Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review

Development and Validation of a Nomogram for Evaluating the Incident Risk of Pain Catastrophizing Among Patients Who Have Severe Knee Osteoarthritis Awaiting Primary Total Knee Arthroplasty

BACKGROUND

It is clinically important to anticipate the likelihood of pain catastrophizing in patients who undergo total knee arthroplasty (TKA). Persistent pain and diminished physical function following TKA are independently associated with preoperative pain catastrophizing. The purpose of this study was to develop and validate a nomogram model to predict pain catastrophizing in patients who have severe osteoarthritis undergoing primary TKA.

METHODS

Data were collected from patients who have severe osteoarthritis undergoing primary TKA at four tertiary general hospitals in Changsha, China, from September to December 2023. The study cohort was randomly divided into a training group and a validation group in the proportion of 70 to 30%. Least absolute shrinkage and selection operator regression analysis was utilized to select the optimal predictive variables for the model. A nomogram model was created using independent risk factors that were identified through multivariate regression analysis. Their performance was assessed using the concordance index and calibration curves, and their clinical utility was analyzed using decision curve analysis.

RESULTS

A total of 416 patients were included, 291 in the training group and 125 in the validation group. There were 115 (27.6%) who had pain catastrophizing. The predictors contained in the nomogram were pain intensity during activity, anxiety and depression, body mass index, social support, and household. The area under the curve of the nomogram was 0.976 (95% confidence interval = 0.96 to 0.99) for the training group and 0.917 (95% confidence interval = 0.88 to 0.96) for the validation group. The calibration curves confirmed the nomogram's accuracy, and decision curve analysis showed its strong predictive performance.

CONCLUSIONS

The comprehensive nomogram generated in this study was a valid and easy-to-use tool for assessing the risk of pain catastrophizing in preoperative TKA patients, and helped healthcare professionals to screen the high-risk population.

The influence of pain catastrophizing on pain and function after knee arthroplasty in knee osteoarthritis

Pain catastrophizing is an exaggerated focus on pain sensations. It may be an independent factor influencing pain and functional outcomes of knee arthroplasty. We aimed to evaluate the association between pre-operative pain catastrophizing with pain and function outcomes up to one year after knee arthroplasty. We used data from a cohort study of patients undergoing primary knee arthroplasty (either total or unicompartmental arthroplasty) for knee osteoarthritis. Pain catastrophizing was assessed pre-operatively using the Pain Catastrophizing scale (PCS). Other baseline variables included demographics, body mass index, radiographic severity, anxiety, depression, and knee pain and function assessed using the Western Ontario and McMaster University Index (WOMAC). Patients completed the WOMAC at 6- and 12-months after arthroplasty. WOMAC pain and function scores were converted to interval scale and the association of PCS and changes of WOMAC pain and function were evaluated in generalized linear regression models with adjustment with confounding variables. Of the 1136 patients who underwent arthroplasty (70% female, 84% Chinese, 92% total knee arthroplasty), 1102 and 1089 provided data at 6- and 12-months post-operatively. Mean (± SD) age of patients was 65.9 (± 7.0) years. PCS was associated with a change in WOMAC pain at both 6-months and 12-months (β = - 0.04, 95% confidence interval: - 0.06, - 0.02; P < 0.001) post-operatively after adjustment in multivariable models; as well as change in WOMAC function at 6-months and 12-months. In this large cohort study, pre-operative pain catastrophizing was associated with lower improvements in pain and function at 6-months and 12-months after arthroplasty.

Development of quality assessment tool for systematic reviews and meta-analyses of real-world studies: a Delphi consensus survey

The increasing adoption of real-world studies in healthcare for decision making and planning has further necessitated the need for a specific quality assessment tool for evidence synthesis. This study aimed to develop a quality assessment tool for systematic reviews (SR) and meta-analysis (MA) involving real-world studies (QATSM-RWS) using a formal consensus method. Based on scoping review, the authors identified a list of items for possible inclusion in the quality assessment tool. A Delphi survey was formulated based on the identified items. A total of 89 experts, purposively recruited, with research experience in real-world data were invited to participate in the first round of Delphi survey. The participants who responded in the first Delphi round were invited to participate (n = 15) in the phrasing of the items. Strong level of agreement was found on the proposed list of items after the first round of Delphi. A rate of agreement ≥ 0.70 was used to define which items to keep in the tool. A list of 14 items emerged as suitable for QATSM-RWS. The items were structured under five domains: introduction, methods, results, discussions, and others. All participants agreed with the proposed phrasing of the items. This is the first study that has developed a specific tool that can be used to appraise the quality of SR and MA involving real-world studies. QATSM-RWS may be used by policymakers, clinicians, and practitioners when evaluating and generating real-world evidence. This tool is now undergoing validation process.

A Meta-Analysis to Evaluate Implant Survival and Benefits of the Use of Dual Mobility Constructs in Total Hip Replacement Following Hip Fracture

Total hip replacement (THR) is commonly performed to treat hip fractures. Dual-mobility constructs (DMCs) are increasingly used for this indication. The aim of this study was to use evidence synthesis techniques to estimate net all-cause construct survival for THR with DMC performed for hip fracture. Additionally, we aimed to investigate and describe differences in all-cause construct survival (if present) between THRs performed with DMC (DMC-THR) or with a conventional bearing construct following hip fracture. We performed a systematic review and meta-analysis of published studies (including joint registries), including DMC-THR for hip fracture which provided Kaplan-Meier (KM) survival estimates. The primary outcome was all-cause construct survival over time. The study was prospectively registered on PROSPERO (CRD42020173117). A total of 557 papers and 17 registry reports were identified. Six studies (four registry reports, one matched-pair cohort study utilising joint registry data, and one single-institution case series) met the inclusion criteria, including 17,370 DMC THRs and 167,377 conventional THRs. Five-year KM survival estimates (95% confidence intervals) were similar at 95.4% (94.9 to 95.8%) for DMC-THR and 96.2% (96.0 to 96.4%) for conventional THR. The relative risk of revision for DMC-THR at five years was 1.21 (1.05 to 1.41). These results suggest that DMC-THR has a lower all-cause survival than conventional THR following hip fracture. This analysis does not support the routine use of DMC-THR over conventional bearing THR.

Construction and validation of chronic pain prediction model after total knee arthroplasty

Objective

To explore the risk factors of chronic pain after total knee arthroplasty (TKA) and to establish and verify a prediction model.

Methods

As a retrospective observational study, medical records of 239 patients who underwent TKA in Affiliated Hospital of Jiangnan University from January 2020 to December 2022 were reviewed. Fifty four patients suffered from chronic pain after TKA surgery. Univariate and multivariate logistic regression were used to analyze factors associated with the occurrence of chronic pain after TKA. A nomogram prediction model was established based on the identified independent risk factors, and its predictive effectiveness was evaluated.

Results

Gender, postoperative 24-hourss numerical rating scale (NRS) and postoperative three months Hospital for Special Surgery Knee-Rating (HSS) scores were independent risk factors for chronic pain after TKA (p<0.05). The area of the receiver operating characteristic (ROC) of the nomogram model based on these factors was 0.904 (95% confidence interval [CI): 0.861-0.947), which indicates a good predictive value for the postoperative chronic pain. When the optimal cut off value was selected, the sensitivity and specificity of the model were 92.6% and 74.1%, respectively, indicating that the predictive model is effective.

Conclusions

Gender, postoperative 24-hours NRS and postoperative three months HSS score are independent risk factors for chronic pain after TKA. The nomogram prediction model based on these factors is effective and can provide auxiliary reference for patients with chronic pain after TKA.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study

OBJECTIVE

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA.

METHODS

A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1 week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6 months after surgery.

RESULTS

Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6 months after surgery in a univariate analysis. However, at 3 months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6 months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress.

CONCLUSION

The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA.

IMPACT

Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

Long-Term Outcomes of Birmingham Hip Resurfacing Arthroplasty: A Systematic Review of Independent Series with At Least 10 Years of Follow-up

Background

Hip resurfacing arthroplasty (HRA) provides an attractive alternative to total hip arthroplasty (THA) for the management of osteoarthritis in younger, more active patients; however, concerns persist over complications specific to HRA. The aims of this systematic review were to assess the documented long-term survival rates of the metal-on-metal BIRMINGHAM HIP Resurfacing System at a follow-up of at least 10 years and to analyze the functional outcomes and cause of failures.

Methods

A systematic review was undertaken of all published cohort studies available in the MEDLINE, Cochrane, Embase, and PubMed research databases up to December 2021, as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extraction was focused on survival rates, causes of failure, and functional outcomes. Survival estimates at 10 years were pooled in a meta-analysis, with each series weighted by its variance. Causes of failure were presented as a percentage of the pooled revisions.

Results

A total of 11 studies were identified, encompassing 3,129 cases. Across the 9 studies that had reported a mean follow-up, the mean follow-up was 11.7 years (range, 9.55 to 13.7 years). We found a pooled 10-year survival rate of 95.5% (95% confidence interval, 93.4% to 97.1%). There were 149 revisions among the studies (range, 4 to 38 revisions per study), a rate of 4.8% of the total procedures performed. The 2 main causes of revision were aseptic loosening (20.1% of revisions) and adverse reactions to metal debris (20.1%). There were no revisions for dislocation. Of the studies that reported preoperative functional scores, all reported significant improvement in mean scores postoperatively except for 1 study in which the mean Tegner activity score did not significantly improve.

Conclusions

When performed for appropriate indications, patients undergoing an HRA with use of the BIRMINGHAM HIP Resurfacing System can expect good implant survivorship at 10 years with acceptable functional results and low rates of dislocation and infection. This systematic review, however, confirms concerns regarding adverse reactions to metal debris as a leading cause of revision.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intravitreal Injection of Anti-Vascular Endothelial Growth Factors Combined with Corticosteroids for the Treatment of Macular Edema Secondary to Retinal Vein Occlusion: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) and corticosteroid combination therapy for the management of treatment-naïve or recurrent/refractory macular edema caused by retinal vein occlusion (RVO) in comparison with anti-VEGF monotherapy.

METHODS

In this systematic review and meta-analysis study, the data from publications in the electronic databases including PubMed, Embase, Cochrane Library Central Register of Controlled Trials, ISI and Scopus from January 1, 2007, through November 20, 2020, were compiled. Heterogeneity was statistically quantified by the I2 statistic, and meta-analysis was performed using a random-effects model.

RESULTS

Twenty-four related studies were identified, including a total of 1280 eyes, which consisted of 685 and 507 patients with central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO), respectively. This study demonstrated a greater improvement in best-corrected visual acuity (BCVA) in the combination group compared to anti-VEGF monotherapy for both CRVO and BRVO cases at 6 months after initiating therapy. The improvement in vision was more notable in BRVO cases than in CRVO cases. However, the changes in central macular thickness (CMT) did not differ significantly between the different treatment approaches, and the results were inconclusive. Including all cases with RVO, there was no inferiority in terms of BCVA improvement and CMT reduction in the triamcinolone subgroup compared with the slow-release dexamethasone implant subgroup. A greater improvement was noticed in terms of BCVA in the sequentially treated subgroup compared to the simultaneous treatment subgroup, while there was a greater reduction in CMT in the simultaneous subgroup with the highest reduction recorded at 1 month after treatment.

CONCLUSIONS

This study suggests that combination therapy with intravitreal anti-VEGF and corticosteroid (such as intravitreal or subtenon triamcinolone or dexamethasone implant) has a slightly better effect on improving BCVA in cases with BRVO or CRVO at 6 months compared to monotherapy.

Evaluation of Neuropathic Pain after Total Knee Arthroplasty: Do Yellow Flags Matter?

Up to 20% of total knee arthroplasty (TKA) patients continue to experience chronic postsurgical pain. Various factors have been identified as potential contributors, including so-called "yellow flags", encompassing symptoms of depression, anxiety, and catastrophizing, which were examined in this study to assess their predictive value concerning functional outcomes after TKA.

METHODS

Fifty TKA patients were categorized into high-risk and low-risk groups based on clinical assessment, demographic data, medication, and patient-reported outcome measures (DN4, SF-36, WOMAC, NRS, Fibromyalgia Survey Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale). Postoperative outcomes within six months after TKA were then compared.

RESULTS

Both groups exhibited significant (p < 0.001) improvements in all WOMAC and NRS subscales, as well as in the physical function, role physical, pain, and energy/fatigue subdomains of the SF-36 after six months, while the high-risk group showed lower WOMAC scores regarding stiffness (19.0 ± 18.3 vs. 27.2 ± 20.7, p < 0.001) and pain (13.5 ± 13.3 vs. 15.1 ± 16.3, p = 0.029). The high-risk group showed significantly worse preoperative DN4 scores (1.8 ± 1.3 vs. 3.0 ± 1.1, p = 0.002) than the low-risk group, which persisted for one day (2.3 ± 1.2 vs. 3.5 ± 1.5, p = 0.005) and six weeks (2.2 ± 1.9 vs. 3.6 ± 2.3, p = 0.041) postoperatively.

CONCLUSIONS

Our results indicate that pre-existing yellow flags contribute to a more challenging early postoperative phase, underscoring the importance of considering individual patient characteristics and psychological factors to optimize TKA outcomes.

Severe Postoperative Pain in Total Knee Arthroplasty Patients: Risk Factors, Insights and Implications for Pain Management via a Digital Health Approach

Up to 25% of patients undergoing knee arthroplasty report chronic pain postoperatively. Early identification of high-risk individuals can enhance pain management strategies. This retrospective analysis investigates the incidence of severe postoperative pain and its associated risk factors among 740 patients who underwent total knee arthroplasty. Utilizing a digital application, patients provided comprehensive data encompassing pre- and postoperative pain levels, analgesic usage, and completed a chronic pain risk assessment. Participants were categorized into two distinct groups based on their pain status at three months post-op: Group D+ (14%), characterized by pain scores exceeding 40/100 and/or the utilization of level 2 or 3 analgesics, and Group D- (86%), who did not meet these criteria. An analysis of pain trajectories within these groups revealed a non-linear progression, with specific patterns emerging amongst those predisposed to chronic pain. Notably, patients with a trajectory towards chronic pain exhibited a plateau in pain intensity approximately three weeks post-surgery. Significant preoperative risk factors were identified, including elevated initial pain levels, the presence of comorbidities, pain in other body areas, heightened joint sensitivity and stiffness. This study highlights the utility of digital platforms in enhancing patient care, particularly through the continuous monitoring of pain. Such an approach facilitates the early identification of potential complications and enables timely interventions.

Prognostic Factors for Postoperative Chronic Pain after Knee or Hip Replacement in Patients with Knee or Hip Osteoarthritis: An Umbrella Review

Knee and hip osteoarthritis are highly prevalent in the older population. Management of osteoarthritis-related pain includes conservative or surgical treatment. Although knee or hip joint replacement is associated with positive outcomes, up to 30% of patients report postoperative pain in the first two years. This study aimed to synthesize current evidence on prognostic factors for predicting postoperative pain after knee or hip replacement. An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for prognostic preoperative factors predictive of postoperative chronic pain (>6 months after surgery) in patients who had received knee or hip replacement. Searches were conducted in MEDLINE, CINAHL, PubMed, PEDro, SCOPUS, Cochrane Library, and Web of Science databases from inception up to 5 August 2022 for reviews published in the English language. A narrative synthesis, a risk of bias assessment, and an evaluation of the evidence confidence were performed. Eighteen reviews (nine on knee surgery, four on hip replacement, and seven on both hip/knee replacement) were included. From 44 potential preoperative prognostic factors, just 20 were judged as having high or moderate confidence for robust findings. Race, opioid use, preoperative function, neuropathic pain symptoms, pain catastrophizing, anxiety, other pain sites, fear of movement, social support, preoperative pain, mental health, coping strategies, central sensitization-associated symptoms, and depression had high/moderate confidence for an association with postoperative chronic pain. Some comorbidities such as heart disease, stroke, lung disease, nervous system disorders, and poor circulation had high/moderate confidence for no association with postoperative chronic pain. This review has identified multiple preoperative factors (i.e., sociodemographic, clinical, psychological, cognitive) associated with postoperative chronic pain after knee or hip replacement. These factors may be used for identifying individuals at a risk of developing postoperative chronic pain. Further research can investigate the impact of using such prognostic data on treatment decisions and patient outcomes.

Suprascapular nerve blockage for painful shoulder pathology - a systematic review and meta-analysis of treatment techniques

BACKGROUND

Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality.

METHODS

MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system.

FINDINGS

Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome.

CONCLUSION

SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the COVID-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.

Survivorship of the dual-mobility construct in elective primary total hip replacement: a systematic review and meta-analysis including registry data

INTRODUCTION

Dislocation is a common complication associated with total hip replacement (THR). Dual-mobility constructs (DMC-THR) may be used in high-risk patients and have design features that may reduce the risk of dislocation. We aimed to report overall pooled estimates of all-cause construct survival for elective primary DMC-THR. Secondary outcomes included unadjusted dislocation rate, revision for instability, infection and fracture.

METHODS

MEDLINE, EMBASE, Web of Science, Cochrane Library and National Joint Registry reports were systematically searched (CRD42020189664). Studies reporting revision (all-cause) survival estimates and confidence intervals by brand and construct including DMC bearings were included. A meta-analysis was performed weighting series by the standard error.

RESULTS

Thirty-seven studies reporting 39 case series were identified; nine (10,494 DMC-THR) were included. Fourteen series (23,020 DMC-THR) from five national registries were included. Pooled case series data for all-cause construct survival was 99.7% (95% CI 99.5-100) at 5 years, 95.7% (95% CI 94.9-96.5) at 10 years, 96.1% (95% CI 91.8-100) at 15 years and 77% (95% CI 74.4-82.0) at 20 years. Pooled joint registry data showed an all-cause construct survivorship of 97.8% (95% CI 97.3-98.4) at 5 years and 96.3% (95% CI 95.6-96.9) at 10 years.

CONCLUSIONS

Survivorship of DMC-THR in primary THR is acceptable according to the national revision benchmark published by National Institute for Clinical Excellence (NICE).

A scoping review on quality assessment tools used in systematic reviews and meta-analysis of real-world studies

Risk of bias tools is important in identifying inherent methodical flaws and for generating evidence in studies involving systematic reviews (SRs) and meta-analyses (MAs), hence the need for sensitive and study-specific tools. This study aimed to review quality assessment (QA) tools used in SRs and MAs involving real-world data. Electronic databases involving PubMed, Allied and Complementary Medicine Database, Cumulated Index to Nursing and Allied Health Literature, and MEDLINE were searched for SRs and MAs involving real-world data. Search was delimited to articles published in English, and between inception to 20 of November 2022 following the SRs and MAs extension for scoping checklist. Sixteen articles on real-world data published between 2016 and 2021 that reported their methodological quality met the inclusion criteria. Seven of these articles were observational studies, while the others were of interventional type. Overall, 16 QA tools were identified. Except one, all the QA tools employed in SRs and MAs involving real-world data are generic, and only three of these were validated. Generic QA tools are mostly used for real-world data SRs and MAs, while no validated and reliable specific tool currently exist. Thus, there is need for a standardized and specific QA tool of SRs and MAs for real-world data.

Patient-relevant outcomes following elective, aseptic revision knee arthroplasty: a systematic review

BACKGROUND

The aim of this systematic review was to summarise the evidence for the clinical effectiveness of revision knee arthroplasty (rKA) compared to non-operative treatment for the management of patients with elective, aseptic causes for a failed knee arthroplasty.

METHODS

MEDLINE, Embase, AMED and PsychINFO were searched from inception to 1st December 2020 for studies on patients considering elective, aseptic rKA. Patient-relevant outcomes (PROs) were defined as implant survivorship, joint function, quality of life (QoL), complications and hospital admission impact.

RESULTS

No studies compared elective, aseptic rKA to non-operative management. Forty uncontrolled studies reported on PROs following elective, aseptic rKA (434434 rKA). Pooled estimates for implant survivorship were: 95.5% (95% CI 93.2-97.7%) at 1 year [seven studies (5524 rKA)], 90.8% (95% CI 87.6-94.0%) at 5 years [13 studies (5754 rKA)], 87.4% (95% CI 81.7-93.1%) at 10 years [nine studies (2188 rKA)], and 83.2% (95% CI 76.7-89.7%) at 15 years [two studies (452 rKA)]. Twelve studies (2382 rKA) reported joint function and/or QoL: all found large improvements from baseline to follow-up. Mortality rates were low (0.16% to 2% within 1 year) [four studies (353064 rKA)]. Post-operative complications were common (9.1 to 37.2% at 90 days).

CONCLUSION

Higher-quality evidence is needed to support patients with decision-making in elective, aseptic rKA. This should include studies comparing operative and non-operative management. Implant survivorship following elective, aseptic rKA was ~ 96% at 1 year, ~ 91% at 5 years and ~ 87% at 10 years. Early complications were common after elective, aseptic rKA and the rates summarised here can be shared with patients during informed consent.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196922.

Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update

INTRODUCTION

Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids.

AREAS COVERED

This is a narrative review of the literature.

EXPERT OPINION

Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.

Did the dislocation risk after primary total hip arthroplasty decrease over time? A meta-analysis across six decades

BACKGROUND

While continuous optimization is attempted to decrease the incidence of dislocation after total hip arthroplasty (THA), dislocation remains a major complication. This meta-analysis aims to analyze the evolution of the dislocation risk after primary THA over the decades and to evaluate its potential publication bias.

PATIENTS AND METHODS

A systematic search was performed according to the PRISMA guidelines for this meta-analysis in the literature published between 1962 and 2020. MEDLINE, Cochrane and Embase databases were searched for studies reporting the dislocation risk and length of follow-up. Studies that reported on revision rates only and did not mention separate dislocations were excluded. All study designs were eligible. Study quality was assessed by existing quality assessment tools adjusted for arthroplasty research. Overall risk and yearly dislocation rates were calculated and related to historical time frame, study design, sample size and length of follow-up.

RESULTS

In total, 174 studies were included with an overall moderate quality. In total there were 85.209 dislocations reported in 5.030.293 THAs, showing an overall dislocation risk of 1.7%, with a median follow-up of 24 months. The overall dislocation risk classified per decade decreased from 3.7% in 1960-1970 to 0.7% in 2010-2020. The yearly dislocation rate decreased from 1.8 to 0.7% within these same decades. There was no significant correlation between the reported dislocation risk and the duration of follow-up (p = 0.903) or sample size (p = 0.755). The reported dislocation risk was higher in articles with registry data compared to other study designs (p = 0.021).

CONCLUSION

The dislocation risk in THA has been decreasing over the past decades to 0.7%. Non-selective registry studies reported a higher dislocation risk compared to studies with selective cohorts and RCTs. This indicates that the actual dislocation risk is higher than often reported and 'real-world data' are reflected better in large-scale cohorts and registries.

With or without a Tourniquet? A Comparative Study on Total Knee Replacement Surgery in Patients without Comorbidities

Background and Objectives: This study aimed to determine the effects of tourniquet use and the complications of total knee arthroplasty (TKA) in patients without comorbidities to investigate whether tourniquet application can be employed without adverse effects and to assess its impact on the occurrence of any complications. Materials and Methods: A total of 106 patients who underwent unilateral TKA were divided randomly into two groups according to whether a tourniquet was used during the surgery or not. Patients with comorbidities (except arterial hypertension) were excluded from the study. Knee Injury and Osteoarthritis Outcome Score, joint range of motion, visual analog scale (VAS) score, total blood loss during and after surgery, postoperative analgesic consumption, and side effects were the main factors evaluated in the study. Results: In the tourniquet group, where the VAS scores were higher, the use of analgesics was also significantly higher. While there was no statistically significant difference in total blood loss between the tourniquet and non-tourniquet groups, the postoperative and occult blood losses were higher in the tourniquet group. The differences between the two groups in all other parameters were very small and not statistically significant. Conclusions: The findings of the current study suggest that when the comorbidities of patients are thoroughly documented and clarified prior to surgery, tourniquets should be applied selectively to individuals without any pre-existing health conditions.

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.

Implant survivorship, functional outcomes and complications with the use of rotating hinge knee implants: a systematic review

Background

With more complex primary and revision total knee arthroplasty procedures there is often the need to use more constrained prostheses. This study aims to investigate patient-relevant outcomes following primary and revision rotating-hinged total knee arthroplasty.

Methods

Electronic searches were performed using four databases from their date of inception to January 2021. Relevant studies were identified, with data extracted and analysed using PRIMSA guidelines.

Results

Nineteen studies were included, producing a cohort of 568 primary and 413 revision rotating hinge total knee arthroplasties (TKAs). Survival was assessed at 1-, 5-, and 10-year post-implantation. Sensitivity analyses based on person-time incidence ratios (PTIRs) were prespecified for studies not reporting survival at these timepoints. From the primary hinge TKA cohort, the median survival at 1 year was 93.4% and at 10 years it was 87%. The PTIR at long-term follow-up of this primary cohort was 1.07 (95% CI 0.4–1.7) per 100 person-years. From the revision hinge TKA cohort, the median survival at 1 year was 79.6%, and at 10 years it was 65.1%. The PTIR at long term-follow-up of this revision cohort was 1.55 (95% CI 0.9–2.3) per 100 person-years. Post-operative flexion range of motion (ROM) was 110° for primary hinge TKA and 103° for revision hinge TKA. Compared with baseline, the Knee Society Score (KSS) and Knee Society Function Score (KSFS) improved for both groups post-operatively (primary: KSS 17 to 86, KSFS 28 to 58; revision: KSS 37 to 82, KSFS 34 to 61).

Conclusion

The quality of the evidence for patient-relevant outcomes following hinged knee arthroplasty was limited. While there is the potential for high early revision rates, where successful, large functional benefits may be achieved.

Viral infections in orthopedics: A systematic review and classification proposal

BACKGROUND

Although the impact of microbial infections on orthopedic clinical outcomes is well recognized, the influence of viral infections on the musculoskeletal system might have been underestimated.

AIM

To systematically review the available evidence on risk factors and musculoskeletal manifestations following viral infections and to propose a pertinent classification scheme.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), the Reference Citation Analysis (RCA), and Scopus for completed studies published before January 30, 2021, to evaluate risk factors and bone and joint manifestations of viral infection in animal models and patient registries. Quality assessment was performed using SYRCLE's risk of bias tool for animal studies, Moga score for case series, Wylde score for registry studies, and Newcastle-Ottawa Scale for case-control studies.

RESULTS

Six human and four animal studies were eligible for inclusion in the qualitative synthesis. Hepatitis C virus was implicated in several peri- and post-operative complications in patients without cirrhosis after major orthopedic surgery. Herpes virus may affect the integrity of lumbar discs, whereas Ross River and Chikungunya viruses provoke viral arthritis and bone loss.

CONCLUSION

Evidence of moderate strength suggested that viruses can cause moderate to severe arthritis and osteitis. Risk factors such as pre-existing rheumatologic disease contributed to higher disease severity and duration of symptoms. Therefore, based on our literature search, the proposed clinical and pathogenetic classification scheme is as follows: (1) Viral infections of bone or joint; (2) Active bone and joint inflammatory diseases secondary to viral infections in other organs or tissues; and (3) Viral infection as a risk factor for post-surgical bacterial infection.

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Background

People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.

Objectives

To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.

Design

Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.

Setting

Our studies are relevant to the NHS, to the Swedish health system and internationally.

Participants

People with prosthetic joint infection after hip or knee replacement and surgeons.

Interventions

Revision of hip prosthetic joint infection with a single- or two-stage procedure.

Main outcome measures

Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.

Data sources

National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.

Review methods

Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.

Results

In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.

Limitations

Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.

Conclusions

We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.

Future work

For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.

Study registration

The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

Use of regional analgesia to prevent the conversion from acute to chronic pain

PURPOSE OF REVIEW

Chronic post-surgical pain (CPSP) prevalence has not changed over the past decades what questions the efficacy of preventive strategies. Regional analgesia is used to control acute pain, but preventive effect on CPSP remains debated. Failures and future application of regional analgesia to prevent transition from acute to chronic pain will be discussed.

RECENT FINDINGS

After thoracotomy, perioperative regional analgesia does not seem to prevent CPSP. After breast cancer surgery, paravertebral block might prevent CPSP intensity and impact on daily life up to 12 months, particularly in high catastrophizing patients. In knee arthroplasty, perioperative regional analgesia or preoperative genicular nerve neuroablation do not prevent CPSP, although current studies present several bias. The protective role of effective regional analgesia and early pain relief in trauma patients deserves further studies.

SUMMARY

Regional analgesia failure to prevent CPSP development should prompt us to reconsider its perioperative utilization. Patients' stratification, for example high-pain responders, might help to target those who will most benefit of regional analgesia. The impact of regional analgesia on secondary pain-related outcomes such as intensity and neuropathic character despite no difference on CPSP incidence requires more studies. Finally, the preventive effect of regional analgesia targeted interventions on CPSP in patients suffering from severe subacute pain deserves to be assessed.

Is inpatient rehabilitation a predictor of a lower incidence of persistent knee pain 3-months following total knee replacement? A retrospective, observational study

Background

Moderate to severe levels of persistent knee pain have been estimated to affect up to 25% of people 3-months or more after a total knee replacement. It is unknown whether the type of rehabilitation pathway is associated with persistent high pain after surgery. Using a prospectively followed Australian cohort who underwent total knee replacement for knee osteoarthritis, this study aimed to i) report the incidence of high-intensity knee pain (defined as a score ≤ 15 on the Oxford Knee Score pain subscale) across time and ii) identify whether referral to inpatient rehabilitation was one of the predictors of persistent pain at 3-months post-surgery.

Methods

A retrospective analysis of a large prospective study was conducted using the Oxford Knee Score pain subscale to determine if participants had high pain at 3-months, 12-months and 36-months post-surgery. Relative risks for high pain at 3-, 12- and 36-months between the type of rehabilitation pathway were determined using Poisson multivariable regression with robust standard errors. The same technique was also employed to determine potential predictors, including rehabilitation pathway, of high pain at 3 months.

Results

The incidence of high pain in all participants was 73% pre-surgery and 10, 5 and 6% at 3-, 12- and 36-months respectively following knee replacement. There was a significant interaction between time and rehabilitation pathway, suggesting that the effect of the rehabilitation pathway varied across time. The incidence of high pain at 3-months did not significantly differ between those who attended inpatient rehabilitation (11.6%) and those discharged directly home (9.5%). Multivariable Poisson regression analysis identified the pre-surgical presence of high pain, co-morbid low back pain or other lower limb problem, younger age and having a major complication within 3-months following surgery as significant predictors of persistent pain whilst discharge to inpatient rehabilitation was not.

Conclusion

A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. Participation in an inpatient rehabilitation program does not appear to be an important predictor of ongoing knee pain.

Trial registration

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

The duration of postoperative analgesic use after total knee arthroplasty and nomogram for predicting prolonged analgesic use

Background

Total knee arthroplasty is currently a reliable treatment for end-stage knee osteoarthritis. However, chronic postsurgical pain (CPSP) is substantially thought to reduce patient satisfaction. NSAID-based oral analgesics were used to manage CPSP, but research on the duration of postoperative analgesic use (DAU) and prolonged analgesic use (PAU) are presently scarce.

Methods

Preoperative, perioperative, and one-year or above postoperative follow-up data were collected from 162 patients who underwent total knee arthroplasty between 1 June 2018 and 1 March 2019, and the DAU and the discontinuation time of each patient after discharge were recorded. Observational statistical analysis, diagnostic test, and predictive nomogram construction were performed on the collected data.

Results

The 3-month DAU has good diagnostic utility for poor outcome of postoperative months twelve (POM12). The constructed nomogram shows that gender, preoperative Numeric Rating Scale (NRS) movement pain scores, duration of surgery, postoperative days three (POD3) moderate to severe movement pain, and POD3 pain rescue medication were significant prognostic predictors of PAU after discharge. The area under the curve (AUC) of the 3-month, 6-month, and 12-month nomogram receiver operating characteristic (ROC) curves were calculated to be 0.741, 0.736, and 0.781.

Conclusion

PAU was defined as more than three months of NSAID-based oral analgesic use after TKA. Prognostic predictors of PAU after TKA were identified, and visualized nomogram was plotted and evaluated. The evaluation indicated that the prediction model had the good predictive ability and was a valuable tool for predicting PAU after discharge.

Mortality and complication rates in nonagenarians and octogenarians undergoing total hip and knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Advancing age is a significant risk factor for the development of perioperative complications and mortality in patients undergoing total hip or knee arthroplasty (THA or TKA) due to their compromised health status and the associated medical comorbidities. The purpose of this review is to identify if nonagenarians having a THA or TKA are associated with a higher incidence of mortality and morbidity compared to octogenarians.

METHODS

Medline, Scopus, and the Cochrane library were searched for relevant studies. The primary outcome of the review was the incidence of mortality. The secondary outcomes were the 30-day readmission, the perioperative complications, and the length of hospital stay (LOS).

RESULTS

Six studies with 479,630 patients were included in the review. No difference between nonagenarians and octogenarians was detected regarding the in-hospital mortality, the 30-day readmission rate, and the LOS. However, nonagenarians were associated with a greater 1-year mortality rate (OR: 2.4; 95% CI 1.91-3.01, P < 0.001; I2 = 0%) and increased odds of perioperative complications (OR: 1.6; 95% CI 1.48-1.72, P < 0.001; I2 = 0%). This finding was unchanged after adjusting for baseline characteristics (ORadj: 1.68; 95% CI 1.53-1.84, P < 0.001; I2 = 0%).

CONCLUSION

Although nonagenarians undergoing TKA or THA can achieve the same clinical benefit as octogenarians, they have a higher risk of perioperative complications and 1-year mortality. Therefore, meticulous preoperative screening, proper patient selection and optimization of comorbidities are essential to minimize any postoperative side effects in patients over 90 years of age.

Hemiarthroplasty or total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years : a systematic review and meta-analysis of patient outcomes and complications

AIMS

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

METHODS

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42021228329).

RESULTS

A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified.

CONCLUSION

This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559-566.

Insulin dependence increases the risk of postoperative complications and inferior outcome but not the survivorship of total joint arthroplasty among diabetic population: a systematic review and meta-analysis

PURPOSE

Diabetes mellitus (DM) has been associated with poorer outcomes in total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is not clear if insulin-dependent diabetes mellitus (IDDM) patients display more perioperative complications and a worse clinical outcome compared to patients with non-insulin-dependent diabetes mellitus (NIDDM).

METHODS

Medline, Scopus, and the Cochrane library were systematically searched from inception to December 2020 to identify studies evaluating the results of THA and TKA in IDDM and NIDDM patients. The primary outcomes of the review were the surgical and systemic complications, 30-day mortality and readmission, and revision arthroplasty. Secondary outcomes were the survival of the prosthetic joints and the Knee Society Score (KSS).

RESULTS

Thirteen studies with 54,215 patients were included in the review. IDDM patients showed a greater risk for developing periprosthetic joint infection (p = 0.02), wound complications (p = 0.01), 30-day readmission (p < 0.01) and mortality (p < 0.01), reoperation (p < 0.01), revision joint surgery (p = 0.02), and systemic complications (p < 0.01) than NIDDM patients. The KSS-knee score was similar in IDDM and NIDDM patients, but the KSS-function score was lower in IDDM patients (p = 0.002). The overall survival rates of the prosthetic joints were similar between the groups.

CONCLUSION

Among diabetic population who undergo THA and TKA, insulin dependence is a risk factor for postoperative complications, and inferior functional outcome but not for shorter survivorship of the prosthetic joints.

Prevalence and Predictors of Chronic Pain with Two-Year Follow-Up After Knee Arthroplasty

Background

Pain relief is the most important issue in the long-term outcome of arthroplasty surgery, with nearly one-third of patients still suffered persistent pain and caused dissatisfaction after the surgery.

Methods

A total of 713 patients underwent primary elective primary TKA and UKA were included consecutively between July 2018 and December 2019, using binary logistic method to analyze the data.

Results

The prevalence of CPSP at rest and on movement at 2-year was 12.1% and 37.7% respectively after primary knee arthroplasty and CPSP at rest factors included: age above 80 (odds ratio [OR]= 6.72, 95% confidence interval [CI] 1.58 to 28.56), BMI above 30 (2.339, 1.02 to 5.383), and moderate to severe pain variables: preoperative pain, (1.95, 1.11 to 3.41); APSP on movement, 4.9 (2.31–10.6); and follow-up contralateral knee pain-at-rest scores (12.6, 5.5 to 28.5). Factors associated with presence of CPSP on movement included: no smoking (2.59, 1.07 to 6.26); and moderate to severe pain variables: preoperative pain, (1.57, 1.073 to 2.30); APSP at rest, (1.85, 1.13 to 3.02); APSP on movement, 6.11 (3.82 to 9.78); and follow-up contralateral knee pain-on-movement scores, 3.22 (2.08 to 5.00). Factors to occurrence of moderate to severe CPSP on movement include: presence of COPD (12.20, 2.19 to 67.98); and moderate to severe pain variables: preoperative pain (2.36, 1.32 to 4.23); APSP on movement (4.68, 1.95 to 11.25); and follow-up contralateral knee pain-on-movement scores (2.71, 1.66 to 4.42).

Conclusion

Prevention strategies should be targeted to different types of pain, and the comorbidity of COPD undergoing knee arthroplasty should receive early identification and attention.

Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study

BACKGROUND

Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors.

METHODS

This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity.

RESULTS

The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain.

CONCLUSIONS

This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.

What is the patient experience following revision knee replacement: A systematic review and meta-analysis of the medium term patient reported outcomes

AIMS

Revision knee replacement is an increasingly common procedure, however, information on patient-focused outcomes is limited. This systematic review and meta-analysis aimed to investigate the medium-term patient reported outcomes following a revision knee replacement.

METHODS

We performed a systematic review of MEDLINE and EMBASE (from inception to 1st March 2021) for articles reporting five year or greater patient reported outcome measures (PROMs) following revision knee replacement. A meta-analysis of PROMs data was undertaken using the Standardised Mean Difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROPSERO (CRD42021199289).

RESULTS

A total of 23 studies met the inclusion criteria containing 2414 patients at a mean minimum follow-up of 74 months (60-122). The reporting of PROMs were poorly standardised with several PROMs being used. The most commonly reported patient reported outcome was the Knee Society Score reported in 65% of studies (15/23). A meta-analysis of 629 eligible patients undergoing revision knee replacement revealed a significant improvement in pre-operative state with a SMD 2·05 95% CI 0.87, 3.23.

CONCLUSION

This systematic review has found a significant and sustained improvement in patient-reported outcomes following a revision knee arthroplasty beyond five years. We found a variation in the usage and administration of PROMs which hinders a clear synthesis of results. Furthermore, the PROMs have not been robustly tested for validity in the context of a revision knee replacement.

Mortality After Postoperative Periprosthetic Fracture of the Femur After Hip Arthroplasty in the Last Decade: Meta-Analysis of 35 Cohort Studies Including 4841 Patients

BACKGROUND

Postoperative periprosthetic fracture of the femur (POPFF) is associated with increased mortality. There is a lack of general estimates of mortality after POPFF and a need for higher-level evidence in this area. The aim of this study was to estimate mortality after POPFF using data reported in cohort studies from the last decade.

METHODS

Literature search was conducted using Medline and Embase. The primary outcome was all-cause mortality during time as an inpatient, within 30 days, within 90 days, and within one year of POPFF. Mortality (95% confidence interval [CI]) was estimated using metaregression.

RESULTS

A total of 4841 patients from 35 cohort studies were included. Study quality was generally low. The weighted mean follow-up was 2.3 years, and the most common POPFF was Vancouver B. The pooled mortality as an inpatient was 2.4% (95% CI 1.6% to 3.4%). The pooled mortality within 30 days was 3.3% (95% CI 2.0% to 5.0%). The pooled mortality within 90 days was 4.8% (95% CI 3.6% to 6.1%). The pooled mortality within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality after POPFF was like that of neck of femur fracture up to 30 days, but better at one year.

CONCLUSION

Mortality is like that experienced by patients after neck of femur fracture up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future.

Phase 3 Trials of Enhanced Versus Usual Care Physical Therapy for Patients at Risk of Poor Outcome Following Knee Arthroplasty: A Perspective on Meaning and a Way Forward

Physical therapy is routinely delivered to patients after discharge from the hospital following knee arthroplasty. Posthospitalization physical therapy is thought to be beneficial, particularly for those patients most at risk of poor outcome, the subgroup with persistent function-limiting pain, despite an apparently successful surgery. Research teams have undertaken 3 large-scale multicenter Phase 3 randomized clinical trials designed specifically for patients at risk of poor outcome following knee arthroplasty. All 3 trials screened for poor outcome risk using different methods and investigated different physical therapist interventions delivered in different ways. Despite the variety of types of physical therapy and mode of delivery, all trials found no effects of the enhanced treatment compared with usual care. In all cases, usual care required a lower dosage of physical therapy compared with the enhanced interventions. This Perspective compares and contrasts the 3 trials, speculates on factors that could explain the no-effect findings, and proposes areas for future study designed to benefit the poor outcome phenotype.

Early Postoperative Pain After Total Knee Arthroplasty Is Associated With Subsequent Poorer Functional Outcomes and Lower Satisfaction

BACKGROUND

There are few studies investigating the effects of acute postoperative pain on functional outcomes after total knee arthroplasty (TKA). The aims of this study are to identify perioperative factors associated with increased early postoperative pain and investigate the effects of acute postoperative day 1 and 2 pain on outcomes at 6 months and 2 years post-TKA.

METHODS

1041 unilateral TKA patients were included in this retrospective cohort study. Patients were categorized into minor (visual analog scale: VAS <5) and major (VAS ≥5) pain groups based on postoperative day 1/2 VAS scores. Patients were assessed preoperatively, at 6 months and 2 years using Knee Society Knee Score and Function Scores (KSFS), Oxford Knee Score (OKS), SF-36 physical and mental component score (SF-36 PCS), expectation and satisfaction scores. Perioperative variables including age, gender, race, body mass index, American Society of Anesthesiologist status, type of anesthesia, and presence of caregiver were analyzed as predictors of postoperative acute pain. Wilcoxon two-sample test was used to analyze outcomes significantly associated with "major pain." Multiple logistic regression was used to identify predictors of "major pain."

RESULTS

Patients with "minor pain" had significantly better KSFS, Knee Society Knee Score, OKS, and SF-36 PCS scores at 6 months and significantly better KSFS, OKS, SF-36 PCS, and satisfaction at 2 years (P < .05). A significantly higher percentage of patients with "minor pain" met the minimal clinically important difference for SF-36 PCS at 6 months and KSFS at 2 years (P < .05). Women, Indian/Malay race, higher BMI, and use of general over regional anesthesia were independent predictors of getting "major pain" (P < .05).

CONCLUSION

Patients should be counseled about risk factors of postoperative pain to manage preoperative expectations of surgery. Patients should be managed adequately using multimodal pain protocols to improve subsequent functional outcomes while avoiding unnecessary opioid use.

Covid-19 in end-stage renal disease patients with renal replacement therapies: A systematic review and meta-analysis

Background

The novel coronavirus (COVID-19), caused by SARS-CoV-2, showed various prevalence and case-fatality rates (CFR) among patients with different pre-existing chronic conditions. End-stage renal disease (ESRD) patients with renal replacement therapy (RRT) might have a higher prevalence and CFR due to reduced immune function from uremia and kidney tropism of SARS-CoV-2, but there was a lack of systematic study on the infection and mortality of the SARS-CoV-2 infection in ESRD patients with various RRT.

Methodology/Principal findings

We searched five electronic databases and performed a systematic review and meta-analysis up to June 30, 2020, to evaluate the prevalence and case fatality rate (CFR) of the COVID-19 infection among ESRD patients with RRT. The global COVID-19 data were retrieved from the international database on June 30, 2020, for estimating the prevalence and CFR of the general population as referencing points. Of 3,272 potential studies, 34 were eligible studies consisted of 1,944 COVID-19 confirmed cases in 21,873 ESRD patients with RRT from 12 countries in four WHO regions. The overall pooled prevalence in ESRD patients with RRT was 3.10% [95% confidence interval (CI) 1.25–5.72] which was higher than referencing 0.14% global average prevalence. The overall estimated CFR of COVID-19 in ESRD patients with RRT was 18.06% (95% CI 14.09–22.32) which was higher than the global average at 4.98%.

Conclusions

This meta-analysis suggested high COVID-19 prevalence and CFR in ESRD patients with RRT. ESRD patients with RRT should have their specific protocol of COVID-19 prevention and treatment to mitigate excess cases and deaths.

Chronic kidney disease (CKD) was associated with increasing severity and mortality of COVID-19. End-stage renal disease (ESRD) patients were at the terminal stage of CKD and had reduced immune function due to uremia. Additionally, ESRD patients with kidney transplantation had a diminished immune system from immunosuppressive agents. Kidneys might be the secondary target of SARS-CoV-2 after the respiratory tract regardless of the previous history of kidney disease, preferably the glomerulus, which was associated with the richness of some specific protein-coding genes in the kidney. The overall pooled prevalence in ESRD patients with renal replacement therapy was approximately 22 times the referencing global average prevalence. The overall estimated case fatality rate of COVID-19 in ESRD patients with renal replacement therapy was approximately 3.6 times the global average. ESRD patients with renal replacement therapy had high COVID-19 prevalence and case fatality rate. We suggested that ESRD patients with renal replacement therapy should have their specific protocol of COVID-19 prevention and treatment to mitigate excess cases and deaths.

The Central Aspects of Pain in the Knee (CAP-Knee) questionnaire; a mixed-methods study of a self-report instrument for assessing central mechanisms in people with knee pain

OBJECTIVES

Pain is the prevailing symptom of knee osteoarthritis. Central sensitisation creates discordance between pain and joint pathology. We previously reported a Central Pain Mechanisms trait derived from eight discrete characteristics: Neuropathic-like pain, Fatigue, Cognitive-impact, Catastrophising, Anxiety, Sleep disturbance, Depression, and Pain distribution. We here validate and show that an 8-item questionnaire, Central Aspects of Pain in the Knee (CAP-Knee) is associated both with sensory- and affective- components of knee pain severity.

METHODS

Participants with knee pain were recruited from the Investigating Musculoskeletal Health and Wellbeing study in the East Midlands, UK. CAP-Knee items were refined following cognitive interviews. Psychometric properties were assessed in 250 participants using Rasch-, and factor-analysis, and Cronbach's alpha. Intra-class correlation coefficients tested repeatability. Associations between CAP-Knee and McGill Pain questionnaire pain severity scores were assessed using linear regression.

RESULTS

CAP-Knee targeted the knee pain sample well. Cognitive interviews indicated that participants interpreted CAP-Knee items in diverse ways, which aligned to their intended meanings. Fit to the Rasch model was optimised by rescoring each item, producing a summated score from 0 to 16. Internal consistency was acceptable (Cronbach's alpha = 0.74) and test-retest reliability was excellent (ICC2,1 = 0.91). Each CAP-Knee item contributed uniquely to one discrete 'Central Mechanisms trait' factor. High CAP-Knee scores associated with worse overall knee pain intensity, and with each of sensory- and affective- McGill Pain Questionnaire scores.

CONCLUSION

CAP-Knee is a simple and valid self-report questionnaire, which measures a single 'Central Mechanisms' trait, and may help identify and target centrally-acting treatments aiming to reduce the burden of knee pain.

Tourniquet use in lower limb trauma and fracture surgery

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

Oral administration of prednisone effectively reduces subacute pain after total knee arthroplasty

INTRODUCTION

Controlling the pain after TKA has always been our research focus. Dexamethasone has a significant effect in controlling acute pain following TKA. We hypothesis oral administration of prednisone could alleviate post-TKA subacute pain.

METHODS

This was a prospective, randomized controlled trial dividing patients into prednisone group and control group. Routine analgesic regimens included injection of cocktail mixture intraoperatively, oral celecoxib and tramadol postoperatively. Patients in prednisone group received oral administration of prednisone (10mg, qd, from the first day postoperatively, for 2 weeks). VAS was applied for evaluating pain with ambulation (PWA) and pain at rest (PAR). Follow-up was performed for about three months. The primary end-points were PWA and PAR; secondary end-points were postoperative daily celecoxib use and tramadol use.

RESULTS

A total of 49 patients were enrolled in prednisone group and control group, respectively. VAS of PWA was lower in prednisone group on the 7^th, 14^th and 28^th (p=0.05) day after TKA than that in the control group. Meanwhile, VAS of PAR was lower in prednisone group on the postoperative 14^th and 28^th day (p=0.05) than that in the control group.

CONCLUSIONS

Continuous oral administration of 10mg prednisone for 14 days after TKA effectively alleviates subacute pain (including PWA and PAR) and reduces postoperative consumption of analgesics.

LEVEL OF EVIDENCE

II; low power randomized trial.

Opposing and Operated Side Electroacupuncture Generates Similar Analgesic Effects on Pain after Knee Surgery

The purpose of this study was to investigate whether opposing electroacupuncture (EA) could produce similar analgesic effects as operated side EA after knee surgery in rats. Sprague Dawley rats were randomly divided into the sham surgery group, and three surgery groups: opposing EA, operated side EA, and model. After surgery, compared with the sham surgery group, three kinds of pain behavior test methods (mechanical withdrawal threshold (MWT), cumulative pain score [CPS], and mechanical hypersensitivity of knee) were used to assess the pain behavior of the rats in the surgery groups. After knee surgery, the three surgery groups were intervened for three consecutive days: EA on the nonoperated side in the opposing EA group, EA on the operated side in the operated side EA group, and no intervention in the model group. It was shown that MWT was higher and CPS was lower in the two EA groups than in the model group on the first and second days after surgery. On the third day after surgery, MWT in the two EA groups was the highest among the 3 days, CPS was the lowest among the 3 days, and the number of nonvocalizations in rats also increased compared with the model group. Moreover, the MWT of the nonoperated side increased more in the opposing EA group than in the model and operated side EA groups. This indicated that both opposing EA and operated side EA methods can be used to relieve pain after knee joint surgery.

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

Aims

Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Methods

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.

Results

We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).

Conclusion

TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery.

Cite this article: Bone Joint J 2021;103-B(5):830–839.

Reverse total shoulder arthroplasty

AIMS

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

METHODS

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).

RESULTS

A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies.

CONCLUSION

This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J 2021;103-B(5):813-821.

Postoperative Psychosocial Factors in Health Functioning and Health-Related Quality of Life After Knee Arthroplasty: A 6-Month Follow up Prospective Observational Study

OBJECTIVE

Knee arthroplasty (KA) is an effective and cost-effective treatment for end-stage knee osteoarthritis. Despite high surgical success rates, as many as 25% of patients report compromised postoperative functioning, persistent pain, and reduced quality of life. The purpose of this study was to assess the predictive value of psychological factors in health functioning and quality of life, during a 6-month period after KA.

DESIGN

A prospective observational study.

SETTING

Surgery at two hospitals and follow-up was carried out through the domiciliary rehabilitation service.

SUBJECTS

In total, 89 patients (age 70.27 ± 7.99 years) met the inclusion criteria.

METHOD

A test battery composed of Health functioning associated with osteoarthritis (WOMAC), Health-related quality of life (EQ-5D-5L), Anxiety and Depression (HADS), Pain attitudes (SOPA-B), Pain catastrophizing (PCS), and Fear of Movement (TSK-11) was assessed at 1 week, and 1, 3, and 6 months after surgery. A mixed effects linear model was used to estimate the effect of time and covariates. An exploratory factor analysis was used to identify the number of dimensions underlying the group of psychological measurements.

RESULTS

In WOMAC model, anxiety level (F = 120.8), PCS (F = 103.9), depression level (F = 93.6) and pain score (F = 72.8) were the most influential variables. Regarding EQ-5D-5L model, anxiety level (F = 98.5), PCS (F = 79.8), depression level (F = 78.3) and pain score (F = 45) were the most influential variables. Pain score and the psychosocial variables of PCS, TSK, HADS-A, HADS-D, SOPA-B Emotion, SOPA-B Harm and SOPA-B Disability loaded in one single dimension.

CONCLUSIONS

Postoperative acute pain and psychosocial factors of pain catastrophizing, anxiety, depression, and pain attitudes might influence health functioning and quality of life during KA rehabilitation. Such factors could be gathered into one single dimension defined as pain-related psychologic distress.

Survivorship of fixed vs mobile bearing unicompartmental knee replacement: A systematic review and meta-analysis of sixty-four studies and National Joint Registries

BACKGROUND

Unicompartmental knee replacement (UKR) prostheses can use fixed (FB) or mobile bearing (MB) constructs. We compared survivorship and failure modes of both designs.

METHODS

The inclusion criteria were studies published between 2005 and 2020 with minimum average follow-up of five years reporting the survival and/or number of revisions of specific designs in medial and lateral UKRs. Pooled rate of revision per 100 patient years (PTIR) was estimated using a random effects model.

RESULTS

Seventy cohorts of 17,405 UKRs with weighted mean follow-up of 7.3 years (0.1-29.4 years) were included. A total of 170,923 UKRs were identified in registry reports at a weighted mean implant survival time of 15.4 years. PTIR in MB UKR versus FB UKR was similar [1.45 vs 1.40, (p = 0.8)]. In cohort studies, the overall PTIR for MB was also similar to FB [1.03 vs 0.78, (p = 0.1)]. For medial UKR, the PTIR for MB was marginally greater but not significantly different to FB [0.96 vs 0.81, (p = 0.3)], whilst for lateral UKR, the PTIR for MB was significantly worse than for FB [2.20 vs 0.72, (p < 0.01)]. Polyethylene wear is more common in FB implants, whilst MB implants are revised more often for bearing dislocation.

CONCLUSIONS

Overall implant survival in mid- to long-term studies is similar for MB versus FB medial UKRs. MB have a four-fold higher risk of revision in comparison to FB when used for lateral UKR.

Predictors of chronic pain and level of physical function in total knee arthroplasty: a protocol for a systematic review and meta-analysis

INTRODUCTION

One in five patients undergoing total knee arthroplasty (TKA) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavourable outcomes is necessary to develop tailored interventions to minimise risk. There is a need to review more current literature with updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses. We present a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of predictors of chronic pain and impaired function after TKA.

METHODS AND ANALYSIS

This review will include prospective longitudinal observational studies, or randomised trials (including cluster and crossover designs) that report arm-wise predictors of chronic postsurgical pain or impaired physical function at 3 months, 6 months or 12 months. A comprehensive literature search of studies published between 2000 and 2019 will be performed in Medline, Embase, CINAHL, Cochrane Library and PEDro. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction and assessment of bias risk (Quality in Prognosis Studies tool). The co-primary outcomes, pain and impaired function, at 12 months after TKA will be analysed separately. Estimates of association between each outcome and any preoperative or intraoperative factor that may predict chronic pain or impaired physical function will be extracted from the included studies, where possible. For randomised studies, results will only be extracted from TKA arms (or the first period of crossover trials). Estimates of association from the primary evidence will be synthesised narratively, and quantitatively using multivariate meta-analysis to provide 'pooled' estimates of association. Subgroup and sensitivity analyses will be performed. Certainty of evidence for each predictor will be derived from the Grading of Recommendations Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

No ethical issues are associated with this project. The results from this review will be published in peer-reviewed journals and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018079069.

Assessment of postoperative health functioning after knee arthroplasty in relation to pain catastrophizing: a 6-month follow-up cohort study

BACKGROUND

Knee arthroplasty (KA) is a typically successful surgical procedure commonly performed to alleviate painin participants with end-stage knee osteoarthritis. Despite its beneficial effects, a significant proportion of individuals with KA continue experiencing persistent pain and functional limitations. The purpose of this study was to assess the postoperative outcomes after KA in relation to postoperative pain catastrophizing.

METHODS

Participants were recruited at a domiciliary physiotherapy service, using a prospective, observational, hypothesis-generating cohort design. Participants were divided into two groups based on their Pain Catastrophizing Scale (PCS) total score (50th percentile), which resulted in high and low PCS groups. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, quality of life, walking speed, physical performance, range of motion, and pain were measured. Outcome measures were collected at baseline (1 week postoperatively) and at follow-up (1, 3, and 6 months postoperatively).

RESULTS

A total of 60 participants (21 total KA and 39 unicompartmental KA) were recruited. Individuals with a higher degree of pain catastrophizing showed significantly higher WOMAC total scores at every follow-up, indicating poorer health functioning (p < 0.01). Similarly, the high PCS group showed higher WOMAC pain, stiffness and disability subscale scores (p < 0.05), poorer quality of life (p < 0.01), and poorer physical performance (p < 0.05) at every follow-up. In addition, the high PCS group achieved a slower walking speed at baseline and at 3 months follow-up (p < 0.05), and a higher degree of pain at rest, on walking and on knee flexion at every follow-up (p < 0.01, p < 0.05 and p < 0.05, respectively) except for walking pain at 3 months follow-up. No significant differences were observed between groups in range of motion, except for active knee extension at the 6-month follow-up (p < 0.05). Effect size was large at 1 month follow-up in WOMAC total score (r = 0.578) and pain intensity during knee flexion (r = 0.529). Longitudinal analyses revealed different improvement trends during the rehabilitation process between groups, with a lack of significant improvements in the high PCS group between the 3- and 6-month follow-up in WOMAC total score, WOMAC pain, WOMAC disability, quality of life, physical performance, active knee extension and resting pain (p > 0.05).

CONCLUSION

The results of the present study suggest that participants with high postoperative pain catastrophizing might have poorer outcomes during the rehabilitation process after KA. Future work should seek to clarify if this relationship is causal.

How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up

BACKGROUND

Shoulder replacement is an increasingly common treatment for end-stage degenerative shoulder conditions. Some shoulder replacements are unsuccessful and additional operations might be required. It is important for patients and clinicians to know how long shoulder replacements last and how effectively they reduce pain and improve function. This study aims to determine the longevity and long-term efficacy of shoulder replacements.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE and Embase from their inception to Sept 24, 2019, for case series and registry data reporting 10-year or longer survival of total shoulder replacements, humeral hemiarthroplasties, and reverse total shoulder replacements of a specific brand of implant. Survival, implant, and patient-reported outcome measures data were extracted. The primary outcome was implant survival. We reviewed and analysed national joint replacement registries separately. We weighted each series by SE and calculated a pooled survival estimate at years 10, 15, and 20. For patient-reported outcome measures we pooled the standardised mean difference at 10 years. This study is registered with PROSPERO, CRD42019140221.

FINDINGS

927 non-duplicate articles were identified by our search, nine articles (reporting ten series) were eligible for analysis of survival and six articles were eligible for analysis of patient reported outcomes. The ten series reported all-cause survival of 529 total shoulder replacements and 364 humeral hemiarthroplasties; no series for reverse total shoulder replacement met the inclusion criteria. The estimated 10-year survival for total shoulder replacement was 94·6% (95% CI 93·6-97·6) and humeral hemiarthroplasties was 90·4% (87·0-94·0). A single registry contributed 7651 total shoulder replacements, 1395 humeral hemiarthroplasties, and 7953 reverse total shoulder replacements. The pooled registry 10-year survival was 92·0% (95% CI 91·0-93·0) for total shoulder replacement, 85·5% (83·3-87·7) for humeral hemiarthroplasties, and 94·4% (93·4-95·7) for patients with osteoarthritis who had reverse total shoulder replacement and 93·6% (91·1-95·8) for patients with rotator cuff arthropathy who had reverse total shoulder replacement. Pooled 10-year patient-reported outcome measures showed a substantial improvement from baseline scores, with a standardised mean difference of 2·13 (95% CI 1·93-2·34).

INTERPRETATION

Our data show that approximately 90% of shoulder replacements last for longer than 10 years and patient-reported benefits are sustained. Our findings will be of use to surgeons and patients in the informed consent process and to health-care providers for resource planning.

FUNDING

The National Institute for Health Research, the National Joint Registry for England, Wales, Northern Ireland, and Isle of Man, and the Royal College of Surgeons of England.