Factors Related to Postoperative Pain Trajectories following Total Knee Arthroplasty: A Longitudinal Study of Patients Admitted to a Russian Orthopaedic Clinic

The Effect of Lidocaine-Prilocaine Cream Combined with or Without Remimazolam on VAS and APAIS Anxiety Score in Patient Undergoing Spinal Anesthesia

Purpose

This study aimed to investigate patients' expectative pain of spinal anesthesia puncture and anxiety pre-anesthesia, and to examine the effect of lidocaine-prilocaine cream and remimazolam prior to spinal anesthesia puncture on pain relief and anxiety release.

Methods

Patients undergoing spinal anesthesia were divided into control, lidocaine-prilocaine cream, and lidocaine-prilocaine cream with remimazolam groups. A questionnaire consisting of The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and patient's concerns and Visual Analog Scale (VAS) was used to evaluate patient's anxiety and pain. The primary outcomes were differences in VAS and anxiety scores. Patient's spinal anesthesia-related concerns, advent events and hemodynamic index were also recorded.

Results

The expected spinal anesthesia puncture pain was 5.34±0.27 and anxiety scores before spinal anesthesia was 10.88 ± 0.64. A statistically significant positive correlation of 31.3% was detected between VAS and APAIS scores (r = 0.313; P=0.003). The VAS score at the time of puncture decreased by 29.7% (3.78±0.40, P=0.001) in lidocaine-prilocaine cream group and 29.2% (3.75±0.39, P=0.001) in lidocaine-prilocaine cream with remimazolam group compared with the expected VAS score. Lidocaine-prilocaine cream combined with or without remimazolam reduced the percentage of moderate pain (21.4% and 31.3% vs 50.0%, P=0.0001) and increased mild pain (60.7% vs 59.4% vs 22.7%, P=0.03). Anxiety score in lidocaine-prilocaine cream group was reduced by 2.84 (8.04±0.76 vs 10.88 ± 0.46, P=0.05) when compared with pre-anesthesia. Concerns about postoperative pain (P=0.03) and fear of the needle or intervention (P=0.000) both decreased post-anesthesia among groups.

Conclusion

Approximately half of the patients scheduled for spinal anesthesia experienced a moderate level of preoperative anxiety. The patient's pain expectation from the spinal anesthesia puncture was moderate, which was higher than the actual pain. Lidocaine-prilocaine cream with or without remimazolam sedative before spinal anesthesia puncture reduced the patient's pain and anxiety scores after surgery.

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis

Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2  = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2  = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2  = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2  = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.

Comparing Apotel and Remifentanil for Multimodal Patient-Controlled Analgesia in Postoperative Pain Management Following Total Knee Arthroplasty Surgery: A Randomized Controlled Trial

Background

Total knee arthroplasty (TKA) is a standard surgical procedure for individuals with debilitating knee arthritis. Effective postoperative pain management is essential for successful recovery, although traditional opioid-based methods have limitations.

Objectives

This study aimed to compare the efficacy of Apotel and remifentanil patient-controlled analgesia in managing postoperative pain after TKA.

Methods

This double-blind, randomized, controlled clinical trial took place at Amir-al-Momenin and Qods Hospitals in Arak, Iran, spanning from June 2022 to September 2023. Sixty-two eligible patients scheduled for knee joint replacement were randomly assigned to receive either Apotel (Group A) or remifentanil (Group R) as part of multimodal analgesia administered via a pain pump for postoperative pain relief in TKA. The study assessed hemodynamic parameters, pain levels (measured using the Visual Analog Scale), analgesic duration, and narcotic consumption. Statistical analyses were performed using SPSS v.27 and Plotly.

Results

Subjects exhibited no statistically significant differences in age, gender distribution, duration of surgery, or anesthesia. The hemodynamic status assessment in the recovery room showed no significant differences in SPO2, PR, or MAP between the groups. However, remifentanil demonstrated superior effectiveness in reducing pain over 24 hours post TKA surgery compared to Apotel, as evidenced by lower average Visual Analog Scale (VAS) scores (P < 0.001), longer duration without the need for narcotic painkillers (P < 0.001), and lower cumulative opioid analgesic consumption in Group R (P < 0.001).

Conclusions

Remifentanil demonstrates superior pain control in a multimodal pain management approach compared to Apotel, providing sustained pain reduction over 24 hours post-surgery. Moreover, remifentanil offers longer-lasting pain relief and results in lower cumulative narcotic painkiller consumption compared to Apotel.

Preoperative anxiety and need for support - A qualitative analysis in 1000 patients

OBJECTIVES

Preoperative anxiety is prevalent, emotionally distressing for many patients, and can have harmful effects on postoperative outcomes. Despite its high prevalence, there has been little research on preoperative anxiety using qualitative methods. This study's main goal was to qualitatively examine factors that may contribute to preoperative anxiety in a large sample.

METHODS

In a survey, a total of 1000 patients awaiting surgery were asked open questions i) about reasons which they associate with their preoperative anxiety and ii) which coping strategies they would prefer in addition to premedication.

RESULTS

The qualitative analysis indicated five overarching domains, 16 themes, and 54 subthemes of preoperative anxiety. Intra- or postoperative complications was the most common theme regarding preoperative anxiety (n = 516). Personal conversation was the most frequently desired supportive measure in addition to premedication.

CONCLUSIONS

This study indicated a considerable heterogeneity of reasons associated with preoperative anxiety based on an unbiased assessment in a large sample. The study further suggests that a personal conversation is a clinically important coping strategy in addition to premedication.

PRACTICE IMPLICATIONS

Providers should assess patients' preoperative anxiety and the resulting need for support individually to offer supportive measures adapted to the patients' needs.

Relationship Between Pre- and Post-Operative C-Reactive Protein (CRP), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) With Post-Operative Pain After Total Hip and Knee Arthroplasty: An Observational Study

BACKGROUND

Anesthetic technique and postoperative pain management are crucial for total joint arthroplasty (TJA) patients. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) are new, simple, and cost-effective predictors for prognosis. The predictive value of NLR as an inflammatory marker can predict post-operative pain caused by inflammatory pathways secondary to surgical trauma. CRP is also the most sensitive and specific biomarker of inflammation whereas PLR was also recently considered a possible marker for inflammation which may further contribute to pain and sequelae. Thus, anesthetists can make decisions about the amount, time, and type of analgesic to use based on preoperative values of these parameters to provide maximum postoperative pain control and facilitate early rehabilitation. Thus, the current study was conducted to determine the relationship between CRP, NLR, and PLR levels and the intensity of pain in patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

MATERIALS AND METHODS

A total of 105 patients scheduled for THA and TKA fulfilling the study's inclusion criteria were enrolled. Inclusion criteria of the study were all the patients giving written consent, ASA Grade I-III, patients between 18 and 90 years who were scheduled for elective lower extremity TJA, and all the patients who remained admitted until stitches were removed. Patients were given intrathecal 15 mg hyperbaric bupivacaine via 25G atraumatic spinal needle in the L3-L4 interspace. The recorded data were demographic characteristics, preexisting comorbidities, number of blood transfusions, and operation time, postoperative analgesics given, duration of hospital stay, time of mobility, pain scoring as per visual analog scale (VAS) scoring system with an aim to establish a relationship between pre- and post-operative (Days 3 & 5) CRP, NLR, and PLR with post-operative pain after THA and TKA.

RESULT

The present study demonstrated a significant correlation (p < 0.002) between preoperative and postoperative NLR with pain after TJA whereas PLR and CRP did not show any significant relationship with post-operative pain after THA and TKA. A significantly higher NLR ratio was observed for patients on all the periods of observation (pre-op., Day 3, and Day 5). Pre-op. and Day 5 NLR of patients who required transfusion were significantly higher than those who did not require transfusion and patients with higher NLR values could be mobilized significantly later and had significantly higher duration of hospital stay. The correlation of CRP levels and PLR levels at different time intervals did not show a significant correlation with Day 3 and Day 5 pain scores.

CONCLUSION

The present study demonstrated a significant correlation between preoperative and postoperative NLR with pain after TJA.

The Use of Lavender Aromatherapy for Pain After Total Hip and Total Knee Arthroplasty: A Randomized Trial

A randomized clinical trial was conducted over a threemonth period with 102 participants undergoing a total hip arthroplasty (THA) or total knee arthroplasty (TKA). The study purpose was to assess whether there was a reduction in the use of opioids in the postoperative period for THA or TKA participants that utilized lavender aromatherapy as an adjunct to pain medication. The participants in the control and intervention group were administered nonopioid pain medication around the clock and opioids as needed after surgery. However, the intervention group also received a pre-packaged lavender essential oil inhaler. Total oral morphine equivalents (OME) were calculated for each participant to determine opioid usage. Although the total OME was similar for the groups overall, the total OME was slightly lower for THA patients that were enrolled in the intervention group (median 22.5) compared to THA patients that were enrolled in the control group (median 31.2). In the intervention group, 58% of participants reported that the lavender inhaler was a useful tool for pain management and 76% indicated they would continue to use the lavender inhaler after discharge.

Incidence and associated factors of acute postoperative pain within the first 24 h in women undergoing cesarean delivery at a resource-limited setting in Addis Ababa, Ethiopia: A prospective observational study

Objective:

This study aimed to assess the incidence and associated factors of acute postoperative pain after cesarean section within the first 24 h of postoperative period.

Methods:

An institutional-based prospective observational study was conducted on parturients who had undergone cesarean section in Gandhi Memorial Hospital from 1 December 2019 to 28 February 2020. A numerical rating scale was used to evaluate the incidence of acute postoperative pain. Patients having a pain score of >4 were considered having moderate-to-severe pain on numerical rating scale. Data were analyzed using SPSS version 20. Bivariable and multivariable logistic regression were used to assess the association of variables. A p value of less than 0.05 was taken as significant association with dependent variables.

Result:

In total, 290 parturients participated in the study with a response rate of 98%. Moderate-to-severe acute postoperative pain after cesarean section was 76.2% (95% confidence interval: 71%, 81%) in the first 24 h postoperatively. On multivariable analysis, previous cesarean section history (adjusted odds ratio: 2.80, 95% confidence interval: 1.40, 5.55; p = 0.003), preoperative anxiety (adjusted odds ratio: 2.70, 95% confidence interval: 1.45, 5.05; p = 0.003), transverse incision type (adjusted odds ratio: 3.35, 95% confidence interval: 1.67, 6.72; p = 0.002), and incision length (adjusted odds ratio: 2.46, 95% confidence interval: 1.24, 4.85; p = 0.009) were identified as risk factors for postoperative moderate-to-severe acute pain.

Conclusion:

The incidence of moderate-to-severe postoperative pain was high in the first 24-h postoperative period; this indicates that pain management after cesarean section was treated inadequately. History of previous cesarean section, preoperative anxiety, transverse incision, and incision length >10 cm were the factors of postoperative acute pain after cesarean section. Therefore, we suggest the study institution develop a protocol for pain management.

How could perioperative anxiety be addressed via surgical team communication approaches? Findings from a scoping review

OBJECTIVES

Surgical patients and their families experience high rates of perioperative anxiety, which determine a negative impact on their surgery-related outcomes. Understanding what communicational aspects positively impact perioperative anxiety may help promote more efficient, patient-centered communication approaches which could address this issue. The aim of this scoping review was to synthesize published research on communication between surgical employees and adult patients and their relatives, and its role in managing perioperative anxiety.

METHODS

A scoping review approach was used across four international databases to search for publications detailing communicational interventions and approaches employed in surgical contexts and their impact on surgical patients' and their caregivers' perioperative anxiety levels. Results were narratively synthesized.

RESULTS

Twenty-two studies were included in this scoping review, which were grouped according to their communication intervention into one of five categories: technology-assisted interventions, interpersonal communication, educational programs, tools for facilitating exchange of information and theory-derived communication strategies. Records reported mixed results in terms of reducing perioperative anxiety. Facilitating and hindering factors in interpersonal communication in this context were further synthesized.

CONCLUSION

A multitude of communicational approaches and their effect on anxiety have been investigated within surgical settings, with varying results. Existing evidence suggests that it is vital to address surgical patients' anxiety through personalized empathetic communication, tailored to an individual's case, preferences, and needs. Key aspects of patient-healthcare professional communication which may impact perioperative anxiety were identified and may be utilized in future trainings for communication skills among surgical teams.

The Time Course of Quadriceps Strength Recovery After Total Knee Arthroplasty Is Influenced by Body Mass Index, Sex, and Age of Patients: Systematic Review and Meta-Analysis

Introduction

For patients with osteoarthritis who have undergone total knee arthroplasty (TKA), quadriceps strength is a major determinant of general physical function regardless of the parameters adopted for functional assessment. Understanding the time course of quadriceps strength recovery and effectiveness of different rehabilitation protocols is a must. Therefore, the aim of this study was to: (i) determine the magnitude of maximal voluntary strength (MVS) loss and the time course of recovery of the quadriceps muscle following TKA, (ii) identify potential moderators of strength outcomes, and (iii) investigate whether different rehabilitation practices can moderate the strength outcomes following TKA, respectively.

Design

General scientific databases and relevant journals in the field of orthopedics were searched, identifying prospective studies that investigated quadriceps’ MVS pre-to post-surgery.

Results

Seventeen studies with a total of 832 patients (39% males) were included. Results showed that in the early post-operative days, the involved quadriceps’ MVS markedly declined, after which it slowly recovered over time in a linear fashion. Thus, the greatest decline of the MVS was observed 3 days after TKA. When compared to pre-operative values, the MVS was still significantly lower 3 months after TKA and did not fully recover up to 6 months following TKA. Furthermore, a meta-regression analysis identified that the variables, time point of evaluation, patient age, sex, and BMI, significantly moderate the MVS of the quadriceps muscle.

Conclusion

The analyzed literature data showed that the decrease in strength of the involved quadriceps muscles following TKA is considerable and lasts for several months post-surgery. Therefore, we recommend to specifically target the strengthening of knee extensor muscles, preserve motor control, and apply appropriate nutrition to ensure a holistic quadriceps muscle recovery. Since age, sex, and BMI were found to be moderating factors in patients’ recovery, further research should include specific analyses considering these moderators.

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

One of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam's analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.

METHODS

We conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.

RESULTS

Patients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.

CONCLUSION

Continuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.

LEVEL OF EVIDENCE

Therapeutic Level I.

Comparison of Efficacy of Adductor Canal Block, Local Infiltration Analgesia and Both Combined in Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial

PURPOSE

The aim of our study is to compare the efficacy of adductor canal block (ACB), periarticular local infiltration (PLI) and both combined (ACB + PLI) in multimodal pain management after TKA.

METHODS

This is a prospective, randomized controlled double-blinded study undergoing primary unilateral TKA. They were randomized into three groups with fifty patients in each group: ACB alone (30 ml of 0.2% ropivacaine), PLI alone (30 ml 0.5% ropivacaine in 20 ml of normal saline), and both combined (ACB + PLI). The primary outcome studied was pain using visual analog score (VAS) in postoperative days (POD) 1 and 2. The secondary outcomes estimated were the ambulation capacity, the knee range of motion, need for rescue analgesia and length of hospital stay.

RESULTS

The mean VAS score was significantly lower at rest and after mobilization in the combined group (3.51 at POD 1, 2.04 at POD 2), compared with either alone group (ACB = 4.70, 2.86 versus PLI = 4.39, 3.41 at POD 1 and 2 respectively after mobilization, p < 0.001). The ambulation capacity (combined = 103.3 steps versus ACB = 98.1 and PLI = 95.2 steps, p = 0.04) and the knee range of motion (arc of motion 106.7 degrees versus ACB = 104.9 and PLI = 102.2 degrees, p = 0.004) were significantly higher in the combined group compared to the other groups. There was no significant difference in the length of stay between the groups (p = 0.12).

CONCLUSION

Adductor canal block combined with periarticular local infiltration provides better pain relief, good range of motion, quicker rehabilitation, and reduced opioid consumption.

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study

PURPOSE

Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure.

RESULTS

Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002).

CONCLUSION

The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.

Investigating the True Effect of Psychological Variables Measured Prior to Arthroplastic Surgery on Postsurgical Outcomes: A P-Curve Analysis

Patients' presurgical psychological profiles have been posited to predict pain and function following arthroplastic surgery of the hip and knee. Nevertheless, findings are conflicting, and this may be rooted in biased reporting that makes the determination of evidential value difficult. This ambiguity may have negative consequences for researchers and governmental agencies, as these rely on findings to accurately reflect reality. P-Curve analyses were used to establish the presence of evidential value and selective reporting in a sample of studies examining the effect of presurgical psychological predictors on outcomes following knee and hip arthroplastic surgery. A systematic search of the literature revealed 26 relevant studies. The examined sets of studies indicate that there is evidential value for the effect of depression on pain intensity and function, anxiety on pain intensity and function, pain catastrophizing on pain intensity, as well as the combined effects of all psychological predictors on pain intensity and function. The presence of evidential value was inconclusive for the effect of optimism on pain intensity. There were no signs that any results were influenced by biased reporting. The results highlight the importance of patients' psychological profiles in predicting surgical outcomes, which represent a promising avenue for future treatment approaches. PERSPECTIVE: The effects of P-hacking are difficult to detect and might be at the root of conflicting findings pertaining to the predictive properties of presurgical psychological variables on postsurgical outcomes. P-Curve analysis allows the determination of evidential value underlying these relationships and detection of P-hacking to ensure that findings are not the result of selective reporting.

Prevalence of Preoperative Anxiety and Its Relationship with Postoperative Pain in Foot Nail Surgery: A Cross-Sectional Study

Preoperative anxiety has been studied in different medical disciplines, but it is unknown in minor surgical procedures such as foot nail surgery. This study aimed to determine the prevalence of preoperative anxiety and postoperative pain in foot nail surgery. The validated Amsterdam preoperative anxiety and information scale (APAIS) was used to evaluate preoperative anxiety and the need for information in 155 patients undergoing foot nail surgery. In addition, a questionnaire was used to collect other variables such as age, sex and educational level. The verbal numeric scale was employed to value the postoperative pain after 24 h. Age and sex influenced (p < 0.05) preoperative anxiety, which had a prevalence of 22.6%. More than 43% of patients needed more information and this was correlated with anxiety (r = 0.629; p < 0.001). There was a significant difference when comparing the total anxiety between the group of participants who had more pain and that who had less pain (p < 0.001). The prevalence of anxiety was high in the participants of this study, being greater in young patients and in women. There was a deficit of information, increasing the level of preoperative anxiety, which in turn was related with greater postoperative pain.

Neurostructural correlates of strength decrease following total knee arthroplasty: A systematic review of the literature with meta-analysis

Recent literature suggests that alterations in both neural and structural components of the neuromuscular system are major determinants of knee extensor muscle weakness after total knee arthroplasty (TKA). Therefore, the goal of this study was to investigate the maximal voluntary strength (MVS), voluntary muscle activation (VMA), and the cross-sectional area (CSA) of the muscle, up to 33 months after the TKA.  We searched relevant scientific databases and literature for outcomes of interest, including quadriceps MVS, VMA, and CSA. Ten studies met the inclusion criteria and involved a total of 289 patients. The quality of the studies was evaluated by Methodological Index for Non-Randomized Studies (MINORS). Results showed that quadriceps MVS markedly declines in the early postoperative period, after which it slowly and linearly recovers over time. However, the same phenomenon was not observed for VMA and CSA, which were not significantly altered after the TKA. Furthermore, a meta-regression analysis revealed that the change in VMA accounted for 39% of the relative change in quadriceps strength (R2=0.39; p=0.015) in the early postoperative period. Patients treated with TKA had considerable weakness of the quadriceps muscle, which was detectable up to 3 months after surgery. Although the change in VMA largely explains quadriceps weakness, this change and CSA differences were not significant, suggesting that other neural correlates, such as hamstrings coactivation, might alter quadriceps muscle function. Thus, more attention should be paid to address VMA failure and coactivation of antagonist muscles.  More comprehensive rehabilitation approaches may be required to target the whole neural circuit controlling the motor action.

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

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

Higher physical activity and lower pain levels before surgery predict non-improvement of knee pain 1 year after TKA

PURPOSE

The purpose of this study was to describe patterns of pain during the first year following total knee arthroplasty (TKA) and evaluate pre- and postoperative factors associated with pain and patient satisfaction at 1 year. It was hypothesized that more severe preoperative pain would be associated with more residual pain and lower patient satisfaction 1 year after surgery.

METHODS

A longitudinal cohort study was performed with repeated measures of pain (0-10 numeric rating scale) and evaluation of other self-reported symptoms (Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Score), daily functioning (Lawton Instrumental Activities of Daily Living Scale), quality of life (EQ-5D-3L), knee function (KSS Knee and Function Score), perioperative and clinical characteristics (e.g. surgery duration, brand of implant, comorbidities), biochemical parameters (haemoglobin, C-reactive protein, creatinine), and patient satisfaction (20-item scale). Post-surgical improvement was defined as at least a two-point decrease in the patient's rating of pain interference with walking from baseline to 1 year. Hundred patients (mean age 64 ± 8 years and 93% female) consecutively admitted for uncomplicated primary TKA participated, and 79 with complete data were included in this analysis.

RESULTS

Pain generally decreased during the first postoperative year, from an average rating of 6 (SD = 3) to 1 (SD = 2). However, 18 of the 79 patients experienced no improvement in pain from baseline to 1 year. Factors associated with non-improvement of pain interference with walking after TKA included lower preoperative ratings of pain interference with walking (p < 0.001) and lower preoperative ratings of average pain (p = 0.004), active or very active levels of preoperative physical activity (p = 0.017), and higher ratings of worst pain on the first three postoperative days (p = 0.028). Pain at 1 year was the only predictor of lower patient satisfaction at 1 year.

CONCLUSIONS

Patients with low preoperative pain ratings or high preoperative levels of physical activity are at increased risk of non-improvement in knee pain after TKA. This finding should be taken into consideration when selecting appropriate candidates for TKA surgery. Orthopaedic surgeons should pay particular attention to patients reporting low pain interference with walking and consider other conservative or surgical treatment options before TKA. Effective strategies for detection and treatment of TKA patients with high pain ratings at early follow-up visits also need to be developed.

LEVEL OF EVIDENCE

Prognostic study, Level II.

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

Background

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

Methods

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

Results

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

Conclusion

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

Women report higher pain intensity at a lower level of inflammation after knee surgery compared with men

Women report more pain than men after arthroscopic surgery, but analyses of pro-inflammatory cytokines indicates higher male concentrations of pain biomarkers in synovial fluid.

Introduction and Objectives:

We previously found that women report more pain after knee arthroscopic procedures than men. It remains unclear whether this is due to different biochemical responses or nociceptive mechanisms.

Methods:

We analyzed acute pain-related inflammatory markers in a clinical model of patient self-reported pain immediately after knee surgery. To simultaneously measure 92 inflammatory biomarkers, we used the proximity extension assay with the Proseek Multiplex Inflammation I panel (Olink Bioscience, Uppsala, Sweden). Knee surgery was performed under general anesthesia with propofol and remifentanil. Analgesic drugs were only administered on patient request.

Results:

Women were 4.9 times more likely to report moderate or severe pain than men (95% confidence interval, 1.2–19.6, P = 0.024). Patient age, preoperative pain, and surgery duration were not significant factors. We analyzed synovial fluids from 44 patients (23 women, 21 men). After false discovery rate correction, MMP-10 was the only biomarker that was higher among men (P = 0.01). Linear discriminant analysis showed that 3 proteins (IL-8, CCL-4, and MCP-2) were expressed at higher levels in men, with differences of >1 normalized protein expression. No proteins were overexpressed by >1 normalized protein expression in women.

Conclusion:

Acute pain after knee arthroscopy was more intense in women, but pro-inflammatory biomarkers and MMP-10 were higher in men. Further knowledge of cytokine function is required before concluding that the disparities in biomarker expression are clinically unimportant. The similar biochemical signaling between sexes suggests that central mechanisms are of greater importance in sex-specific joint pain perception.