Development and Persistence of Suspected Neuropathic Pain After Total Knee Arthroplasty in Individuals With Osteoarthritis

Prevalence and patterns of neuropathic pain in people with chronic post-surgical pain after total knee arthroplasty

Aims

The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

Methods

Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey.

Results

Symptoms of neuropathic pain were common among patients reporting chronic pain at three months post-TKA, with half reporting neuropathic pain on painDETECT (191/363; 53%) and 74% (267/359) on DN4. Of those with neuropathic pain at three months, half continued to have symptoms over the next 12 months (148/262; 56%), one-quarter had improved (67/262; 26%), and for one-tenth their neuropathic symptoms fluctuated over time (24/262; 9%). However, a subgroup of participants reported new, late onset neuropathic symptoms (23/262; 9%). Prevalence of neuropathic symptoms was similar between the screening tools when the lower cut-off painDETECT score (≥ 13) was applied. Overall, mean neuropathic pain scores improved between three and 15 months after TKA.

Conclusion

Neuropathic pain is common in patients with chronic pain at three months after TKA. Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. Postoperative care should include screening, assessment, and treatment of neuropathic pain in patients with early chronic postoperative pain after TKA.

Neuropathic pain in patients with osteoarthritis of the hip before and after total hip arthroplasty

OBJECTIVES

The pain associated with osteoarthritis (OA) was thought to be nociceptive; however, neuropathic pain is also observed. We investigated the relationship between hip OA and neuropathic pain using the PainDETECT questionnaire (PDQ).

METHODS

A total of 159 hips of 146 consecutive patients who underwent total hip arthroplasty (THA) with a diagnosis of OA were enrolled in this study. The prevalence of each pain phenotype was evaluated preoperatively and at 6 months postoperatively using the PDQ. Patient characteristics and numerical rating scale (NRS) scores were compared between a group with possible neuropathic pain (NP group) and a group with nociceptive pain (non-NP group).

RESULTS

Before THA, neuropathic, unclear, and nociceptive pain was observed in 18, 36, and 105 hips, respectively. The prevalence in the NP group was 54 hips, accounting for approximately one-third of all hips, which decreased significantly to seven hips after THA. A significantly higher NRS score was observed in the NP group, both before and after THA.

CONCLUSION

Approximately one-third of the patients with hip OA had neuropathic pain. Therefore, neuropathic pain should be considered when treating patients with hip OA.

Prevalence and interference of neuropathic pain in the quality of life in patients with knee osteoarthritis

OBJECTIVE

With the aging of the population, more patients have complained of pain due to knee Osteoarthritis (OA), and the number of arthroplasties has also increased. The objective of this study is to evaluate the prevalence of the neuropathic pain component in candidates for Total Knee Replacement and the effects of this component on their quality of life.

METHODS

In this cross-sectional study, patients with OA candidates for knee arthroplasty in the present institution were evaluated using the pain detection questionnaire and the Visual Analog Pain (VAS) scale to measure the pain index and the presence of associated neuropathic pain. In addition, evaluation of the quality of life and functionality using the EQ5D and SF12 questionnaires and their relationship with cases of neuropathic pain were performed.

RESULTS

One hundred twenty-six patients were evaluated, and 71.4 % were female. The age ranged from 46 to 85 years, and about 70 % of the patients had some associated clinical comorbidity. Neuropathic pain was present in 28.6 % of the patients evaluated. Patients with neuropathic pain presented worse results in the VAS evaluation, in the care, pain, and anxiety domains of the EQ5D, and in the physical and mental scores of the SF12.

CONCLUSION

Neuropathic pain was present in 28.6 % of the patients with knee OA who are candidates for arthroplasty. Patients with associated neuropathic pain present a higher level of pain and worse quality of life scores. Recognizing this type of pathology is extremely important in fully monitoring gonarthrosis.

Effect of medial opening wedge distal tibial tuberosity osteotomy on possible neuropathic pain in patients with osteoarthritis of the knee

BACKGROUND

There is a paucity of literature regarding the changes and features of neuropathic pain (NP) in knee osteoarthritis (OA) following medial opening wedge distal tibial tuberosity osteotomy (OWDTO). This study aimed to investigate the effect of OWDTO on NP in knee OA; we hypothesized that OWDTO improves knee symptoms and functions and also meets patient satisfaction in those with knee OA with possible NP or without NP.

METHODS

Fifty-two consecutive patients who underwent OWDTO were categorized into the unlikely NP and possible NP groups using the painDETECT questionnaire. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) score and the Knee Society Score 2011 (KSS 2011) were compared between the groups preoperatively and at the 1-year follow-up.

RESULTS

The number of patients having possible NP significantly decreased from 12 (23.1%) preoperatively to one (1.9%) postoperatively (p < 0.001). The patient with postoperative possible NP also had possible NP preoperatively. All preoperative sub-scores of WOMAC were significantly higher in the possible NP group than in the unlikely NP group (p = 0.018, 0.013, 0.004, and 0.005, respectively); however, the postoperative scores did not differ between the two groups. Regarding the KSS 2011, the preoperative scores for symptom and functional activities were significantly lower in the possible NP group than in the unlikely NP group (p = 0.031 and 0.024, respectively).

CONCLUSIONS

OWDTO is an effective surgery for patients with possible NP; it improves symptoms and knee function as well as meets patient satisfaction.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Evaluation of disease burden, patient journey, unmet diagnosis and treatment needs of patients with HIP and knee osteoarthritis in Turkey: A study through Delphi Methodology

Objective

To get information-driven insights from expert physicians regarding multiple aspects of the patient journey in knee and hip OA and establish a consensus for future studies and decision tree models in Turkey.

Design

157 questions were asked in total during this three-round modified Delphi-method panel to 10 physical medicine and rehabilitation specialists (2 have rheumatology and 3 have algology subspeciality), one orthopaedic surgeon and one algology specialist from anaesthesia specialty background. A consensus was achieved when 80% of the panel members agreed with an item. Contradictions between different disciplines were accepted as a non-consensus factor.

Results

Panellists agreed that American College of Rheumatology classification criteria is mostly sufficient to provide an OA diagnosis in clinical practice, OA patients with ≥5 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain or physical function score can be defined as moderate-to-severe OA if they have an additional ≥2 Kellgren-Lawrence (KL) score, a minimum improvement of 30% from baseline in WOMAC pain or function subscales or in PGA score can be accepted as moderate treatment response where ≥50% improvement from baseline in those scores as substantial response. Panellists stated that arthroplasty procedures need to be delayed as long as possible, but this delay should not jeopardize a beneficial and successful operation.

Conclusions

These findings show that there is a significant disease burden, unmet treatment needs for patients with moderate-to-severe OA in Turkey from experts' perspective. Therefore, an updated systematic approach and decision tree models are needed to be implemented.

Presence of Night Pain, Neuropathic Pain, or Depressive Disorder Does Not Adversely Affect Outcomes After Total Knee Arthroplasty: A Prospective Cohort Study

BACKGROUND

A considerable proportion of patients warranting total knee arthroplasty (TKA) have night pain, neuropathic pain, and/or depressive disorder, which may not be resolved by TKA. This prospective, longitudinal cohort study aimed to document the prevalence of night pain, neuropathic pain, and depressive disorder in patients with advanced knee osteoarthritis undergoing TKA and to determine whether the specific coexisting pain and/or disorder at the time of TKA adversely affected postoperative outcomes.

METHODS

In this study, 148 patients undergoing TKA were longitudinally evaluated. The presence of night pain, neuropathic pain (determined using Douleur Neuropathique 4 [DN4]) and depressive disorder (determined using the Patient Health Questionnaire-9 [PHQ-9]) was determined before and 6 weeks, 3 months and 1 year after TKA. In addition, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol-5 Dimension (EQ-5D) scores were assessed before and 1 year after TKA. Potential associations of night pain, neuropathic pain, and/or depressive disorder with pre- and postoperative WOMAC and EQ-5D scores were examined in subgroup analyses.

RESULTS

Preoperatively, 72% (n = 106) of patients reported night pain, and the prevalences of neuropathic pain and depressive disorder were 15% and 17%, respectively. Preoperatively, compared with patients without night pain, those with night pain had significantly poorer preoperative WOMAC scores, but no significant difference was seen between groups 1 year after TKA. Preoperatively, the WOMAC, EQ-5D, and EQ-5D health scores of patients with neuropathic pain were not significantly different from those of patients without neuropathic pain, and there was no difference in clinical outcome scores 1 year after TKA between these groups. Preoperatively, the patients with depressive disorder showed significantly poorer preoperative WOMAC, EQ-5D, and EQ-5D health scores than those without depressive disorder, but no significant differences in scores were observed 1 year after TKA between these groups.

CONCLUSION

This study revealed a considerable prevalence of night pain, neuropathic pain, and depressive disorder in patients undergoing TKA and that patients with these specific conditions reported poorer functional and quality of life scores preoperatively. However, such adverse effects disappeared after TKA. Our study findings suggest that TKA can provide satisfactory outcomes for patients with these specific conditions.

Individualized multidisciplinary analgesia to prevent persistent postsurgical pain

PURPOSE OF REVIEW

Persistent postsurgical pain as outcome of surgery has reached more attention in the past years. In the first place because of related disability, long-term use of (opioid)analgesics and impact on the quality of life of individual patients. In addition, the individual and societal socio-economic burden of PPSP is high and increasing in the light of increasing numbers of surgery world-wide.

RECENT FINDINGS

Actual studies identified risk factors for persistent postsurgical pain in relevant patient populations. Astonishingly, most of predicting factors seem unrelated to surgery.

SUMMARY

Future perioperative practice will have to focus on identifying patients at risk for PPSP before surgery and develop/offer suitable individually tailored preventive interventions.

High Prevalence of Pain Sensitization in Knee Osteoarthritis: A Meta-Analysis with Meta-Regression

OBJECTIVE

The aim of this meta-analysis was to study the evidence on pain sensitization in knee osteoarthritis (OA), providing a quantitative synthesis of its prevalence and impact. Factors associated with pain sensitization were also investigated.

METHODS

Meta-analysis; PubMed (MEDLINE), Cochrane Central Register (CENTRAL), and Web of Science were searched on February 2021. Level I to level IV studies evaluating the presence of pain sensitization in patients with symptomatic knee OA, documented through a validated method (questionnaires or quantitative sensory testing), were included. The primary outcome was the prevalence of pain sensitization. Factors influencing the prevalence were also evaluated, as well as differences in terms of pain thresholds between knee OA patients and healthy controls.

RESULTS

Fifty-three articles including 7,117 patients were included. The meta-analysis of proportion documented a prevalence of pain sensitization of 20% (95% confidence interval [CI] = 16%-26%) with a significant heterogeneity of results (I² = 89%, P < 0.001). The diagnostic tool used was the main factor influencing the documented prevalence of pain sensitization (P = 0.01). Knee OA patients presented higher pain sensitivity compared with healthy controls, both in terms of local pressure pain threshold (standardized mean difference [SMD] = -1.00, 95% CI = -1.67 to -0.32, P = 0.007) and distant pressure pain threshold (SMD = -0.54, 95% CI = -0.76 to -0.31, P < 0.001).

CONCLUSIONS

Knee OA pain presents features that are consistent with a significant degree of pain sensitization. There is a high heterogeneity in the reported results, mainly based on the diagnostic tool used. The identification of the best methods to detect pain sensitization is warranted to correctly evaluate and manage symptoms of patients affected by knee OA.

REGISTRATION

PROSPERO CRD42019123347.

A randomized, controlled trial on the effect of anesthesia on chronic pain after total knee arthroplasty

Aim: The study sought to evaluate the influence of anesthesia on chronic pain after total knee arthroplasty (TKA). Methods: This was a single-center, randomized controlled study, with patients receiving a spinal anesthetic (SP) alone or a general anesthetic (GA) with femoral block, with follow-up at 3 and at 6 months. The primary outcome was the WOMAC^® score at 6 months. Results: 199 patients were enrolled. Group SP had better function (WOMAC: GA: 16.9 vs SP: 14.4, p = 0.015) and less pain (WOMAC pain: GA: 3.04 vs SP: 2.69, p = 0.02) at 3 months, but not at 6 months. Overall, 11% of patients had chronic postsurgical pain (CPSP), with Group GA having a higher incidence of CPSP at 6 months. Neuropathic pain increased during the follow-up and was more common in patients with CPSP. Conclusion: An SP reduces pain and incidence of CPSP after TKA. Clinical Trial Registration: NCT04206046 (ClinicalTrials.gov).

Does the Presence of Neuropathic Pain Influence the Response to Hyaluronic Acid in Patients with Knee Osteoarthritis?

OBJECTIVES

Up to 50% of patients with symptomatic knee osteoarthritis (OA) present with neuropathic pain (NP) features. We assessed the impact of NP according to DN4 (Douleurs Neuropathiques 4 questions) score on the response to intra-articular (IA) hyaluronic acid (HA) injections and the effects of HA injections on NP.

MATERIALS AND METHODS

We conducted a post hoc analysis from a multicenter, randomized, double-blind, noninferiority trial comparing the efficacy of 2 HA in symptomatic knee OA at 24 weeks. At baseline, demographic, anthropometric, radiologic data, and symptoms were recorded. The symptomatic effect of HA was assessed by VAS pain, patient global assessment (PGA), WOMAC, DN4, and OMERACT-OARSI response.

RESULTS

A total of 187 patients were included. NP according to DN4 score was present in 20 patients (10.7%) at baseline. Most common positive DN4 items were tingling (36.9%) and burning (36.4%). NP was associated with WOMAC pain score (P = 0.02). The presence of NP at baseline did not affect the symptomatic improvement after HA injections according to the VAS pain (P = 0.71), PGA (P = 050), WOMAC pain (P = 0.89), WOMAC function (P = 0.52), and rate of OMERACT-OARSI responders (P = 0.21). The prevalence of patients with NP decreased by 50% (n = 10) at 24 weeks after HA injections. Most improved DN4 items were itching (90%), hypoesthesia to pinprick (88%), and burning (50%).

CONCLUSION

In our study, NP was associated with pain severity, but did not influence the response to IA HA. On the other hand, HA injections reduced some NP features, especially itching, sting hypoesthesia, and burning.

Possible Neuropathic Pain in Patients with Osteoarthritis of the Knee Before and After Total Knee Arthroplasty

Purpose

Although the pain of osteoarthritis (OA) is traditionally considered to be nociceptive, some patients also have neuropathic pain. The objective of this study was to evaluate the presence of neuropathic pain in the knees of OA patients using the painDETECT questionnaire (PDQ).

Methods

A total of 180 knees in 158 consecutive patients who underwent total knee arthroplasty (TKA) were enrolled prospectively. The prevalence of neuropathic pain, unclear pain, and nociceptive pain in the knee was determined before and after TKA using a numerical rating scale (NRS). All patients were evaluated preoperatively and 6 months postoperatively. Neuropathic pain and unclear pain were grouped together as possible neuropathic pain. The relationship between possible neuropathic pain and pain intensity was evaluated.

Results

Before TKA, neuropathic pain and unclear pain were found in 10 and 30 knees, respectively. The remaining 140 knees were categorized as nociceptive pain. After TKA, the numbers of knees with neuropathic and unclear pain decreased to one and five, respectively. The prevalence of possible neuropathic pain decreased significantly from 22.2% to 3.3% after surgery. Among the six knees with possible neuropathic pain postoperatively, four had possible neuropathic pain preoperatively as well, while the remaining two patients had been classified as nociceptive pain preoperatively. Knees with possible neuropathic pain postoperatively had higher postoperative NRS scores than those with nociceptive pain.

Conclusion

Although the prevalence of possible neuropathic pain decreased significantly after TKA, the preoperative presence of possible neuropathic pain might be associated with the development of persistent postoperative pain following TKA.

The Canine Postamputation Pain (CAMPPAIN) initiative: a retrospective study and development of a diagnostic scale

OBJECTIVE

To develop a scale to diagnose and assess the severity of postamputation pain (PAP) in dogs.

STUDY DESIGN

Single-center retrospective study.

ANIMALS

A total of 66 dogs that underwent thoracic or pelvic limb amputation and 139 dogs that underwent tibial plateau leveling osteotomy (TPLO) at a veterinary teaching hospital.

METHODS

An online survey regarding postoperative behavioral changes was sent to owners. Categorical, multiple-choice responses were entered into a univariable logistic regression model and tested for association with amputation using the Wald test. If p < 0.2, variables were forwarded to a multivariable logistic regression model for manual build. Model simplicity and predictive ability were optimized using the area under the receiver operating curve (AUROC) characteristic, and model calibration was assessed using the Hosmer-Lemeshow test. The selected model was converted to an integer scale (0-10), the Canine Postamputation Pain (CAMPPAIN) scale. Univariable logistic regression related each dog's calculated score to the probability of PAP.

RESULTS

Multivariable logistic regression identified four independent predictors of PAP (p < 0.05): 1) restlessness or difficulty sleeping, 2) episodes of panic or anxiety, 3) sudden vocalization, and 4) compulsive grooming of the residual limb. Score AUROC was 0.70 (95% confidence interval = 0.63-0.78) with good calibration (Hosmer-Lemeshow statistic p = 0.82). A score of 2 corresponded to a risk probability of 0.5. Taking a score ≥ 2 to indicate PAP, score specificity and sensitivity were 92.1% and 36.4%, respectively. When this score was used to diagnose PAP, prevalence was 36.4% (24/66) and 7.9% (11/139) in the amputation and TPLO groups, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Postamputation pain is characterized by specific postoperative behaviors and appears to affect approximately one-third of canine amputees. The CAMPPAIN scale generated from these data could facilitate diagnosis, treatment and further study of PAP but requires external validation.

PROMIS Neuropathic and Nociceptive Pain Quality in Musculoskeletal Pain Presentations

OBJECTIVE

Musculoskeletal pain is a significant contributor to the global disease burden. Management of musculoskeletal pain where a neuropathic component is present can be challenging. This study evaluated the internal structure of the Patient-Reported Outcome Measures Information System (PROMIS) pain quality scales, explored the prevalence of neuropathic and nociceptive pain, and identified health demographics and behaviors related to musculoskeletal pain presentations.

METHODS

Patients presenting to the Victoria University Osteopathy Clinic (Melbourne, Vic., Australia) were invited to complete a health demographics and behaviors questionnaire, and the PROMIS Neuropathic (NeuroPQ) and Nociceptive (NociPQ) pain quality scales, before their initial consultation. Descriptive, inferential, and correlation statistics were used to evaluate the PROMIS scales, health demographics, and behaviors. Mokken scale analysis was used to evaluate the internal structure and dimensionality of the NeuroPQ and NociPQ scales.

RESULTS

Three hundred eighty-three (N=383) patients completed the measures. Mokken scaling suggested the PROMIS scales demonstrated acceptable internal structure and were unidimensional. Over 22% of patients demonstrated cutoff scores above 50, suggesting a substantive neuropathic pain component to their musculoskeletal presentation. Patients who reported cigarette smoking, not being born in Australia or not speaking English at home, demonstrated higher NeuroPQ scores. Females demonstrated significantly higher NociPQ scores than males. Pain intensity demonstrated small to medium correlations with NeuroPQ and NociPQ scores.

DISCUSSION

This study provides support for the use of the NeuroPQ and NociPQ scales in musculoskeletal pain patients. Associations with health demographics and behaviors were identified, and patients typically experienced a combination of neuropathic and nociceptive pain.

Systematic review and meta-analysis of the prevalence of neuropathic-like pain and/or pain sensitization in people with knee and hip osteoarthritis

OBJECTIVE

To determine the prevalence of neuropathic-like pain (NP) and pain sensitization (PS) defined by self-report questionnaires in knee and hip osteoarthritis, and whether prevalence is potentially explained by disease-severity or affected joint.

DESIGN

MEDLINE, EMBASE, CINAHL were systematically searched (1990-April 2020) for studies describing the prevalence of NP and PS in knee and hip osteoarthritis using self-report questionnaires. Random-effects meta-analysis was performed. Statistical heterogeneity between studies and sub-groups (affected joint and population source as a proxy for disease severity) was assessed (I² statistic and the Chi-squared test).

RESULTS

From 2,706 non-duplicated references, 39 studies were included (2011-2020). Thirty-six studies reported on knee pain and six on hip pain. For knee osteoarthritis, the pooled prevalence of NP was: using PainDETECT, possible NP(score ≥13) 40% (95%CI 32-48%); probable NP(score >18) 20% (95%CI 15-24%); using Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, 32% (95%CI 26-38%); using Douleur Neuropathique (DN4) 41% (95% CI 24-59%). The prevalence of PS using Central Sensitization Inventory (CSI) was 36% (95% CI 12-59%). For hip osteoarthritis, the pooled prevalence of NP was: using PainDETECT, possible NP 29% (95%CI 22-37%%); probable NP 9% (95%CI 6-13%); using DN4 22% (95%CI 12-31%) in one study. The prevalence of possible NP pain was higher at the knee (40%) than the hip (29%) (difference 11% (95% CI 0-22%), P = 0.05).

CONCLUSIONS

Using self-report questionnaire tools, NP was more prevalent in knee than hip osteoarthritis. The prevalence of NP in knee and hip osteoarthritis were similar for each joint regardless of study population source or tool used. Whether defining NP using self-report questionnaires enables more effective targeted therapy in osteoarthritis requires investigation.

Prevalence of Persistent Pain of the Neuropathic Subtype after Total Hip or Knee Arthroplasty

Purpose: This study aimed to (1) estimate the point prevalence of persistent postoperative pain (PPP) identified using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) after unilateral primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using data from a registry of total joint arthroplasty (TJA) patients in Ontario, (2) estimate the effect of PPP on function, (3) estimate the prevalence of neuropathic pain (NP) features among patients with persistent pain, (4) determine participant characteristics in order to estimate the potential predictors of NP classification among individuals with persistent pain after TJA, (5) estimate the extent to which the estimates of prevalence depended on the measure used (i.e., S-LANSS vs. NP sub-scale of the Short-Form McGill Pain Questionnaire 2 [NP-SF-MPQ-2]), and (6) determine the difference in characteristics between those with and without NP. Method: This was a prospective follow-up study of a historical cohort of individuals who had undergone primary unilateral THA or TKA. Persistent pain was operationally defined as pain rated as 3 or more (out of 5) on the Oxford Pain Questionnaire 6 months or 1 year after THA or TKA. Participants with persistent pain completed the S-LANSS and the NP-SF-MPQ-2. Results: A total of 1,143 participants were identified as having had a TJA, 148 (13%) of whom had PPP. A total of 67 recipients completed the S-LANSS and the NP-SF-MPQ-2. Of these, an NP subtype was identified among 19 (28%; those with an S-LANSS score ≥ 12) to 29 (43%; those with an NP-SF-MPQ-2 score ≥ 0.91). Individuals with persistent pain of the NP subtype after TJA reported severe pain intensity and higher disability levels 1.5–3.5 years after surgery compared with those without persistent pain. Conclusions: A significant proportion of patients have persistent pain post-unilateral THA or TKA.

Functional improvement in hip pathology is related to improvement in anxiety, depression, and pain catastrophizing: an intricate link between physical and mental well-being

Background

Pain catastrophizing, anxiety, and depression are risk factors for poor functional outcomes and worse post-treatment pain that can be treated alongside physical care given to orthopedic patients. While these factors have been shown to be common in patients with hip pathology, there is limited literature that follows these conditions throughout treatment. The purpose of this study was to track psychological factors in patients with various hip pathology to determine if they improved alongside functional measures following treatment.

Methods

Patients presenting to a specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, depression, and hip function. Pre- and post-treatment assessments were undertaken: Pain Catastrophizing Scale, the Hospital Anxiety Depression Scale, the Hip Outcome Survey, and Hip Disability and Osteoarthritis Outcome Score (HOOS). Patient characteristics were recorded. A correlation analysis, using the Spearman partial correlation coefficient (r_s), was conducted to evaluate the relationship between change in psychological factors with change in functional outcomes.

Results

A total of 201 patients (78 male, 123 female) with a mean age of 53.75 ± 18.97 years were included, with diagnoses of hip dysplasia (n = 35), femoroacetabular impingement (n = 35), lateral trochanteric pain syndrome (n = 9), osteoarthrosis (n = 109), and avascular necrosis of the hip (n = 13). Statistical analysis revealed a significant negative relationship between change in function level (as measured by HOOS ADL) and change in pain catastrophizing (r_s = − 0.373, p < 0.0001), depression (r_s = − 0.363, p < 0.0001), and anxiety (r_s = − 0.264, p = 0.0002). Pain catastrophizing, depression, and anxiety improved with function. Spearman correlation coefficients also revealed that pain catastrophizing, HADS anxiety, and HADS depression improved with improvement in other patient-reported functional outcomes.

Conclusions

Patients with hip pathology often exhibit pain catastrophizing, anxiety, and depression, but improvements in hip functionality are associated with decreased severity of these psychological comorbidities. Exploring this connection demonstrates the correlation between musculoskeletal impairment and psychosocial outcomes and mental health. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04001-5.

Chronic postsurgical pain after total knee arthroplasty: A prospective cohort study in Japanese population

OBJECTIVES

To elucidate the prevalence and risk factors of chronic postsurgical pain (CPSP) after primary total knee arthroplasty (TKA) in Japanese population.

METHODS

Consecutive patients undergoing primary TKA in a Japanese tertiary hospital (211 knees) were assessed. CPSP after TKA was defined as moderate to severe pain (VAS >30 mm), either at rest or during walking, one year after surgery. Clinical and radiographic data were compared between CPSP and non-CPSP groups and multivariate logistic regression was used to identify predictors of CPSP.

RESULTS

The prevalence of CPSP was 8.8%. CPSP group showed significantly higher preoperative WOMAC subscales (pain, function and stiffness), higher rate of postoperative coronal malalignment (femorotibial angle >178° or <170°) and larger varus angle of tibial component compared with non-CPSP group. Logistic regression analysis revealed that preoperative higher WOMAC pain and postoperative coronal malalignment were independent risk factors of CPSP. In a subgroup analysis of patients with well-aligned TKA, preoperative pain VAS at rest was the only risk factor of CPSP.

CONCLUSION

Preoperative severe pain and postoperative coronal malalignment were independent risk factors of CPSP after TKA. Preoperative pain management in patients with severe pain and good coronal alignment after TKA possibly minimize the development of CPSP.

Does preoperative neuropathic-like pain and central sensitisation affect the post-operative outcome of knee joint replacement for osteoarthritis? A systematic review and meta analysis

BACKGROUND

Almost a third of those undergoing knee replacement for osteoarthritis have poor outcomes despite technically successful surgery. Preoperative neuropathic-like pain and/or pain sensitisation may increase the risk of pain following joint replacement.

OBJECTIVE

To examine whether preoperative neuropathic-like pain and pain sensitisation predicts pain, function and satisfaction following joint replacement for knee osteoarthritis.

DESIGN

Systematic review with meta-analysis.

METHODS

Medline, EMBASE and CINAHL were systematically searched until March 2020. Studies detecting neuropathic-like pain and/or sensitisation using self-report questionnaires prior to knee replacement for osteoarthritis, and relating this to post-operative outcomes were identified. Data extraction, risk of bias assessment and meta-analysis were performed, where appropriate.

RESULTS

Five manuscripts, including one preprint, examining six cohorts were included: four used painDETECT or modified painDETECT, one the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, and another the Central Sensitisation Inventory to identify preoperative characteristics. Three studies showed preoperative neuropathic-like pain or sensitisation was associated with more intense post-operative pain. All four studies examining the risk of significant pain after knee replacement suggested it was increased after >3 months. The only study examining patient satisfaction and function found reduced satisfaction, but no difference in function in those with preoperative sensitisation. Meta-analysis found the relative risk of increased pain following knee replacement in those with neuropathic-like pain (painDETECT ≥13) to be 2.05 (95% confidence intervals 1.51, 2.79).

CONCLUSION

These results provide consistent but limited evidence that self-report tools detecting neuropathic-like pain and/or pain sensitisation, predict patients at higher risk of pain following knee replacement.

How Does Preoperative Central Sensitization Affect Quality of Life Following Total Knee Arthroplasty?

BACKGROUND

Central sensitization (CS) has been recently identified as a significant risk factor for persistent pain and patient dissatisfaction following total knee arthroplasty (TKA). However, it remains unclear as to whether the preoperative CS persists after the elimination of a nociceptive pain source by TKA, or how CS affects the quality of life after TKA.

METHODS

A total of 222 consecutive patients undergoing primary TKA were enrolled in the study. All patients were preoperatively screened for CS using the Central Sensitization Inventory (CSI) and categorized into either a CS (n = 55; CSI ≥ 40) or non-CS group (n = 167; CSI < 40). CSI, pain visual analog scale (VAS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score, and satisfaction were recorded at postoperative 2 years.

RESULTS

Two years after TKA, preoperative CS remained unchanged; there was no difference between preoperative and postoperative CSI scores, and both preoperative and postoperative CSI severity levels were similar (P > .1). The CS group showed worse pain VAS, KSS, and Western Ontario and McMaster Universities Osteoarthritis Index scores than did the non-CS group (P < .01) and more patients in the CS group were dissatisfied with all activities (P < .01). However, a similar percentage of the CS group achieved the previously documented minimal clinically important difference in pain VAS and KSS, compared with the non-CS group. Multivariate regression analysis revealed that preoperative CSI scores were associated with dissatisfaction at postoperative 2 years.

CONCLUSION

Preoperative CS was persistent at 2 years after TKA. Although CS patients achieved comparable clinical improvement following TKA, CS patients had worse quality of life, functional disability, and dissatisfaction than non-CS patients.

Dorsal Root Ganglion Stimulation for the Treatment of Chronic Neuropathic Knee Pain

BACKGROUND

To elucidate the efficacy of dorsal root ganglion stimulation in the treatment of chronic neuropathic pain confined to the knee.

METHODS

Retrospective analysis of prospectively collected data of 14 consecutive patients undergoing dorsal root ganglion stimulation for chronic knee pain, in a single center. The primary outcome measure was pain reduction assessed by numeric pain rating scale score preoperatively and postoperatively. Secondary outcomes included quantification of percentage of pain area covered by stimulation, and reduction in usage of opioid medications. Responders were defined as patients that experienced a greater than or equal to 50% improvement in their preoperative pain score.

RESULTS

Fourteen patients were implanted with dorsal root ganglion stimulator electrodes; 8 had a single L3 lead implanted, 1 patient had a single L4 lead implanted, and 3 patients had 2 leads implanted (L3 and L4). Two patients had their leads explanted: 1 for non-efficacy, and 1 for repeated electrode displacement. The most common indication for surgery was type 2 complex regional pain syndrome, secondary to either trauma or postoperative chronic pain (either knee replacement or arthroscopy). Median preoperative numeric rating scale score was 8.5, median postoperative numeric rating scale score was 2 (P = 0.002, Wilcoxon signed rank test). The median improvement in pain score was 80%. All 12 patients undergoing chronic stimulation were responders. Median coverage of pain area was 85%. All but 1 patient who was on opioid medication prior to surgery had reduced the dosage of regular opioid.

CONCLUSIONS

In selected patients, dorsal root ganglion stimulation is an extremely efficacious means of treating otherwise refractory chronic knee pain.

Prevalence of Neuropathic Pain Symptoms in Foot and Ankle Patients

BACKGROUND

The management of pain in patients with foot and ankle pathology can be challenging. Cumulative data suggest that, in addition to nociceptive mechanisms, other neuropathic mechanisms can contribute to pain in a subset of people with orthopedic conditions, and can be found in 10.5% to 53% of patients with chronic pain, depending on the location of the pathology. Preoperative diagnosis of neuropathic pain (NP) can potentially change decision making and management of foot and ankle pathologies.

METHODS

We used a validated patient-reported pain questionnaire (painDETECT) as a cross-sectional study to investigate the prevalence of NP symptoms in a population of patients undergoing foot and ankle surgery. A total of 533 patients were prospectively included and completed the painDETECT questionnaire.

RESULTS

Sixty-six patients (12.4%) were classified as having a component of NP symptoms according to their painDETECT score. Current smokers (23.2%) had a significantly higher rate of developing NP symptoms than current nonsmokers (11.1%) ( P = .016). The location of the pathology and obesity had a moderate effect on the prevalence of NP symptoms. Patients with ankle-level pathology, excluding tarsal tunnel syndrome, had a marginally increased risk of having NP symptoms (15.4%) compared to patients with forefoot pathologies, excluding Morton's neuroma (7.5%, P = 0.06). Obesity also had a moderate effect on the NP risk, with 15.6% risk of NP symptoms for patients with BMI of 30 or more compared to 10% risk for patients with a BMI of less than 30 ( P = .06). Patients with NP symptoms reported significantly higher levels of current pain (7.2 vs 4.6, P < .001).

CONCLUSION

A considerable number of patients with foot and ankle problems requiring surgery had a neuropathic component of pain. Evaluation of their risk factors and level of pain may help with the diagnosis, decision making, and pain control. Further research is needed to evaluate the effect of preoperative NP on the short- and long-term results of surgeries.

LEVEL OF EVIDENCE

Level II, prospective cohort survey study.