Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patientreported outcomes after manipulation under anesthesia

In-Hospital Pain and Opioid Consumption After Primary Total Knee Arthroplasty Compared to Primary Total Hip Arthroplasty: Results from 7330 Patients Treated in a Fast-Track Setting

INTRODUCTION

Differences in in-hospital pain and consumption of opioids after primary total hip arthroplasty (THA) and knee arthroplasty (TKA) have been rarely studied in a setting where the patient course is otherwise similar. The aim of this study was to compare early pain intensity and opioid usage between patients who have undergone THA and TKA to identify potential implications for outpatient surgery.

METHODS

This institutional register study included 4655 patients receiving THA and 2675 patients receiving TKA. Pain at rest and during mobilization were collected once preoperatively, and postoperatively at five time-points, twice on the Day of surgery, once each on day 1 and day 2 after surgery, and at discharge, on a numeric rating scale (NRS) 0-10. Rescue opioids in oral morphine-equivalent doses (MME) were consecutively registered. Postoperative mobilization was registered twice daily.

RESULTS

Overall mean pain were 2.0 (Cl 2.0-2.0) after THA and 2.3 (Cl 2.3-2.4) after TKA at rest, and 3.3 (Cl 3.3-3.3) and 3.7 (Cl 3.7-3.8) during mobilization, respectively. Patients undergoing TKA had a transient increase in pain intensity the day after surgery, whereas patients undergoing THA had improved pain levels. Outpatient criteria for pain (NRS < 5 during mobilization) were feasible for 37% of THA and 35% of TKA. Total median MME was 30.0 (0-573) after THA and 52.5 (0-390) after TKA. Patients undergoing TKA were less mobilized during hospitalization.

CONCLUSION

A comparable number of THA and TKA cases were eligible for same-day discharge based on outpatient discharge criteria for pain. Patients receiving TKA can expect an increase in pain intensity and opioid needs on the day after surgery.

Risk Factors for the Need for Manipulation Under Anesthesia Following total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Postoperative knee stiffness following total knee arthroplasty (TKA) is a complication that can result in poor patient outcomes, reduced satisfaction, and even necessitate a revision surgery. A common treatment for knee stiffness after TKA is manipulation under anesthesia (MUA). The purpose of this systematic review was to identify and evaluate risk factors for stiffness following primary TKA that resulted in MUA.

METHODS

There were six databases searched from inception to October 1, 2023, with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were 1,108 abstracts and 390 full-text articles that were screened for those that included risk factors predictive of MUA following TKA. The risk of biases was assessed using Quality in Prognostic Studies criteria. Meta-analysis using odds ratio was calculated. The database search yielded 53 studies involving 2,931,517 patients.

RESULTS

There were five risk factors that were found to be significant: Younger age (mean differences: -4.23 years; 95% confidence interval [CI]: -8.17 to -0.29), Black race (odds ratio [OR]: 1.94; 95% CI: 1.56 to 2.40), smoking (OR: 1.43; 95% CI: 1.02 to 2.02), preoperative American Society of Anesthesiologists score ≤ 2 (OR: 0.64; 95% CI: 0.55 to 0.76), and prior knee procedure (OR: 2.00; 95% CI: 1.49 to 2.69). There was no evidence for sex (OR: 1.30, 95% CI: 0.74 to 2.30, P = 0.32), obesity (OR; 0.84, 95% CI: 0.67 to 1.05, P = 0.12), and diabetes (OR: 0.85, 95% CI: 0.69 to 1.05, P = 0.14) as potential risk factors for stiffness requiring MUA.

CONCLUSIONS

The results of our meta-analysis indicate that the Black race, younger age, smoking, preoperative American Society of Anesthesiologists scores ≤ 2, and prior knee surgery are strong evidence as risk factors for postoperative need for MUA.

Patients Undergoing Manipulation under Anesthesia following Primary Total Knee Arthroplasty: Are Their Patient-Reported Outcome Measures Inferior?

Stiffness after total knee arthroplasty (TKA) can lead to decreased function and patient dissatisfaction. Manipulation under anesthesia (MUA) is often performed to improve range of motion (ROM); however, there is no consensus on indications or timing. The purpose of this study was to compare clinical results and patient-reported outcome measures (PROMs) between patients who underwent MUA versus those with an uncomplicated postoperative course following primary TKA. This was an institutional review board-approved retrospective review of 116 consecutive patients who underwent MUA from 2013 to 2019 following primary TKA due to stiffness. Indication for MUA was failure to achieve 105 degrees of knee flexion at 6 weeks following surgery. Five patients underwent revision surgery and 15 patients from the MUA group were excluded: 12 lost to follow-up and 3 deaths. The remaining 96 MUA patients were matched to 288 TKAs who did not require MUA or revision, all with a minimum 2-year follow-up. Patients who underwent MUA were younger (60.7 vs. 66.3 years, p < 0.001) and had less preoperative knee flexion (105.4 vs. 110.7 degrees, p < 0.001). There were five (4.9%) revisions in the MUA group: two instability, two chronic pain, and one arthrofibrosis. There were no differences between the groups with respect to postoperative Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Forgotten Joint Score-12, satisfaction, or complications. Satisfaction rates were 88.5% among MUA patients and 89.6% among non-MUA patients (p = 1.0). Patients undergoing MUA following TKA, using the criteria of failure to achieve 105 degrees of flexion by 6 weeks postoperatively, were able to achieve similar PROMs and satisfaction compared with a control group with a low incidence of revision due to persistent arthrofibrosis.

Racial and ethnic differences in the use of lumbar imaging, opioid analgesics and spinal surgery for low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

There is a substantial gap between evidence and clinical care for low back pain (LBP) worldwide despite recommendations of best practice specified in clinical practice guidelines. The aim of this systematic review was to identify disparities associated with race or ethnicity in the use of lumbar imaging, opioid analgesics, and spinal surgery in people with LBP.

DATABASES AND DATA TREATMENT

We included observational studies which compared the use of lumbar imaging, opioid analgesics, and spinal surgery for the management of non-serious LBP between people from different racial/ethnic populations. We searched in MEDLINE, EMBASE and CINAHL from January 2000 to June 2021. Risk of bias of included studies was appraised in six domains. For each type of care, we pooled data stratified by race and ethnicity using random effects models.

RESULTS

We identified 13 eligible studies; all conducted in the United States. Hispanic/Latino (OR 0.69, 95%CI 0.49-0.96) and Black/African American (OR 0.59, 95%CI 0.46-0.75) people with LBP were less likely to be prescribed opioid analgesics than White people. Black/African Americans were less likely to undergo or be recommended spinal surgery for LBP (OR 0.47, 95%CI 0.33-0.67) than White people. There was a lack of high certainty evidence on racial/ethnic disparities in the use of lumbar imaging.

CONCLUSION

This review reveals lower rate of the use of guideline-discordant care, especially opioid prescription and spinal surgery, in racial/ethnic minority populations with LBP in the United States. Future studies in other countries evaluating care equity for LBP are warranted. PROSPERO Registration ID: CRD42021260668.

SIGNIFICANCE

This systematic review and meta-analysis revealed that people with low back pain from the minority racial/ethnic backgrounds were less likely to be prescribed opioid analgesics and undergo spinal surgery than the majority counterparts. Strategic interventions to improve the access to, and the value of, clinical care for minority populations with low back pain are warranted.