TKA, higher NRS (NRS >3) and WOMAC pain scores (score > 10) are risk factors of NP.

Pain detect questionnaire and pain catastrophizing scale affect gait pattern in patients with knee osteoarthritis

Purpose

Although pain phenotype affects clinical score in patients with knee osteoarthritis (OA), little information has been available on the relationship between pain phenotype and gait analysis. The purpose was to investigate the relationship between pain phenotype and gait parameters. 

Methods

A total of 34 patients (24 females and 10 males) with end-stage medial compartmental knee OA participated. All the patients were evaluated based on pain detect questionnaire (PD-Q) and pain catastrophizing scale (PCS). They were divided into two categories: Group Low (PD-Q score ≤ 12) and Group High (PD-Q score > 12), PCS + (PCS ≥ 23) and PCS- (PCS < 23). Gait analysis was performed using three-dimensional motion analysis system. Statistical analysis was done to compare gait parameters between groups for each allocation of PD-Q or PCS, separately. 

Results

Peak vertical ground reaction forces in Group Low and High were 0.99 ± 0.054 and 0.82 ± 0.17, respectively (P = 0.015). Peak knee adduction moments in Group Low and High were 0.70 ± 0.19 and 0.39 ± 0.14, respectively (P = 0.0022). For PCS allocation, knee extension limitation during mid-stance during gait were significantly larger in PCS- (P = 0.038).

Conclusions

Patients with high PD-Q score had atypical gait pattern with smaller peak vertical ground reaction force and knee adduction moment, compared to patients with low PD-Q score. Moreover, patient with low PCS had different gait pattern in extension limitation, compared to those with high PCS. PD-Q and PCS would affect gait pattern in patients with knee OA. Level of evidence: III.

A retrospective study on patients with chronic knee pain treated with ultrasound-guided radiofrequency of the genicular nerves (RECORGEN trial)

INTRODUCTION

Radiofrequency (RF) treatment of the genicular nerves is a promising treatment for chronic osteoarthritic and persistent postsurgical knee pain (PPSP), refractory to conventional medical management.

METHODS

The RECORGEN study is a retrospective single-center cohort study of patients treated with ultrasound-guided conventional RF of the genicular nerves for chronic knee pain in Hospital Oost-Limburg, Genk from September 2017 to June 2020. Subgroup analysis based on etiology of pain (PPSP and degenerative knee pain) was performed in addition to the total study population analysis. Outcome parameters were global perceived effect (GPE), Numeric Rating Scale for pain, consumption of strong opioids, and safety of the treatment at 6 weeks and cross-sectionally at a variable time point. Treatment success was defined as GPE≥50%.

RESULTS

Sixty-eight cases were screened of which 59 (46 diagnosed with PPSP and 13 with degenerative knee pain) were included in the study. Treatment success at 6 weeks was achieved in 19 of 59 interventions (32.2%) and was similar in both groups. Seventeen responders were evaluated at follow-up. 45.1% (8/17) continued to have a positive effect at the second time point. The mean duration of effect of the RF treatment was 8.3 months. Safety analysis at 6 weeks and at the second time point showed a good safety profile of the treatment.

CONCLUSION

Conventional RF of the genicular nerves was clinically successful in more than 30% of the study population refractory to conventional medical management. Overall, the treatment was well tolerated. The mean duration of effect was 8.3 months.

Comparison of Patient Satisfaction Between Medial Pivot Prostheses and Posterior-Stabilized Prostheses in Total Knee Arthroplasty

OBJECTIVE

To compare medial pivot (MP) prostheses to two types of posterior-stabilized (PS) prostheses (NexGen and NRG) in terms of patient satisfaction, causes of dissatisfaction, and risk factors for dissatisfaction after total knee arthroplasty (TKA).

METHODS

A total of 453 patients who underwent primary TKA by one senior surgeon from August 2016 to August 2018 were investigated in a retrospective study, including 121, 219, and 113 patients in the MP, NexGen, and NRG groups, respectively. The mean age and follow-up time of patients were 70.82 ± 7.06 years and 20.64 ± 3.88 months. A survey was designed and responses were collected by telephone, WeChat, and outpatient follow up. Patient satisfaction, causes of dissatisfaction, post-TKA pain on a numeric rating scale (NRS), and range of motion (ROM) were compared among groups, and risk factors were investigated. Patient satisfaction included a five-level satisfaction rating (very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied), with five options for causes of dissatisfaction (persistent pain, limited ROM, knee instability, asthenia, and/or other factors).

RESULTS

Overall, 89.84% of patients were satisfied with the results of primary TKA. There were no significant differences among the three groups regarding the side of the operation, the length of hospitalization in days, or the average follow-up time. Patient satisfaction was similar among the MP (87.38%), NexGen (89.89%), and NRG groups (90.32%). Persistent pain after TKA was the major cause of dissatisfaction (32/40), but no difference in the frequency of this complaint was found among the groups (P = 0.663). The NRS score (P = 0.598) and the ROM (P = 0.959) of the MP group were not significantly different from those of the NexGen and NRG groups. Gender, length of hospitalization, and follow-up time were all uncorrelated with patient satisfaction, but age showed a very weak correlation with patient satisfaction (r = 0.110, P = 0.033). Moreover, the NRS score (r = 0.459, P < 0.000) and the ROM (r = -0.175, P = 0.001) were significantly correlated with patient dissatisfaction. The odds ratio of dissatisfaction was 6.37 (P < 0.000) in patients with moderate to severe pain (NRS ≥ 3) compared to patients with mild pain (NRS < 3).

CONCLUSION

Patient satisfaction and function were not found to be higher in the MP group than in the two PS groups, and persistent pain was the major cause of and an important risk factor for patient dissatisfaction.

Identification of Functioning Domains in the Presurgical Period and Their Relationships with Opioid Use and Pain Catastrophizing

OBJECTIVES

The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) is a multidimensional screening system evaluating biopsychosocial factors affecting pain and functioning. Using a military sample, the current study 1) examined the structure and domains of the PROMIS, the Defense and Veterans Pain Rating Scale 2.0 (DVPRS), and the Pain Catastrophizing Scale (PCS) within a presurgical setting and 2) examined the relationship of these variables to pre- and postsurgical opioid use.

METHODS

This cross-sectional study included 279 adult patients scheduled for surgery at the Walter Reed National Military Medical Center and a validation sample of 79 additional patients from the Naval Medical Center, San Diego. PROMIS, DVPRS, PCS, and opioid use data were collected before surgery. Exploratory factor analysis and confirmatory factor analysis identified the latent structure for the measures. A structural equation model (SEM) examined their relationship to pre- and postsurgical opioid use.

RESULTS

Two latent factors represented Psychosocial Functioning (PROMIS Depression, PROMIS Anxiety, and PROMIS Social Isolation) and Pain Impact (DVPRS, PROMIS Pain Interference, PROMIS Physical Functioning). The remaining PROMIS scales did not load onto a single factor. In the SEM, the two latent factors and PCS were significantly related to pre- and postsurgical opioid use.

CONCLUSIONS

This study highlights the utility and relative ease of using a convenient multidimensional assessment in presurgical settings. Using such an assessment can help provide targeted interventions for individuals who may be at greatest risk for negative postsurgical outcomes.

Do Sociodemographic Factors Relate to Walking Ability in Individuals Who Underwent Total Knee Arthroplasty?

BACKGROUND AND PURPOSE

Knee osteoarthritis is one of the most common health problems in older adults and total knee arthroplasty (TKA) is able to improve walking ability in these individuals. There have been few studies investigating whether sociodemographic factors influence walking ability after TKA. The aim of this study was to examine which sociodemographic factors relate to walking ability in Japanese older adults following TKA during the acute stage of recovery.

METHODS

This prospective cohort study included 388 participants, from a multicenter database, who underwent TKA. The Timed Up and Go test 2 weeks after TKA was the dependent variable. Sociodemographic factors including age, sex, body mass index, marital status, and academic qualification were independent variables. In addition, type of surgery and severity of osteoarthritis were measured as confounding variables. A hierarchical multiple regression analysis was used to predict the factors that have the greatest influence on walking ability. Models were examined with and without confounding factors.

RESULTS AND DISCUSSION

In the final regression model, older age, conventional TKA approaches, increased severity of Kellgren-Lawrence grade, and women were associated with longer Timed Up and Go time. Academic qualification and marital status were not related to walking ability.

CONCLUSIONS

Our results suggest that age, type of surgery, severity of osteoarthritis, and sex are related to Timed Up and Go time during the acute stage following TKA and need to be assessed.