Persistent pain after total knee or hip arthroplasty: differential study of prevalence, nature, and impact

Early Postoperative Results in Robotic-Arm-Assisted Total Knee Replacement versus Conventional Technique: First Latin American Experience

Early results with robotic-arm-assisted total knee arthroplasty (TKA) are encouraging; nevertheless, literature might be unrepresentative, as it comes mostly from American, European, and Asian countries. There is limited experience and no comparative clinical reports in Latin America, a region of mainly low- and middle-income countries with limited access to these promising technologies. This study aims to compare the early postoperative results of the first Latin American experience with robotic-arm-assisted TKA versus conventional TKA. A cohort study was performed, including 181 consecutive patients (195 knees) with advanced symptomatic knee osteoarthritis (OA) undergoing primary TKA between March 2016 and October 2019. The cohort included 111 consecutive patients (123 knees) undergoing conventional TKA, followed by 70 consecutive patients (72 knees) undergoing robotic-arm-assisted TKA. The same surgical team (surgeon 1 and surgeon 2) performed all procedures. Patients with previous osteotomy, posttraumatic OA, and revision components were not considered. The same anesthetic and rehabilitation protocol was followed. The investigated clinical outcomes (for the first 60 postoperative days) were: surgical tourniquet time, time to home discharge, time to ambulation, postoperative daily pain (Visual Analog Scale), opioid use, range of motion, blood loss, complications, and postoperative mechanical axis. The early clinical postoperative results of this first Latin American comparative experience of robotic-arm-assisted TKA versus conventional technique showed lower opioids requirements and faster functional recovery of ambulation in those patients operated with the robotic system; nevertheless, surgical times were higher, without differences in total postoperative complications and other clinical outcomes.

Ultrasound-guided thermal radiofrequency ablation of the genicular nerves after total knee replacement

The rate of refractory chronic pain after total knee replacement (TKR) is 20-25%, with no identifiable etiology in 6% of cases. Without an etiologic diagnosis, the surgeon is unlikely to consider revision, but pain poses a therapeutic challenge for achieving satisfaction and an acceptable quality of life. Genicular nerve radiofrequency ablation (GNRFA) was recently developed as a non-drug analgesic option. It is minimally invasive and safe, with few adverse effects, opening a new perspective for management of refractory chronic pain after TKR. LEVEL OF EVIDENCE: IV.

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life

BACKGROUND AND AIMS

Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively.

METHODS

A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain.

RESULTS

There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01).

CONCLUSIONS

Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery.

TRIAL REGISTRATION

The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Sex moderates the association between quantitative sensory testing and acute and chronic pain after total knee/hip arthroplasty

OBJECTIVES

Acute postsurgical pain (APSP) may persist over time and become chronic. Research on predictors for APSP and chronic postsurgical pain (CPSP) has produced inconsistent results. This observational study aimed to analyze psychological and psychophysical variables associated with APSP and CPSP after total knee or hip arthroplasty, and to explore the role of sex.

METHODS

Assessments were conducted before surgery, 48 h, and 3 months postsurgery, including questionnaires (sociodemographic, pain related, and psychological) and quantitative sensory testing (QST). Hierarchical linear regression models analyzed potential predictors of APSP and CPSP, and moderation analyses evaluated the role of sex.

RESULTS

The study included 63 participants undergoing total knee (34, 54%) or hip (29, 46%) arthroplasty. Thirty-one (49.2%) were female and 32 (50.8%) were male. APSP (48 h) was associated with impaired conditioned pain modulation (CPM) (β = 0.301, p = 0.019). CPSP (3 months) was associated with being female (β = 0.282, p = 0.029), longer presurgical pain duration (β = 0.353, p = 0.006), knee arthroplasty (β = -0.312, p = 0.015), higher APSP intensity (β = 373, p = 0.004), and impaired CPM (β = 0.126, p = 0.004). In multivariate analysis, these clinical variables were significant predictors of CPSP, unlike sex, and CPM (adj. R 2 = 0.349). Moderation analyses showed that wind-up ratio (WUR) was a significant predictor of APSP in men (WUR × sex: b = -1.373, p = 0.046) and CPM was a significant predictor of CPSP in women (CPM × sex: b = 1.625, p = 0.016).

CONCLUSIONS

Specific QST parameters could identify patients at risk for high-intensity APSP and CPSP, with sex as a moderator. This has important clinical implications for patient care, paving the way for developing tailored preventive pain management strategies.

Factors associated with persistent postsurgical pain after total knee or hip joint replacement: a systematic review and meta-analysis

Studies have identified demographic, clinical, psychosocial, and perioperative variables associated with persistent pain after a variety of surgeries. This study aimed to perform a systematic review and meta-analysis of factors associated with persistent pain after total knee replacement (TKR) and total hip replacement (THR) surgeries. To meet the inclusion criteria, studies were required to assess variables before or at the time of surgery, include a persistent postsurgical pain (PPSP) outcome measure at least 2 months after a TKR or THR surgery, and include a statistical analysis of the effect of the risk factor(s) on the outcome measure. Outcomes from studies implementing univariate and multivariable statistical models were analyzed separately. Where possible, data from univariate analyses on the same factors were combined in a meta-analysis. Eighty-one studies involving 171,354 patients were included in the review. Because of the heterogeneity of assessment methods, only 44% of the studies allowed meaningful meta-analysis. In meta-analyses, state anxiety (but not trait anxiety) scores and higher depression scores on the Beck Depression Inventory were associated with an increased risk of PPSP after TKR. In the qualitative summary of multivariable analyses, higher preoperative pain scores were associated with PPSP after TKR or THR. This review systematically assessed factors associated with an increased risk of PPSP after TKR and THR and highlights current knowledge gaps that can be addressed by future research.

Total Elbow Arthroplasty from Indian Perspective: A Systematic Review

Background

Total elbow arthroplasty (TEA) provides satisfactory pain relief and restores elbow range of motion and function in patients with end-stage arthritis. Due to advances in implant design and surgical techniques, the indications for surgery have expanded to include various other conditions affecting the elbow. The previous studies and systematic reviews reported satisfactory mid-term and long-term clinical outcomes after TEA with relatively stable complication and revision rates. However, there is lack of information in the literature about the results of TEA in Indian patients.

Methods

Two reviewers performed a comprehensive literature search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in three online databases-Pubmed/MEDLINE, Google scholar and the Cochrane database for clinical trials. Only original studies published in the English literature reporting outcomes of primary TEA in Indian patients were included for analysis. Using pre-defined inclusion and exclusion criteria, articles were screened and the relevant articles identified. Data were extracted with the primary objective to assess pain relief and functional outcome after TEA in Indian patients, and secondary objective to identify indications for surgery, complication rates and incidence of implant removals.

Results

A total of 212 TEAs (210 patients) from ten articles were included in this systematic review. All the TEAs were done using Baksi's semi-constrained sloppy-hinged elbow prosthesis. The most common indication of TEA was post-traumatic sequelae (124 elbows, 58.5%), followed by comminuted intra-articular fracture distal humerus (53 elbows, 25%). At a weighted mean follow-up of 7.5 years, 80.7% cases had complete pain relief. The weighted mean flexion, extension restriction, supination and pronation were 122.6°, 20.8°, 57.3°, and 48.6°; respectively. The weighted mean Mayo Elbow Performance Score was 92.1 points with excellent outcome. Overall, a total of 68 complications were reported (32%) and the implants needed to be removed in 14 elbows (6.6%) including two revisions.

Conclusions

This systematic review found that the functional outcome and pain relief obtained with TEA using Baksi's sloppy-hinged prosthesis in Indian patients were satisfactory overall. The complication rates and implant removal rates were lower than those reported with other patient populations.

Relationship between Postoperative Pain and Sociocultural Level in Major Orthopedic Surgery

Background

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are associated with moderate to severe postoperative pain (POP). POP is theoretically predictable and may be influenced by sociocultural differences. This study aimed to identify the relationship between POP and the sociocultural level of the patient undergoing THA or TKA.

Methods

Prospective study, involving informed-consenting adults conducted through consulting patient's clinical processes, preoperative and postoperative questionnaires. Demographic and anthropometric data, type of surgery, ASA classification, sociocultural level of the patient, and POP were assessed.

Results

95 patients, all Caucasian and natural from the north of the Portugal, were included. Younger women undergoing TKA reported higher levels of POP. In females, the ASA 3 physical condition was also associated with higher mean pain intensity. Patients with preoperative chronic pain, without depression diagnosis, and unsatisfied with the current profession showed higher levels of reported POP. Retirees, with lower school degree, reported higher levels of minimal pain.

Conclusions

Job satisfaction, type of surgery, body mass index, presence of chronic pain, and the absence of depression were identified as the main predictors of pain after THA or TKA.

Low-level laser acupuncture reduces postoperative pain and morphine consumption in older patients with total knee arthroplasty: A randomized placebo-controlled trial

BACKGROUND

Patients commonly develop postoperative pain after total knee arthroplasty (TKA). Acupuncture-related techniques and low-level laser therapy could be beneficial for pain management for older individuals.

OBJECTIVE

To examine the effect of low-level laser acupuncture (LA) in reducing postoperative pain, pain-related interference in daily life, morphine consumption, and morphine-related side effects in older patients with knee osteoarthritis who underwent TKA.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A single-blind randomized placebo-controlled trial was conducted. Patients (N = 82) were recruited and randomly assigned via a computer-generated list to the LA group or a placebo group. The LA group received low-level laser therapy at Sanyinjiao (SP6), Taixi (KI3), Kunlun (BL60), Fengshi (GB31), Futu (ST32) and Neiguan (PC6) after TKA, while the placebo acupuncture group received the same treatment procedure without laser energy output.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain intensity, and it was measured at baseline and hours 2, 6, 10, 24, 48 and 72 after TKA. The secondary outcomes, including relative pain, postoperative pain-related interference in daily life and morphine consumption, were measured at hours 24, 48 and 72 after TKA.

RESULTS

Generalized estimating equations revealed significant between-group differences in pain intensity (P = 0.01), and trend differences in pain intensity for the LA group starting at hours 10 to 72 (P < 0.05) and morphine consumption at hours 48 and 72 (P < 0.05). The changes in pain-related interference in daily life were significant (P < 0.05) at 72 h, with the exception of the parameters for worst pain, mood, and sleep. Nausea and vomiting side effects from morphine had significant between-group differences at hours 10 and 24 (P < 0.05).

CONCLUSION

Low-level LA gradually reduced older patients' postoperative pain intensity and morphine consumption within the first 72 h after their TKA for osteoarthritis. Low-level LA may have benefits as an adjuvant pain management technique for clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT03995446.

Opioid-Prescribing Practices Between Total Knee and Hip Arthroplasty in an Outpatient Versus Inpatient Setting

ABSTRACT

Despite trends showing increases in the utilization of outpatient (OP) ambulatory surgery centers (ASCs) and decreases in the utilization of inpatient (IP) facilities for total knee arthroplasty (TKA) and total hip arthroplasty (THA), little is known about opioid prescribing for these procedures between each setting. This study evaluated differences in opioid prescribing and consumption between OP ASC and IP settings for elective TKA and THA surgeries over a 1-year period. Data collection also included pain and satisfaction of pain control postsurgery. In an OP ASC, analysis revealed a significant decrease in pills prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. There was a significant decrease in the morphine equivalence units prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. For TKA, pain was significantly lower (p = .018) and satisfaction of pain control was significantly higher (p = .007). For THA, pain (p = .374) and satisfaction of pain control (p = .173) were similar between the settings. Benefits of performing these surgeries in an OP ASC setting are patients having similar or lower levels of pain and having similar or higher satisfaction of pain control. Patients are also prescribed and consume less opioids. This has important implications for healthcare systems.

Acute pain after total hip and knee arthroplasty does not affect chronic pain during the first postoperative year: observational cohort study of 389 patients

Chronic pain is frequently reported after total hip and knee arthroplasties (THA/TKA) in osteoarthritis (OA) patients. We investigated if severity of acute postoperative pain following THA/TKA in OA patients was associated with pain during the first postoperative year. From an observational study, OA patients scheduled for primary THA/TKA (June 2012–December 2017) were included from two hospitals in the Netherlands. Acute postoperative pain scores were collected within 72 h postoperatively and categorized as no/mild (NRS ≤ 4) or moderate/severe (NRS > 4). Pain was assessed preoperatively, 3, 6 and 12 months postoperatively using the HOOS/KOOS subscale pain. With Multilevel Mixed-effects-analyses, we estimated associations between acute and chronic pain until one year postoperative, adjusted for confounders and including an interaction term (Time*Acute pain). 193 THA and 196 TKA patients were included, 29% of THA and 51% of TKA patients reported moderate/severe pain acutely after surgery. In the THA group, the difference in pain at 3 months between the no/mild and moderate/severe groups, was approximately six points, in favor of the no/mild group (95% CI [−12.4 to 0.9]) this difference became smaller over time. In the TKA group we found similar differences, with approximately four points (95% CI [−9.6 to 1.3]) difference between the no/mild and moderate/severe group at 6 months, this difference attenuated at 12 months. No association between severity of acute postoperative pain and pain during the first postoperative year was found. These findings suggest that measures to limit acute postoperative pain will likely not impact development of chronic pain.

Objectively Measured Physical Activity, Sedentary Behavior and Functional Performance before and after Lower Limb Joint Arthroplasty: A Systematic Review with Meta-Analysis

Patients after joint arthroplasty tend to be less physically active; however, studies measuring objective physical activity (PA) and sedentary behavior (SB) in these patients provide conflicting results. The aim of this meta-analysis was to assess objectively measured PA, SB and performance at periods up to and greater than 12 months after lower limb arthroplasty. Two electronic databases (PubMed and Medline) were searched to identify prospective and cross-sectional studies from 1 January 2000 to 31 December 2020. Studies including objectively measured SB, PA or specific performance tests in patients with knee or hip arthroplasty, were included in the analyses both pre- and post-operatively. The risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN). After identification and exclusion, 35 studies were included. The data were analyzed using the inverse variance method with the random effects model and expressed as standardized mean difference and corresponding 95% confidence intervals. In total, we assessed 1943 subjects with a mean age of 64.9 (±5.85). Less than 3 months post-operative, studies showed no differences in PA, SB and performance. At 3 months post-operation, there was a significant increase in the 6 min walk test (6MWT) (SMD 0.65; CI: 0.48, 0.82). After 6 months, changes in moderate to vigorous physical activity (MVPA) (SMD 0.33; CI: 0.20, 0.46) and the number of steps (SMD 0.45; CI: 0.34, 0.54) with a large decrease in the timed-up-and-go test (SMD −0.61; CI: −0.94, −0.28) and increase in the 6MWT (SMD 0.62; CI: 0.26–0.98) were observed. Finally, a large increase in MVPA (SMD 0.70; CI: 0.53–0.87) and a moderate increase in step count (SMD 0.52; CI: 0.36, 0.69) were observed after 12 months. The comparison between patients and healthy individuals pre-operatively showed a very large difference in the number of steps (SMD −1.02; CI: −1.42, −0.62), but not at 12 months (SMD −0.75; −1.89, 0.38). Three to six months after knee or hip arthroplasty, functional performance already exceeded pre-operative levels, yet PA levels from this time period remained the same. Although PA and functional performance seemed to fully restore and exceed the pre-operation levels at six to nine months, SB did not. Moreover, PA remained lower compared to healthy individuals even longer than twelve months post-operation. Novel rehabilitation protocols and studies should focus on the effects of long-term behavioral changes (increasing PA and reducing SB) as soon as functional performance is restored.

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.

Long-term outcomes of total elbow arthroplasty: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, dislocation, and revision rates following total elbow arthroplasty (TEA) at a minimum 10 years' mean follow-up.

MATERIALS AND METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and Cochrane Library databases. Studies were only included if they focused on outcomes post-TEA at a minimum 10 years' mean follow-up.

RESULTS

Our search found 23 studies including 1429 elbows (60.4% linked TEA) that met our inclusion criteria. There were 1276 patients (79.0% female), with an average age of 64.7 years (19-93) and a mean follow-up of 137.2 months (120-216). At final follow-up, the mean Mayo Elbow Performance Score, Oxford Elbow Score, and Quick Disabilities of the Arm, Shoulder, and Hand scores were 89.1 (35-100), 64.4 (16-48), and 39.2 (3-93), respectively, and 63.3% of patients reported having no pain. The rates of aseptic loosening, infection, implant dislocation, and nerve injury were 12.9%, 3.3%, 4.2%, and 2.1%, respectively. The overall complication and revision rates were 16.3% and 14.6%, respectively.

DISCUSSION AND CONCLUSION

Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term.

Efficacy of Knee Arthroplasty on the Outcomes of Knee Osteoarthritis in Iranian Elderly Individuals

BACKGROUND

Knee osteoarthritis is a common musculoskeletal condition in elderly individuals. This survey was conducted with the aim to identify the problems of this group of patients for compilation of healthcare programs targeted at determining the outcome of osteoarthritis before and 3 months after knee arthroplasty.

MATERIALS AND METHODS

In the present cross-sectional study, 150 elderly individuals who had volunteered for knee arthroplasty were selected through nonrandomized sampling and were evaluated using the Knee Osteoarthritis Outcome Score (KOOS) questionnaire and a demographic characteristics form before and 3 months after the surgery via nonparametric statistical tests (Wilcoxon, Mann-Whitney U, and Kruskal-Wallis tests).

RESULTS

The mean (SD) age of the study subjects was 64.40 (7.20) years. A significant difference was observed between the mean scores of all subscales (pain with Z=10.62, knee pain/knee stiffness with Z=10.54, daily activity with Z=10.62, sport with Z=2.95, and quality of life with Z=10.48) before and after knee arthroplasty based on Wilcoxon test (˂0.05). The results of the Mann-Whitney U test showed a significant statistical relationship between the difference in the mean score of daily activities and history of opium consumption (Z=1.90, p ˂ 0.05) as well as that between knee pain/knee stiffness and gender (Z=2.57, p ˂ 0.05) and educational level (Z=2.11, p ˂ 0.05).

CONCLUSIONS

Knee arthroplasty and history of opium consumption were correlated with improvement of patients' performance in their daily activities, and gender (women) and educational level (unread) were correlated with improvement of the score of the knee pain/knee stiffness subscale.

Evaluation of an opioid risk mitigation initiative for veterans undergoing hip or knee arthroplasty at San Francisco Veterans Affairs Health Care System

PURPOSE

Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS.

SUMMARY

A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented.

CONCLUSION

Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.

Neuromodulation of the Dorsal Root Ganglion for Chronic Postsurgical Pain

Objective

The objective of this study is to review the available evidence for dorsal root ganglion (DRG) stimulation for the treatment of complex regional pain syndrome type II (CRPS II; peripheral causalgia) associated with chronic neuropathic postsurgical pain (NPP).

Design

Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from published articles also were reviewed for relevant citations.

Results

The data published to date support the use of DRG stimulation to treat chronic NPP of the groin, knee, and foot. NPP following procedures such as thoracotomy, hernia surgery, and knee replacement surgery were identified as some of the conditions for which DRG stimulation is likely to be effective.

Conclusion

DRG stimulation is known to be an effective treatment for focal neuropathic pain. Currently, NPP of the foot, groin, and knee all appear to be the conditions with the most clinical experience, backed by a limited but growing body of evidence. However, prospective studies lag behind real-world clinical experience and are needed to confirm these findings.

Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty

PURPOSE

Pain management after total knee arthroplasty (TKA) is still under debate. Continuous peripheral nerve blocks (PNB) can provide long pain relief but impair muscle function. Continuous intraarticular analgesia could result in longer pain relief than local infiltration analgesia without negative effects on muscle function. This study investigated the efficacy of pain control between PNB's and continuous intraarticular analgesia after TKA.

METHODS

A prospective randomized study on 140 patients undergoing TKA was performed. Patients received either a combination of continuous femoral nerve block, continuous sciatic nerve block and single-shot obturator nerve block (group R) or a local infiltration analgesia and a continuous intraarticular catheter with ropivacaine (group L). Primary outcome was pain measured on a numerical rating scale. Knee function, patient-reported outcome (PRO) and adverse events were assessed until 1 year after surgery.

RESULTS

Pain at rest was lower in group R on the day of surgery (mean NRS 3.0 vs. 4.2) and the morning of postoperative day 1 (mean NRS 3.4 vs. 4.4). Motor blockade longer than postoperative day 3 occurred more often in group R compared to group L (15.3% vs. 1.5%). Pain levels, PRO and satisfaction 3-month and 1-year after surgery were similar.

CONCLUSION

Continuous PNB's were slightly more effective in the first 24 h after surgery but were associated more often with motor blockade which should be avoided. It must be balanced if the small amount of better pain relief immediately after surgery justifies the risks associated with motor blockade following PNB's.

LEVEL OF EVIDENCE

I.

Pain Management Associated with Total Joint Arthroplasty: A Primer

This primer presents a synopsis of pain management strategies associated with total joint arthroplasty. Patients considering total joint arthroplasty often experience moderate to severe pain, which places them at risk of opioid abuse or addiction. Currently, the best practice strategies involve the development of individualized multimodal perioperative approaches to pain management. These practices include prescribing opioids at their lowest dose and for the shortest duration necessary to control symptoms, with close monitoring of common adverse effects. Implementing these practices is essential to battling the ongoing opioid crisis in the US.

Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants

Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire-9 (PHQ-9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p=0.001), greater depression (PHQ-9; p=0.001), more disability (WOOS; p=0.030), and less satisfaction with the surgery (p=0.014). There was no relationship between the presence of NP and patients' age, sex, preoperative pain, range of motion results, or WOOS scores (p>0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research.

Chronic pain after total knee arthroplasty

Despite a good outcome for many patients, approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA).

Chronic pain after TKA can affect all dimensions of health-related quality of life, and is associated with functional limitations, pain-related distress, depression, poorer general health and social isolation.

In both clinical and research settings, the approach to assessing chronic pain after TKA needs to be in-depth and multidimensional to understand the characteristics and impact of this pain. Assessment of this pain has been inadequate in the past, but there are encouraging trends for increased use of validated patient-reported outcome measures.

Risk factors for chronic pain after TKA can be considered as those present before surgery, intraoperatively or in the acute postoperative period. Knowledge of risk factors is important to guide the development of interventions and to help to target care. Evaluations of preoperative interventions which optimize pain management and general health around the time of surgery are needed.

The causes of chronic pain after TKA are not yet fully understood, although research interest is growing and it is evident that this pain has a multifactorial aetiology, with a wide range of possible biological, surgical and psychosocial factors that can influence pain outcomes.

Treatment of chronic pain after TKA is challenging, and evaluation of combined treatments and individually targeted treatments matched to patient characteristics is advocated. To ensure that optimal care is provided to patients, the clinical- and cost-effectiveness of multidisciplinary and individualized interventions should be evaluated.

Cite this article: EFORT Open Rev 2018;3:461-470. DOI: 10.1302/2058-5241.3.180004

Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study

Aims

The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA.

Patients and Methods

This prospective cohort study included 40 consecutive patients undergoing conventional jig-based TKA followed by 40 consecutive patients receiving robotic-arm assisted TKA. All surgical procedures were performed by a single surgeon using the medial parapatellar approach with identical implant designs and standardized postoperative inpatient rehabilitation. Inpatient functional outcomes and time to hospital discharge were collected in all study patients.

Results

There were no systematic differences in baseline characteristics between the conventional jig-based TKA and robotic-arm assisted TKA treatment groups with respect to age (p = 0.32), gender (p = 0.50), body mass index (p = 0.17), American Society of Anesthesiologists score (p = 0.88), and preoperative haemoglobin level (p = 0.82). Robotic-arm assisted TKA was associated with reduced postoperative pain (p < 0.001), decreased analgesia requirements (p < 0.001), decreased reduction in postoperative haemoglobin levels (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001) and improved maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based TKA. Median time to hospital discharge in robotic-arm assisted TKA was 77 hours (interquartile range (IQR) 74 to 81) compared with 105 hours (IQR 98 to 126) in conventional jig-based TKA (p < 0.001).

Conclusion

Robotic-arm assisted TKA was associated with decreased pain, improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based TKA.

Cite this article: Bone Joint J 2018;100-B:930–7.

A comparison of predictors and intensity of acute postsurgical pain in patients undergoing total hip and knee arthroplasty

Background

Acute pain is an expected result after surgery. Nevertheless, when not appropriately controlled, acute pain has a very negative impact on individual clinical outcomes, impairing healing and recovery, and has clear consequences on health care system costs. Augmenting knowledge on predictors and potentially modifiable determinants of acute postsurgical pain can facilitate early identification of and intervention in patients at risk. However, only a few studies have examined and compared acute pain after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aim of this study was to compare THA and TKA in acute postsurgical pain intensity and its predictors.

Methods

A consecutive sample of 124 patients with osteoarthritis (64 undergoing THA and 60 TKA) was assessed 24 hours before (T1) and 48 hours after (T2) surgery. Demographic, clinical, and psychological factors were assessed at T1, and acute postsurgical pain experience was examined at T2. Additionally, the same hierarchical regression analysis was performed separately for each arthroplasty type.

Results

TKA patients reported higher levels of acute postsurgical pain compared with THA (t=8.490, p=0.004, d=0.527, 95% confidence interval, 0.196–0.878). In the final THA predictive model, presurgical pain was the only variable approaching significant results (t[57]=1.746, β=0.254, p=0.086). In the final TKA predictive model, optimism was the only predictor of pain (t[51]=−2.518, β=−0.339, p=0.015), with emotional representation (t[51]=1.895, β=0.254, p=0.064) presenting a trend toward significance.

Conclusion

The current study is the first examining THA and TKA differences on acute postsurgical pain intensity and its predictors using a multivariate approach. Results from this study could prove useful for the design of distinct interventions targeting acute postsurgical pain management depending on whether the site of arthroplasty is the hip or the knee. Finally, the current results also support the argument that these two surgeries, at least with regard to acute pain, should be approached separately.

Neurostimulation for Postsurgical Analgesia: A Novel System Enabling Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation

While neurostimulation—stimulation of the nervous system using electrical current—has been used to treat chronic pain, its use treating postsurgical pain has been limited. Here, we report on the clinical application of a novel investigational lead to provide analgesia following total knee arthroplasty. In 5 subjects, leads were inserted percutaneously using ultrasound guidance within 0.5 to 3.0 cm of the femoral and/or sciatic nerve(s). With the delivery of current, pain decreased an average of 63% at rest, with 4 of 5 subjects having relief of > 50%. During passive and active knee flexion, pain decreased an average of 14% and 50%, with 0/3 and 1/2 subjects attaining > 50% relief, respectively. Ultrasound‐guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postsurgical pain.

Depression and anxiety after total joint replacement among older adults: a meta-analysis

OBJECTIVE

Patients usually experience good physical recovery after total joint replacement (TJR); however, it is unclear whether mood also improves. The current meta-analysis examined changes in depression and anxiety following TJR in older (≥50 years) patients in order to address this gap in the literature.

METHODS

Data from 26 studies (4045 TJR, 55 controls) that assessed depression and/or anxiety pre- and post-surgery in TJR patients, with or without a control group, were analyzed. Prevalence rates and Cohen's d effect sizes were used to evaluate changes in the prevalence and severity of depression/anxiety, respectively.

RESULTS

Approximately 23% of TJR patients had clinically significant levels of depression prior to surgery, which decreased to 13% one year later. The prevalence of anxiety could not be evaluated due to the limited available data. TJR patients did not show any clinically meaningful reductions in symptoms of depression or anxiety, following surgery. Compared to controls, there was no difference in symptom progression over time; although only one study examined this.

CONCLUSIONS

TJR patients appear to have higher rates of clinically significant symptoms of depression before and after surgery, compared to the general population, however more research with adequate control groups is needed to confirm this. Only a modest improvement in the severity of depression and anxiety symptoms was noted post-surgery. However, existing research is limited; preventing definite conclusions regarding the impact of TJR on mood.

[Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter?]

BACKGROUND AND OBJECTIVES

Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery.

METHODS

This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status.

RESULTS

Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in "worst", "medium" and "now" pain at six months. Combined anesthesia was associated with a decrease of "medium" pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in "walking ability". TKA, "worst" pain preoperatively and general were predictors of pain development at six months.

CONCLUSIONS

Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter?

BACKGROUND AND OBJECTIVES

Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery.

METHODS

This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24 hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status.

RESULTS

Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in "worst", "medium" and "now" pain at six months. Combined anesthesia was associated with a decrease of "medium" pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in "walking ability". TKA, "worst" pain preoperatively and general were predictors of pain development at six months.

CONCLUSIONS

Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

Association between Neuropathic Pain and Reported Disability after Total Knee Arthroplasty

PURPOSE

To determine whether reporting neuropathic pain (NP) at an average of 5 years after total knee arthroplasty (TKA) was related to patient age, sex, preoperative comorbidity, arthritis self-efficacy, or disability before surgery and at 1 year after surgery. The estimate of NP prevalence and cross-sectional group differences were explored at 5 years after surgery.

METHODS

A subsample of participants in a formal research study was contacted via mail approximately 5 years after undergoing surgery and were sent four questionnaires: the Western Ontario and McMaster Universities Osteoarthritis Index, the Patient Health Questionnaire, the Self-Administered Leeds Assessment of Neuropathic Signs and Symptoms (S-LANSS), and a satisfaction questionnaire. NP was defined as an S-LANSS score of 12 or more.

RESULTS

Of 89 patients who met the inclusion criteria, data for 63 (71%) patients (47 women; mean age 67 [SD 8] y) were used for analysis. Of these 63, 9 (14%) were identified as having NP. None had a report of failure of prosthesis or other surgical complications according to most recent medical records. There was no relationship between preoperative patient characteristics and development of NP. However, the NP group on average had a higher report of stiffness (p=0.020), physical dysfunction (p=0.019), and pain (p=0.050) at 1 year after surgery. Cross-sectional comparisons showed higher levels of pain (p=0.001), stiffness (p=0.008), physical dysfunction (p=0.003), and depression (p=0.005) and lower satisfaction (p=0.018) at the time of the survey than the patients without NP.

CONCLUSION

The estimated prevalence of NP was 14%. Patients with NP reported higher levels of disability as early as 1 year after surgery. They remained more disabled, with a higher level of depression and less satisfaction, at an average of 5 years after surgery.

Patients' perceptions of physical activity before and after joint replacement: a systematic review with meta-ethnographic analysis

BACKGROUND

It has been perceived that people following total hip arthroplasty (THA) or total knee arthroplasty (TKA) have the capability, with reduced pain, to increase their levels of physical activity.

OBJECTIVES

To determine the attitudes and perceptions of people awaiting or having undergone THA or TKA to physical activity post-arthroplasty and to identify potential facilitators or barriers to engage in active living and physical activity pursuits.

METHODS

Systematic review of published and unpublished databases was undertaken from their inception to November 2014. Studies exploring the attitudes and perceptions of people awaiting or having undergone THA or TKA to physical activity post-arthroplasty were included. Data were analysed through a meta-ethnography approach.

RESULTS

From 528 citations, 13 papers were eligible, sampling 282 people post-THA or TKA. The literature was judged moderate to high quality. Following THA and TKA, people either wished to return to their pre-pathology level of physical activity or simply be able to engage in less physically demanding activities that are meaningful to them and their lifestyles. Barriers to engaging in higher levels of physical activity were largely related to limited information, which culminated in fear surrounding 'doing the right thing' both for individual's recovery and the longevity of the joint replacement.

CONCLUSIONS

While many people post-THA or TKA wish to return to pre-pathological physical activity status, there is limited interest in actually undertaking greater levels of physical activity post-arthroplasty either for pleasure or health gains. Improvement in education and awareness of this may be key drivers to improve habitualisation of physical activity post-arthroplasty.

TRIAL REGISTRATION NUMBER

CRD42014014995.

Efficacy of autologous bone marrow concentrate for knee osteoarthritis with and without adipose graft

Introduction. We investigated the use of autologous bone marrow concentrate (BMC) with and without an adipose graft, for treatment of knee osteoarthritis (OA). Methods. Treatment registry data for patients who underwent BMC procedures with and without an adipose graft were analyzed. Pre- and posttreatment outcomes of interest included the lower extremity functional scale (LEFS), the numerical pain scale (NPS), and a subjective percentage improvement rating. Multivariate analyses were performed to examine the effects of treatment type adjusting for potential confounding factors. The frequency and type of adverse events (AE) were also examined. Results. 840 procedures were performed, 616 without and 224 with adipose graft. The mean LEFS score increased by 7.9 and 9.8 in the two groups (out of 80), respectively, and the mean NPS score decreased from 4 to 2.6 and from 4.3 to 3 in the two groups, respectively. AE rates were 6% and 8.9% in the two groups, respectively. Although pre- and posttreatment improvements were statistically significant, the differences between the groups were not. Conclusion. BMC injections for knee OA showed encouraging outcomes and a low rate of AEs. Addition of an adipose graft to the BMC did not provide a detectible benefit over BMC alone.