Psychological predictors of acute postoperative pain after total knee and hip arthroplasty: A systematic review

BACKGROUND

Identifying patients at high risk of acute postoperative pain after total knee or hip arthroplasty (TKA/THA) will facilitate individualized pain management and research on the efficacy of treatment options. Numerous studies have reported that psychological patient factors may influence acute postoperative pain, but most reviews have focused on chronic pain and functional outcomes. This systematic review aims to evaluate which psychological metrics are associated with acute postoperative pain after TKA and THA.

METHODS

A systematic search was conducted using the databases PubMed, EMBASE, Web of Science, and Cochrane Library until June 2022. Full-text articles reporting associations of preoperative psychological factors with acute pain within 48 h of TKA or THA surgery were identified. Quality was assessed using the Quality in Prognostic Studies tool.

RESULTS

Eighteen studies containing 16 unique study populations were included. TKA was the most common procedure, and anxiety and depression were the most evaluated psychological metrics. Several different anesthetic techniques and analgesic regimens were used. The studies were generally rated as having a low to moderate risk of bias. Catastrophizing was associated with acute pain in six studies (of nine), mainly after TKA. In contrast, three studies (of 13) and two studies (of 13) found anxiety and depression, respectively, to be associated with acute postoperative pain.

CONCLUSION

Pain catastrophizing seemed to be the most consistent psychological predictor of acute postoperative pain after TKA. The results for other psychological factors and THA were inconsistent. However, the interpretation of results was limited by considerable methodological heterogeneity.

Predictors of subacute postoperative pain after total knee arthroplasty: A secondary analysis of two randomized trials

BACKGROUND

Methods for identifying high-pain responders undergoing total knee arthroplasty remain important to improve individualized pain management. This study aimed at evaluating pre- and perioperative predictors of pain on Days 2-7 after total knee arthroplasty.

METHODS

This is a secondary analysis of data from 227 patients participating in two randomized trials. Pain outcomes were mean pain during walking on Days 2-7 and on Days 2, 4 and 7. Multivariable linear and logistic regressions were carried out in two steps. First, only preoperative available variables including demographics, comorbidities, pain catastrophizing scale and preoperative pain were evaluated while controlling for trial intervention and recruitment site. In the second step, perioperative variables and pain during walking 24 h postoperatively were added.

RESULTS

The model with only preoperative predictors for mean pain Days 2-7 showed preoperative pain (R-squared 0.097) as the only predictor. In the second model, adding postoperative available variables, only pain 24 h postoperatively (R-squared 0.248) was significant, with a significant main effect of recruitment site. Results for the separate day analysis similarly showed preoperative pain and pain during walking 24 h postoperatively as predictors. The overall best sensitivity (60%) and specificity (74%) for predicting a high-subacute postoperative pain response on Days 2-7 was with cut-off values of VAS 45.5 (out of 100) for pain during walking 24 h postoperatively.

CONCLUSIONS

Postoperative pain during walking at 24 h is predictive of subacute postoperative pain on Days 2-7 after total knee arthroplasty, while preoperative pain was only a weak predictor.

SIGNIFICANCE STATEMENT

This study investigated factors associated with pain after total knee arthroplasty beyond the immediate postoperative period. The analysis revealed significant associations between preoperative pain levels and, particularly, pain 24 h postoperatively, with subsequent subacute pain the following week. These findings can assist in identifying patients who would benefit from enhanced, individualized analgesic interventions to facilitate postoperative recovery.

Perioperative association between c-reactive protein, pain catastrophizing and acute pain after total knee arthroplasty: A secondary analysis of two randomised trials

BACKGROUND

Total knee arthroplasty is associated with an inflammatory response and high levels of pain in a subset of patients. Pain catastrophizing has been associated with acute postoperative pain. The association between these variables has not been investigated in an optimised fast-track setup including preoperative glucocorticoids. The aim of this study was, first, to investigate the correlation between the increase in postoperative c-reactive protein (CRP) and acute postoperative pain after total knee arthroplasty, and second, to investigate the correlation between the increase in CRP and preoperative pain catastrophizing.

METHODS

This study is a secondary analysis of data from 119 patients participating in two randomised controlled trials. Correlation analyses were performed for preoperative CRP and CRP increase at 24 and 48 h and pain during a well-defined mobilisation at 24 and 48 h after total knee arthroplasty. Additionally, correlation analyses were performed between CRP increase and pain catastrophizing using the pain catastrophizing scale.

RESULTS

There was no correlation between preoperative CRP or postoperative CRP increase and pain at both 24 and 48 h. Analyses were similar when separated into high and low pain catastrophizers. There was no correlation between preoperative CRP or postoperative CRP increase and pain catastrophizing.

CONCLUSION

There was no association between the postoperative CRP response and postoperative acute pain or pain catastrophizing in patients undergoing total knee arthroplasty in a well-defined multimodal fast-track regime including preoperative glucocorticoids. These results suggest that acute pain after knee arthroplasty is not reflected by CRP when applying preoperative glucocorticoids.

Repeat dose steroid in high pain responders after total knee arthroplasty: A study protocol

Pain after total knee arthroplasty (TKA) is a well-known clinical problem potentially delaying ambulation and recovery. Perioperative glucocorticoids reduce pain and facilitate early recovery, but the optimal timing and dose are still unknown. High pain catastrophizers have an increased risk of poorly controlled postoperative pain, and moderate to severe pain at 24 h is associated with a risk of pain relapse at 48 h. To evaluate the effect of a repeat moderate dose of glucocorticoids after TKA in high pain catastrophizers presenting with moderate to severe pain 24 h postoperatively, having received preoperative high-dose glucocorticoids. High pain catastrophizers (Pain Catastrophizing Scale > 20) undergoing TKA are screened 24 h postoperatively and are included if they experience moderate to severe pain (VAS > 30) during a 5 m walk test. The included patients will receive either oral 24 mg dexamethasone (n = 55) or placebo (n = 55) on the evening of Day 1 (~30-37 h) after surgery. In addition, patients receive a standard multimodal analgesic regimen, including paracetamol, celecoxib, local infiltration analgesia, and preoperative dexamethasone (1 mg/kg). Patients will fill out a pain diary for 7 days after surgery. The primary outcome is moderate to severe pain (VAS > 30) during a 5 m walk test on the morning of Day 2 after surgery. The secondary outcomes include cumulated pain at rest and during ambulation, cumulated use of rescue analgesics, quality of sleep, lethargy, dizziness, nausea, satisfaction with the analgesic regimen, length of stay, morbidity, mortality, and reasons for readmissions. Follow-up is at 8 and 30 days. The data from this study will provide evidence for the effect of a repeated dose of dexamethasone as an analgesic adjuvant in patients undergoing TKA with a high risk of postoperative pain.

Repeat-dose dexamethasone to prevent pain relapse after total knee arthroplasty in high-pain-response patients: A randomised, double-blind, placebo-controlled superiority trial

BACKGROUND

Peri-operative glucocorticoids reduce pain after total knee arthroplasty, with evidence suggesting potential benefits of increased dosing in specific patient groups. However, the impact of repeat-dose glucocorticoids has not been studied in high-pain-response patients receiving pre-operative high-dose glucocorticoids.

OBJECTIVE

To investigate the effect on pain of an oral dose of dexamethasone after total knee arthroplasty in selected high-pain-response patients who had received a pre-operative high dose of intravenous dexamethasone (1 mg kg -1 ).

DESIGN

Randomised, double-blind, placebo-controlled superiority study.

SETTING

A multicentre study conducted at two major arthroplasty centres in Denmark from November 2021 to March 2024.

PATIENTS

One hundred and ten patients undergoing total knee arthroplasty who had received multimodal analgesia including pre-operative intravenous dexamethasone 1 mg kg -1 . Selection criteria included a Pain Catastrophising Scale score greater than 20 and moderate-to-severe pain (VAS >30) during walking 24 h postoperatively.

INTERVENTION

Patients were randomised to either oral dexamethasone 24 mg or placebo on postoperative day 1.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients experiencing moderate-to-severe pain during walking at 48 h postoperatively. Secondary outcomes included pain scores at various time points within 1 week postoperatively, rescue analgesics, quality of sleep, length of hospital stay and morbidity with follow-up at 30 days.

RESULTS

At 48 h postoperatively, 65% of patients in the dexamethasone group and 79% in the placebo group reported moderate-to-severe pain during walking: odds ratio 0.48 [95% confidence interval (CI), 0.20 to 1.16]; P  = 0.100. The mean ± SD Visual Analogue Scale (VAS) at 48 h during walking was 43 ± 21 in the dexamethasone group and 51 ± 22 in the placebo group ( P  = 0.051). There were no differences between the groups regarding secondary pain outcomes or the use of rescue analgesics.

CONCLUSION

The administration of a high oral dose of dexamethasone following an initial pre-operative dose of 1 mg kg -1 intravenously in selected high-pain-response patients had no effect on postoperative pain following total knee arthroplasty.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05563155.