Does central sensitization affect hyperalgesia after staged bilateral total knee arthroplasty? A randomized controlled trial

Postoperative Pain and Opiate Requirement is Increased Following Second-Side Surgery Among Patients Undergoing Staged Total Knee Arthroplasty

Background

Primary total knee arthroplasty (TKA) continues to grow exponentially, with a significant subset of patients requiring staged bilateral procedures. The optimal interval between staged procedures and effective strategies to minimize postoperative pain to enhance rehabilitation and mobility remain poorly understood.

Methods

160 consecutive patients undergoing staged bilateral TKA between August 2017 and January-2021 was retrospectively reviewed. Patients with a history of chronic opioid dependency were excluded. Baseline demographics, primary outcome measures, including visual analog scale (VAS) pain scores, perioperative opioid utilization (MME/day), and surgical satisfaction were evaluated. All patients had a minimum follow-up of 1-year-postoperatively. All univariate and multivariate statistical analyses were performed with significance given by P < .05.

Results

The mean interval between staged TKA was 8-weeks (standard deviation, 4.9-weeks). Preoperative VAS pain scores were significantly higher for the initial TKA, confirming that the more symptomatic knee was addressed first. Despite this, VAS pain scores were significantly increased following second-side TKA at 6-months postoperatively (P = .001). Multivariate analysis identified weekly interval duration between staged procedures as the single-most predictive factor of increased pain following second-side TKA (β = -0.106; P < .01). Female patients were increasingly susceptible to elevated pain levels following second-side TKA (β = 0.372; P = .057).

Conclusions

Postoperative pain increases after second-side TKA in staged-bilateral procedures, despite the more symptomatic side being addressed first. Our study identified weekly interval between staged procedures as the single-most predictive factor of pain, and female patients being predisposed to heightened pain following second-side TKA; implicating nociceptive pathways require weeks to normalize, necessitating gender-specific pain management and extended intervals.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BACKGROUND

Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies.

METHODS

All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years).

RESULTS

There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs.

CONCLUSIONS

The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Utilization of Ketamine in Total Knee and Hip Joint Arthroplasty: An Evidence-Based Review

PURPOSE

To evaluate the efficacy of ketamine in total knee and hip arthroplasty.

DESIGN

Evidence-based review.

METHODS

Following the guidelines outlined in the PRISMA statement, a comprehensive search was conducted using Google Scholar, PubMed, CINAHL, Cochrane Collaboration, and other grey literature. Only randomized controlled studies and pre-appraised evidence such as systematic review and meta-analysis examining the effects of ketamine in total knee and hip arthroplasty were included. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide.

FINDINGS

Three systematic reviews and meta-analyses and 2 randomized controlled trials involving 1284 patients were included in this review. The use of ketamine reduced pain scores within the 24 hours after surgery. In addition, evidence suggests that patients who were treated with ketamine consumed fewer opioids 24 and 48 hours after surgery. Furthermore, ketamine reduced the incidence of postoperative nausea and vomiting with no effects on the incidence of hallucinations and central nervous system side effects. All studies included in the review were categorized as Level I and rated Grade A implying strong confidence in the true effects of ketamine in all outcome measures in the review.

CONCLUSIONS

The current evidence demonstrates the viability of ketamine as a safe and effective alternative to opioids in the perioperative setting with major total joint arthroplasty surgery. Decreased pain scores and opioid consumption up to 48 hours into the postoperative period were observed in a number of the appraised articles.