Chronic pain after total knee arthroplasty

Use of spinal cord stimulation for the treatment of post total knee arthroplasty pain

Total knee arthroplasty (TKA), a common elective surgical procedure, is indicated in patients with knee pain that becomes refractory to nonsurgical interventions, such as weight loss, physical activity, physical therapy, and pharmacologic treatment. However, postoperative chronic pain is frequently reported and may lead to opioid use and dependence. Due to the increasing concern of the overuse of opioids in medical treatments, a search for other viable options is recognized. As a consequence, alternative therapies, such as transcutaneous electrical nerve stimulation (TENS), pulsed radiofrequency (PRF), and spinal cord stimulation (SCS) are being tried to potentially replace traditional opioid use in treating persistent postsurgical pain (PPSP), thus reducing opioid dependence across the nation. Here, we provide a brief overview of persistent pain following TKA procedures, with a particular emphasis on the role of promising therapies, such as TENS, PRF, and SCS for the treatment of post-TKA pain.

Assessing Patients' Risk for Opioid Use Disorder

Opioid use disorder and opioid misuse continue to increase rapidly in prevalence in North America. Nurses play a critical role in managing pain in patients who are at risk for opioid use disorder. The interplay of pain and opioid use disorder provides nurses with an opportunity to address urgent needs while treating patients across the continuum of care. This article reviews strategies for assessing risk for opioid use disorder while treating patients with pain. Implementing these approaches into daily nursing practice may improve patient care and help reduce the incidence of opioid use disorder.

Sex-Modified Effects of Depression, Low Back Pain, and Comorbidities on Pain After Total Knee Arthroplasty for Osteoarthritis

OBJECTIVE

The influence of sex on post-total knee arthroplasty (TKA) outcomes has been variable in the literature. Though sex is often reported as an averaged effect, we undertook this study to investigate whether sex modified the influence of presurgery characteristics on post-TKA knee pain.

METHODS

This was a prospective study with data derived from 477 TKA osteoarthritis patients (279 women, 198 men). Questionnaires were completed presurgery and at 3 months postsurgery. The association between 3-month post-TKA knee pain and presurgery covariates (body mass index, comorbidity count, symptomatic joint count, low back pain, knee pain, and depressive symptoms) was assessed by linear regression. Sex-specific effects were evaluated using interactions.

RESULTS

Women had significantly worse presurgery knee pain, joint count, and depressive symptoms, and worse postsurgery knee pain, than men. With simple covariate adjustment, no sex effect on pain was found. However, sex was found to moderate the effects of comorbidities (worse for women [P = 0.013]), presence of low back pain (worse for men [P = 0.003]), and depressive symptoms (worse for men [P < 0.001]) on postsurgery pain. Worse presurgery pain was associated with worse postsurgery pain similarly for women and men.

CONCLUSION

The influence of some patient factors on early post-TKA pain cannot be assumed to be the same for women and men; average effects may mask underlying associations. Results suggest a need to consider sex differences in understanding TKA outcomes, which may have important implications for prognostic tool development in TKA.

Epidemiology of painful knee after total knee arthroplasty in a tertiary care center: Assessment by decision tree

BACKGROUND

Painful knee after arthroplasty concerns up to 21% of patients at six months. We aimed to evaluate: the application of a decision tree to explain painful knee after total knee arthroplasty (TKA), the rate of unexplained pain after complete algorithmic screening. The aim of the study was to evaluate the causes of painful TKA. Our hypothesis was that it is possible to find the cause of the pain in more than 90% of cases.

METHODS

A single-center retrospective study analyzed all 1130 consultations between 1 April 2017 and 31 July 2018. We included all patients consulting for unexplained chronic painful knee arthroplasty.

RESULTS

We included 112 knees in 105 patients as unexplained painful knee arthroplasty. Final diagnostic status was no diagnosis in seven (6.3%) cases; infection in five (4.5%); instability without real dislocation in three (2.7%); placement error in two (1.8%), due to rotational problems; loosening in 25 (22.3%): 24 (21.4%) tibial and two (1.8%) femoral; polyethylene wear in nine (8.0%); periarticular pain in 37 (33.9%): 20 with quadriceps deficiency, four with iliotibial tendinitis, four with pes bursitis, six with stiffness, and three with prepatellar bursitis); zero material problems; projected pain in 21 (18.8%); and complex regional pain syndrome in three (2.7%) cases, improved by gentle physiotherapy.

CONCLUSIONS

The present study was original and presents the problem in the context of everyday practice, from the clinician's point of view, with an easy-to-use decision tree that can be implemented to assess painful knee in consultation.

Long-term results of reconstructing the joints' articular surface in the knee and ankle with the surgical diamond instrumentation (SDI)

PURPOSE

The surgical diamond instrumentation (SDI), a precise wet-grinding technology, promised contact healing of press-fit inserted bone and even hyaline cartilage, lacks medium- and long-term results. This retrospective study was conducted to identify risk factors associated with the failure of the technique and the subjective patient outcome.

METHODS

All patients treated for cartilage defects of the knee or ankle joint using the SDI technology between 2000 and 2012 with a follow-up > 1 year were included. Patients with general joint diseases or joint-related procedures, except for corrective osteotomies, were excluded. A standardized questionnaire (EQ-5D) and a questionnaire-based patient-reported outcome survey were used. Descriptive statistics were applied. A multivariate analysis examining risk factors for joint failure was performed. A p value < 0.05 was considered to indicate significant differences.

RESULTS

87 patients with autologous osteochondral transplantation (68 knee, 19 ankle) were included. The median age was 53 years (IQR 37.5-63.0 years) for knee and 36 years (IQR 27.5-54.0 years) for ankle joints. 57.9% of knee and 55.6% of ankle patients were female. Nine patients (8 knee, 1 ankle) had received arthroplasty. 93.3% of knee and 83.3% of ankle patients had an excellent function or minor disabilities. 73.3% of knee and 64.7% of ankle patients did not require pain medication. The mean EQ-5D score was 0.84 for knee and 0.77 for ankle. Patients with higher age were more likely to receive arthroplasty (p = 0.022).

CONCLUSIONS

The SDI technique provides promising results with excellent joint survival rates and satisfying patient-reported outcomes. Failure of the technique might be associated with higher age.

Effects of presurgical interventions on chronic pain after total knee replacement: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Nearly 100 000 primary total knee replacements (TKR) are performed in the UK annually. The primary aim of TKR is pain relief, but 10%-34% of patients report chronic pain. The aim of this systematic review was to evaluate the effectiveness of presurgical interventions in preventing chronic pain after TKR.

DESIGN

MEDLINE, Embase, CINAHL, The Cochrane Library and PsycINFO were searched from inception to December 2018. Screening and data extraction were performed by two authors. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane tool and quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation.

PRIMARY AND SECONDARY OUTCOMES

Pain at 6 months or longer; adverse events.

INTERVENTIONS

Presurgical interventions aimed at improving TKR outcomes.

RESULTS

Eight randomised controlled trials (RCTs) with data from 960 participants were included. The studies involved nine eligible comparisons. We found moderate-quality evidence of no effect of exercise programmes on chronic pain after TKR, based on a meta-analysis of 6 interventions with 229 participants (standardised mean difference 0.20, 95% CI -0.06 to 0.47, I²=0%). Sensitivity analysis restricted to studies at overall low risk of bias confirmed findings. Another RCT of exercise with no data available for meta-analysis showed no benefit. Studies evaluating combined exercise and education intervention (n=1) and education alone (n=1) suggested similar findings. Adverse event data were reported by most studies, but events were too few to draw conclusions.

CONCLUSIONS

We found low to moderate-quality evidence to suggest that neither preoperative exercise, education nor a combination of both is effective in preventing chronic pain after TKR. This review also identified a lack of evaluations of other preoperative interventions, such as multimodal pain management, which may improve long-term pain outcomes after TKR.

PROSPERO REGISTRATION NUMBER

CRD42017041382.

Post-operative analgesia techniques after total knee arthroplasty: A narrative review

Post-operative knee pain management has become a challenge to provide early relief and pain-free postoperative care to the patient. The major objectives of post-operative analgesic treatment are to reduce opioid requirements, post-operative pain, and adverse events related to opioid intake. This narrative review aimed to document post-operative analgesia techniques after total knee arthroplasty (TKA). The traditional approach involved high-dose opioid-based regimen, though opioid is considered strong analgesic, but are associated with a number of unwanted side effects to seek for alternative techniques. The role of sciatic nerve block in TKA pain is doubtful. Femoral Nerve Block (FNB) is still considered as the gold standard; however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback more distal nerve block techniques has evolved, namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well-delivered regional nerve blocks and postoperative physical therapy are an essential component which not only minimize the side effects of traditional opioid-based analgesia but also speed up functional recovery, increases patient satisfaction, and reduces the overall length of hospitalization and cost.

Effect of preoperative sedentary behavior on clinical recovery after total knee arthroplasty: a prospective cohort study

OBJECTIVES

Prolonged sedentary behavior (SB) may affect clinical improvements following total knee arthroplasty (TKA). We aim to assess preoperative SB effect on improvements in clinical outcomes after TKA. We hypothesized that patients with high proportion of preoperative SB have small improvements in clinical outcomes after TKA.

METHODS

We recruited 115 adults with knee osteoarthritis (OA), planning to undergo TKA. Knee-specific functional outcomes were assessed using the new knee society score (KSS), including total score, symptoms, patient satisfaction, patient expectations, and functional activities. Gait function was assessed using the timed up and go (TUG) test. SB was measured using a triaxial accelerometer. Multiple linear regression analysis was performed to investigate preoperative SB effect on improvements in clinical outcomes 6 months postoperatively by adjusting for several factors as potential confounders.

RESULTS

Of 115 patients, 82 were included. High proportion of preoperative SB had a significant negative effect on recovery at 6 months in the new KSS total score [β, -0.83, 95% confidence interval (CI), -1.53 to -0.12; p = 0.02], symptoms (-0.15, -0.28 to -0.02; p = 0.03), patient satisfaction (-0.22, -0.42 to -0.02; p = 0.03), and functional activities (-0.40, -0.76 to -0.04; p = 0.03) after adjusting for potential confounders.

CONCLUSIONS

A high proportion of preoperative SB was a risk factor for reduced improvements in knee-specific functional outcomes after TKA. To prevent poor functional recovery after TKA, it is essential to understand the preoperative lifestyle factors and intervene proactively during acute postoperative phase in patients with high SB proportion.Key Points• Preoperative high proportion of SB had a negative effect on improvement in new KSS total scores, symptoms, patient satisfaction, and functional activities.• When considering clinical outcomes after TKA, clinicians should closely monitor patients with high proportions of preoperative SB to prevent poor functional recovery.

Effectiveness and reporting standards of psychological interventions for improving short-term and long-term pain outcomes after total knee replacement: a systematic review

OBJECTIVES

To assess the effectiveness and reporting standards of psychological interventions for improving outcomes after total knee replacement (TKR).

DESIGN

Medline, Embase, and PsycINFO were searched from inception to up to 9 May 2019 with no language restrictions applied. Randomised controlled trials (RCTs) assessing the effectiveness of psychological interventions for short-term and long-term postoperative pain after TKR were included. Screening, data extraction, and assessment of methodological quality were performed in duplicate by two reviewers. The primary effectiveness outcome was postoperative pain severity and the primary harm outcome was serious adverse events. Secondary outcomes included function, quality of life, and psychological well-being. Reporting standards were assessed using the Template for Intervention Description and Replication (TIDieR) checklist for intervention reporting.

RESULTS

12 RCTs were included, with a total of 1299 participants. Psychological interventions comprised music therapy (five studies), guided imagery and music (one study), hypnosis (one study), progressive muscle relaxation with biofeedback (one study), pain coping skills programme (one study), cognitive-behavioural therapy (two studies), and a postoperative management programme (one study). Due to the high heterogeneity of interventions and poor reporting of harms data, it was not possible to make any definitive statements about the overall effectiveness or safety of psychology interventions for pain outcomes after TKR.

CONCLUSION

Further evidence about the effectiveness of psychological interventions for improving pain outcomes after TKR is needed. The reporting of harm outcomes and intervention fidelity is currently poor and could be improved. Future work exploring the impact of intervention timing on effectiveness and whether different psychological approaches are needed to address acute postoperative pain and chronic postoperative pain would be of benefit.

PROSPERO REGISTRATION NUMBER

CRD42018095100.

Depression and Anxiety Are Risk Factors for Postoperative Pain-Related Symptoms and Complications in Patients Undergoing Primary Total Knee Arthroplasty in the United States

BACKGROUND

The study was designed to analyze the underlying relationship between psychiatric comorbidities and postoperative outcomes in patients undergoing primary total knee arthroplasty (TKA).

METHODS

We used the National Inpatient Sample data from 2002 to 2014. On the basis of the International Classification of Disease, Ninth Revision, Clinical Modification, we divided TKA patients into 4 subgroups: those diagnosed with depression, those diagnosed with anxiety, those concomitantly diagnosed with both depression and anxiety, and those without depression or anxiety. The chi-squared test and analysis of variance were performed to measure differences among these 4 subgroups. Multiple logistic regression analysis was used to determine whether psychological comorbidities were independent risk factors for postoperative complications and surgery-related pain.

RESULTS

A total of 7,153,750 patients in the United States were estimated to have undergone TKA between 2002 and 2014. The prevalence of depression, anxiety, or both diagnoses in TKA patients significantly increased over time. Patients with psychiatric disorders showed higher hospital costs but shorter periods of hospitalization, with higher odds ratios for most complications and all pain-related symptoms observed in this study.

CONCLUSION

The prevalence of depression and anxiety in TKA patients is increasing steadily each year. Psychiatric disorders were closely correlated with the outcomes of TKA. The mental health of patients undergoing TKA needs more attention to ensure adequate relief from postoperative pain-related symptoms as well as quality of life.

The patient results and satisfaction of knee arthroplasty in a validated grading system

INTRODUCTION

The validated Knee Osteoarthritis Grading System (KOGS) was implemented and clinical results were compared with patient satisfaction data and implant survivorship in a multi-centre study with surgeons familiar with unicompartmental knee arthroplasty (UKA), patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA). This is also the first study to evaluate the prevalence of UKA and TKA in consecutive osteoarthritis (OA) knee arthroplasties assessed by this system..

METHOD

A consecutive cohort of knees was gathered at three different institutions as categorized by KOGS and surgically treated with the recommended implant unless clinical reasons or patient preference precluded such an option. One thousand one hundred seventy-seven consecutive knees were evaluated including 311 TKA (26%), 695 medial UKA (59%), 154 lateral UKA (13%) and 17 PFA (2%) and the results of the categories evaluated with the Oxford Knee Score (OKS) and the complications reflected in the different categories.

RESULTS

The failure rate of the UKA (3.5%) or TKA (1.6%) is not higher than accepted results in the literature and the difference in complications is negligible between the UKA (72%) and TKA (26%) cohorts. Revision of a UKA to a TKA as an endpoint was 0.58% with ipsilateral progression at 0.8% over a period of five to 84 months (mean follow-up of 36 months) despite the 'excessive' proportion of UKA in this cohort. The Oxford Score improvement is significant in TKA and UKA and contributes to the acceptable outcomes (The OKS for TKA improved from 20 pre-operatively to 36 post-operatively and the UKA improved from 22 pre-operatively to 39 post-operatively).

CONCLUSION

KOGS achieves acceptable early survival and functional results when implemented and is a suitable tool for identifying the preferred implant as was validated.

A Case Study of Combined Perception-Based and Perception-Free Spinal Cord Stimulator Therapy for the Management of Persistent Pain after a Total Knee Arthroplasty

INTRODUCTION

Total knee arthroplasty (TKA) is an effective treatment modality for severe osteoarthritis of the knee. Causes of pain following TKA are poorly understood; however, patient-specific biology and various neuropathic underlying mechanisms such as neuroma formation and complex regional pain syndrome (CRPS) have been suggested. Our case demonstrated the successful treatment of CRPS in the knee with the use of combination therapy in spinal cord stimulator.

CASE

We present a 71-year-old Caucasian non-Hispanic male who presented with chronic left knee pain after undergoing a total knee arthroplasty (TKA) 18 months prior. Following his TKA, he reported doing well in the acute post-operative period but began to develop progressively worsening left knee pain at approximately the third post-operative week. He underwent a successful spinal cord stimulator (SCS) trial and subsequent implantation of two 16-contact Boston Scientific leads with a Boston Scientific Spectra WaveWriterTM SCS system. Upon first post-procedural follow-up, and moreover at his 6-month follow-up, the patient reported complete resolution of his symptoms.

DISCUSSION

The development of persistent pain following TKA is a significant complication that is often challenging to treat. Our case demonstrated the successful treatment of CRPS in the knee with the use of combination therapy in spinal cord stimulator therapy. We anticipate that more data will continue to emerge to assess for the safety and efficacy of combination therapy.

Can recent chronic pain techniques help with acute perioperative pain?

PURPOSE OF REVIEW

This article discussed how the knowledge and technique of a few chronic pain procedures benefited the perioperative clinicians in their care of patients receiving specific orthopaedic surgical procedures.

RECENT FINDINGS

Recent emerging interest in hip and knee denervation for chronic pain management secondary to osteoarthritis stimulates publications on the new understanding of hip and knee joint innervation. The improved understanding of the anatomy allows better precision in targeting the articular branches. The procedures for chronic joint pain such as radiofrequency ablation, chemical neurolysis and neuromodulation procedure have recently been applied to the perioperative care in orthopaedic procedures because of the potential long-lasting analgesia, opioid-sparing effect and consequent improvement in physical function and health-related quality of life after surgery.

SUMMARY

Despite the widespread use of regional anaesthesia and multimodal analgesia in the perioperative pain management, more than two-third of the patients reported severe postoperative pain. Therefore, other therapeutic strategies used in chronic pain management such as radiofrequency ablation and neuromodulation have been proposed to optimize acute postsurgical pain. The early experience with those techniques is encouraging, and more studies are required to explore the incorporation of these procedures in the perioperative care.

Study on efficacy and safety of Tong-luo Qu-tong plaster treatment for knee osteoarthritis: study protocol for a randomized, double-blind, parallel positive controlled, multi-center clinical trial

BACKGROUND

Knee osteoarthritis (KOA) is a common chronic musculoskeletal disorder that seriously affects quality of life. Patients with KOA frequently develop one or more of the following typical symptoms: joint pain, stiffness, joint friction noise and impaired functionality. Traditional Chinese medicine (TCM) has been shown to have a superior effect and a particular advantage in the treatment of KOA; among TCM, the Tong-luo Qu-tong plaster is the convenient and most commonly used method in China to improve symptoms including pain, stiffness and limited mobility in patients with KOA, as it causes few adverse effects. But there is a lack of high-quality clinical evidences to support the therapeutic effect that Chinese adhesive plaster can have in relieving pain and stiffness. The purpose of this study will be to evaluate the efficacy and safety of Tong-luo Qu-tong plaster in patients with KOA.

METHODS/DESIGN

This study will be a randomized, double-blind, parallel positive controlled, multi-center clinical trial, a non-inferiority trial design was adopted. A total of 2000 participants older than 40 years, with KOA, will be randomly allocated into an experimental group (n = 1500) and a control group (n = 500). All participants will receive a conventional conservative treatment lasting for 14 days as two courses, once daily. Tong-luo Qu-tong plaster will be administered externally to participants in the experimental group, while the control group will receive a Qi-zheng Xiao-tong plaster. The outcome of the total Western Ontario and McMaster Universities Arthritis Index scores, TCM syndrome quantitative score and visual analog scale scores will be measured during the assessment visits (baseline and 1-week and 2-week follow up). In addition, adverse events related to clinical symptoms and signs and results of laboratory tests will be documented during the clinical trials.

DISCUSSION

This study will provide reliable evidence of the effectiveness and safety of Tong-luo Qutong plaster in patients with KOA. If the results are favorable, it is expected that the patients with KOA will benefit from this study, many patients may have a good alternative treatment for KOA.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03309501 . Registered on 8 November 2017.

The efficacy and safety of modified Robert Jones bandage in total knee arthroplasty: A meta-analysis of randomized-controlled trials

BACKGROUND

The efficacy of modified Robert Jones bandage in primary total knee arthroplasty (TKA) is controversial. On the basis of randomized controlled trials (RCTs), this systematic review and meta-analysis was conducted to evaluate the modified Robert Jones bandage in TKA.

METHODS

The electronic databases of EMBASE, PubMed, Web of Science and Cochrane Library were searched from the inception to November 2018 for all relevant English studies. The outcome measurements consisted of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, and adverse effects. Data were analyzed using STATA 14.0 software (The Cochrane Collaboration, Oxford, United Kingdom).Quality assessment was conducted according to the Cochrane Handbook for systematic review of interventions.

RESULTS

A total of 5 randomized controlled trials (RCTs) were included in the systematic review and meta-analysis. The present meta-analysis indicated that there were no significant differences in terms of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, or adverse effects.

CONCLUSIONS

Although published articles have shown improved outcome of blood loss, pain, and knee swelling after application of a modified Robert Jones bandage, our study suggest the use of modified Robert Jones bandage may not be necessary after primary TKA.