post-TKA Pain Research Articles

Association of Early Postoperative Pain Trajectories With Longer-term Pain Outcome After Primary Total Knee Arthroplasty

Studies to date have not comprehensively examined pain experience after total knee arthroplasty (TKA). Discrete patterns of pain in this period might be associated with pain outcomes at 6 to 12 months after TKA. To examine patterns of individual post-TKA pain trajectories and to assess their independent associations with longer-term pain outcome after TKA. This prospective cohort study combined data from a national US TKA cohort with ancillary pain severity data at 2 weeks and 8 weeks after the index TKA using a numeric rating scale. All participants received primary, unilateral TKA within the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) national network of community sites in 22 states or at the lead site (University of Massachusetts Medical School). Participants had a date of surgery between May 1, 2013, and December 1, 2014. The data analysis was performed between January 13, 2015, and July 5, 2016. Pain trajectories in the postoperative period (8 weeks). Index knee pain at 6 months after TKA using the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale. Group-based trajectory methods examined the presence of pain trajectories in the postoperative period (8 weeks) and assessed whether trajectories were independently associated with longer-term pain (6 months). The cohort included 659 patients who underwent primary TKA with complete data at 4 points (preoperative, 2 weeks, 8 weeks, and 26 weeks). Their mean (SD) age was 67.1 (8.0) years, 64.5% (425 of 659) were female, the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 30.77 (5.66), 94.5% (613 of 649) were white, and the mean (SD) preoperative 36-Item Short Form Health Survey physical component summary and mental component summary scores were 34.1 (8.2) and 53.8 (11.4), respectively. Two pain trajectory subgroups were identified at 8 weeks after TKA: patients who experienced fast pain relief in the first 8 weeks after TKA (fast pain responders, composing 72.4% [477 of 659] of the sample) and patients who did not (slow pain responders, composing 27.6% [182 of 659] of the sample). After adjusting for patient factors, the pain trajectory at 8 weeks after TKA was independently associated with the mean KOOS pain score at 6 months, with a between-trajectory difference of -11.3 (95% CI, -13.9 to -8.7). The trajectory among slow pain responders at 8 weeks after surgery was independently associated with improved but greater persistent index knee pain at 6 months after TKA compared with that among fast pain responders. Early identification of patients with a trajectory of slow pain response at 8 weeks after TKA may offer an opportunity for interventions in the perioperative period to potentially improve the long-term pain outcomes after TKA.

Role and mechanism of nursing cooperation and tetramethylpyrazine application in post-operative pain in patients undergoing total knee arthroplasty.

The aim of the present study was to investigate the effect of nursing cooperation on the post-operative complication of pain following total knee arthroplasty (TKA) and to explore the effects of tetramethylpyrazine (TMP) application on post-TKA pain. A total of 26 patients who received TKA between June 2014 and March 2016 were enrolled in this study. Nursing cooperation was provided to the patients during the TKA surgery, and pain was evaluated based on the visual analog scale (VAS). In addition, 40 male Sprague Dawley rats were used for the TKA model construction. The rats were randomly separated into 4 groups (sham, TKA, TKA+TMP and TKA+TMP+Interferon γ). Pain tolerance in rats was evaluated by mechanical stimulation. Inflammatory cytokine levels in TKA rat tissue were detected using ELISA. mRNA and protein expression of Janus kinase/signal transducer and activator of transcription 3 (JAK/STAT3) was detected using reverse transcription-polymerase chain reaction and western blot analysis, respectively. The results indicated that nursing cooperation serves a critical function during TKA and was associated with a lower level of pain compared with the control (P<0.05). Furthermore, TMP treatment reduced the level of inflammatory cytokines in the rat tissues, including interleukin (IL)-6, IL-10 and tumor necrosis factor-α in post-TKA (P<0.01). TMP was indicated to alleviate pain in post-TKA through suppressing the JAK/STAT3 signaling pathway. The results of the present study suggest that nursing cooperation is critical to TKA, and TMP may alleviate post-TKA pain through inhibiting the JAK/STAT3 signaling pathway.

Anesthesia and analgesia for total knee arthroplasty.

The demand for total knee arthroplasty (TKA) is rising worldwide. Controversy persists in the literature regarding the benefits of general versus neuraxial anesthesia and which anesthetic is associated with the best outcomes. Likewise, the abundance of analgesic options for post-TKA pain have led to debate regarding the safest, most effective regimens. In this paper, we evaluated a selection of recent publications regarding anesthetic and analgesic choices for TKA. High-quality studies and meta-analyses linking anesthetic agents and analgesic modalities to clinically important outcomes were chosen wherever possible. We included a range of clinical and population-based research, incorporating established and emerging techniques. Although not uniform, clinical and population-based data favor neuraxial anesthesia, and suggest less morbidity compared to general anesthesia. There is good evidence to support an opioid-minimizing, multimodal approach to post-TKA analgesia, featuring peripheral nerve blocks and/or peri-articular injection. The recently described IPACK (interspace between the popliteal artery and posterior capsule of the knee) block may address posterior knee pain after TKA. Ultrasound-guided regional analgesia techniques are cost and clinically effective. Liposomal bupivacaine represents an expanding topic of research in TKA-analgesia, but currently, data do not support routine use. Evidence to guide the creation of pathways of care for TKA abounds, but must be tailored to local practice to maximize chances of success. Recent data supports the use of neuraxial anesthesia and regional analgesia techniques for TKA. Recommendations for clinical practice and future research to improve the state of the art are provided.

A randomized study of the efficacy and safety of parecoxib for the treatment of pain following total knee arthroplasty in Korean patients.

PurposeParecoxib is an injectable cyclooxygenase-2 inhibitor with proven postoperative analgesic efficacy in a variety of settings, including total knee arthroplasty (TKA). The effect of ethnicity on the efficacy of parecoxib for post-TKA pain has not been studied.Patients and methodsThis was a parallel-group, double-blind, randomized, placebo- controlled study of ethnically Korean patients aged ≥18 years who had unilateral TKA. Patients who reported moderate or severe pain 6 hours after the end of postoperative opioid analgesia were randomized to receive a single intravenous dose of parecoxib sodium 40 mg or placebo. Patients were evaluated for 24 hours postdose. The primary efficacy endpoints included time-specific pain intensity difference (PID), time-specific pain relief (PR), and time to rescue medication. The incidence and nature of adverse events (AEs) assessed safety.ResultsOf the 116 patients randomized, 58 received parecoxib and 58 placebo. Mean (SD) PID was significantly greater for parecoxib vs placebo 1 hour postdose (0.69 [0.67] vs 0.40 [0.59], respectively; p<0.05), and for each time point up to 24 hours. Similarly, mean (SD) PR was significantly greater for parecoxib vs placebo 1.5 hours postdose (1.63 [0.85] vs 1.07 [0.90], respectively; p=0.001), and for each time point up to 24 hours. The median time (hours:minutes) to rescue medication was significantly longer for parecoxib vs placebo (21:30 vs 4:08, respectively; p<0.001). Generally, fewer AEs were reported with parecoxib than placebo, and the AE profile was consistent with previous studies. These results are comparable to the findings from a similarly designed study in a Caucasian patient population.ConclusionParecoxib 40 mg significantly improved postoperative pain vs placebo in Korean patients after TKA. The efficacy and safety of parecoxib in Korean patients is similar to that seen in Caucasian patients.

QX-OH/Levobupivacaine: Fixed-dose combination to provide a long-acting postoperative pain of knee surgery in rodents

Although total knee arthroplasty (TKA) is a commonly performed procedure, anesthetic efficacy in post-surgical pain remains an issue. Exparel (45mM liposome bupivacaine), a relatively long-acting local anesthetic, has shown efficacy in blocking peripheral nerve or periarticular infiltration to achieve better post-TKA analgesia. In the present work, we tested whether a fixed-dose combination of QX-OH (35mM) and levobupivacaine (10mM) (QX-OH/LB) could confer longer-lasting pain relief and reduce periarticular tissue toxicity compared to liposome bupivacaine (45mM) after TKA operation. In the sciatic nerve block, the duration of sensory block by QX-OH/LB was 2-fold higher than by liposome bupivacaine (median [25th, 75th percentiles], 9.83 [9.33, 10.83] hours versus 4.83 [4.83, 5] hours; P=0.001). Liposome bupivacaine failed to improve post-surgical travel distance and speed (P=0.373) in rats 6h after TKA surgery (versus saline). Similar results were observed in operated mice treated with liposome bupivacaine. However, QX-OH/LB increased locomotor activities markedly both in rats and mice at 6h post-TKA (P<0.001). In addition, there was no difference in the inflammatory recruitment and articular structural damage among murine models-treated with QX-OH/LB, liposome bupivacaine and saline. In conclusion, we show that QX-OH/LB is a safe and long-lasting anesthetic than liposome bupivacaine in the post-TKA pain management in murine models.

The Effect of Preoperative Intra-Articular Methylprednisolone on Pain After TKA: A Randomized Double-Blinded Placebo Controlled Trial in Patients With High-Pain Knee Osteoarthritis and Sensitization

Peripherally driven inflammatory pain and nociceptive changes before TKA has been suggested to be a cause for increased acute postoperative pain. However, preoperative intra-articular MP in patients with high pain osteoarthritis and sensitization did not reduce acute post-TKA pain or sensitization despite a preoperative reduction of intra-articular inflammatory markers.

Pain Control in Total Knee Arthroplasty.

As surgical techniques and pharmacology advance, the management of postoperative pain in patients undergoing total knee arthroplasty (TKA) continues to evolve. The current standards of care are composed of multimodal pain management including opioids, nonsteroidal anti-inflammatory drugs and gabapentinoids, peripheral nerve blocks, and periarticular injections. Newer modalities are composed of delayed release local anesthetics and cryoneurolysis. To summarize the current evidence-based treatment modalities and forecast changes in the management of patients having TKAs, we reviewed available data on: (1) oral analgesics; (2) periarticular injections; (3) peripheral nerve blocks; (4) multimodal regimens; and (5) newer modalities in post-TKA pain management. Multimodal analgesic regimens that target numerous pain pathways may provide the best pain management, rehabilitation, patient satisfaction, and reduce opioid use and related side effects. Periarticular injections of delayed-release local anesthetics may further enhance pain management.

Clinical, nociceptive and psychological profiling to predict acute pain after total knee arthroplasty.

Pre-operative identification of high-pain responders for acute pain after total knee arthroplasty (TKA) could lead to targeted analgesic trials and individualized analgesic strategies to improve recovery and potentially reduce the risk of persistent post-surgical pain. The aim of this study was to use simple clinical tests and questionnaires to identify predictive nociceptive and psychological factors for acute post-TKA pain. Sixty consecutive TKA patients were included in a prospective descriptive study of pain during a 5-m walk-test 24h post-operatively as the primary outcome. Predictive variables collected prior to surgery included demographics, nociceptive testing (pressure pain threshold (PPT), cold pressor tolerance, electrical pain threshold and tolerance) and psychological profile (pain catastrophizing scale (PCS) and hospital anxiety and depression scale). The prediction of acute post-TKA pain was assessed by univariate analysis, logistic regressions and ROC curves. Reduced PPT on the arm and increased PCS were predictive variables for moderate/severe post-TKA pain 24h after surgery (P=0.007 and P=0.026, respectively, R-squared 0.21) in the logistic regression model. Odds ratios were 0.67 for a 50 kPa increased PPT and 1.36 for a 5point increase in PCS. A predictive model with cut-off values of PPT≤245 kPa and PCS≥8 point had a sensitivity of 71.4 and a specificity of 62.5. Pre-operative widespread pressure pain hypersensitivity and pain catastrophizing are predictive of moderate severe post-TKA pain. If validated in a larger population, the clinically applicable tests should be considered in future interventions aiming to minimize post-operative pain in high-risk patients.

Nonpharmacologic Pain Management and Muscle Strengthening following Total Knee Arthroplasty.

Despite technological advances in total knee arthroplasty (TKA), management of postoperative muscle weakness and pain continue to pose challenges for both patients and health care providers. Nonpharmacologic therapies, such as neuromodulation in the form of neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS), and other modalities, such as cryotherapy and prehabilitation, have been highlighted as possible adjuncts to standard-of-care pharmacologic management to treat postoperative pain and muscle weakness. The aim of this review was to discuss existing evidence for neuromodulation in the treatment of pain and muscular weakness following TKA, and to shed light on other noninvasive and potential future modalities. Our review of the literature demonstrated that NMES, prehabilitation, and some specialized exercises are beneficial for postoperative muscle weakness, and TENS, cooling therapies, and compression may help to alleviate post-TKA pain. However, there are no clear guidelines for the use of these modalities. Further studies should be aimed at developing guidelines or delineating indications for neuromodulation and other nonpharmacologic therapies in the management of post-TKA pain and muscle weakness.

Are outcomes after total knee arthroplasty worsening over time? A time-trends study of activity limitation and pain outcomes.

BackgroundTo examine whether function and pain outcomes of patients undergoing primary total knee arthroplasty (TKA) are changing over time.MethodsThe Mayo Clinic Total Joint Registry provided data for time-trends in preoperative and 2-year post-operative activity limitation and pain in primary TKA patients from 1993-2005. We used chi-square test and analysis for variance, as appropriate. Multivariable-adjusted analyses were done using logistic regression.ResultsIn a cohort of 7,229 patients who underwent primary TKA during 1993-2005, mean age was 68.4 years (standard deviation (SD), 9.8), mean BMI was 31.1 (SD, 6.0) and 55% were women. Crude estimates showed that preoperative moderate-severe overall limitation were seen in 7.3% fewer patients and preoperative moderate-severe pain in 2.7% more patients in 2002-05, compared to 1992-95 (p < 0.001 for both). At 2-years, crude estimates indicated that compared to 1992-95, moderate-severe post-TKA overall limitation was seen in 4.7% more patients and moderate-severe post-TKA pain in 3.6% more patients in 2002-05, both statistically significant (p ≤ 0.018) and clinically meaningful. In multivariable-adjusted analyses that adjusted for age, sex, anxiety, depression, Deyo-Charlson index, body mass index and preoperative pain/limitation, patients had worse outcomes 2-year post-TKA in 2002-2005 compared to 1993-95 with an odds ratio (95% confidence interval (CI); p-value) of 1.34 (95% CI: 1.02, 1.76, p = 0.037) for moderate-severe activity limitation and 1.79 (95% CI: 1.17, 2.75, p = 0.007) for moderate-severe pain.ConclusionPatient-reported function and pain outcomes after primary TKA have worsened over the study period 1993-95 to 2002-05. This time-trend is independent of changes in preoperative pain/limitation and certain patient characteristics.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-440) contains supplementary material, which is available to authorized users.

Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: Impact on discharge

IntroductionThe goal of this retrospective study was to compare pain control following total knee arthroplasty (TKA) on a perioperative protocol of local anesthesia (LA) versus the more classical femoral nerve block (FNB) technique. HypothesisFitness for discharge would be achieved earlier using the LA protocol. MaterialsNinety-eight consecutive TKA patients operated on by a single surgeon were included with no selection criteria. In the study group (49 patients), 200mL ropivacaine 5% was injected into the surgical wound and an intra-articular catheter was fitted to provide continuous infusion of 20mL/h ropivacaine for 24h. The control group (49 patients) received ropivacaine FNB. Discharge fitness (independent walking, knee flexion>90°, quadricipital control, pain on VAS≤3) and hospital stay were assessed. ResultsDischarge fitness was achieved significantly earlier in the study group (4.2±2.6 versus 6.7±3.2days; P=0.0003), with significantly shorter mean hospital stay (6.1±3.4 versus 8.8±3.5days; P=0.0002). The complications rate did not differ between study and control groups. DiscussionAlthough retrospective, this study indicates that the LA protocol improves management of post-TKA pain and accelerates rehabilitation, thereby, reducing hospital stay. The acceleration effect may be due to the absence of quadriceps inhibition. Level of evidenceLevel III – Case control study.

Transcranial Direct Current Stimulation (tDCS) Reduces Postsurgical Opioid Consumption in Total Knee Arthroplasty (TKA)

Although pain is often a symptom that precedes total knee arthroplasty (TKA), the procedure itself is associated with considerable postoperative pain lasting days to weeks. Postoperative pain control is an important factor in determining recovery time, hospital length of stay, and rehabilitation success. Several brain stimulation technologies including transcranial direct current stimulation (tDCS) have demonstrated promise as treatments for a variety of pain conditions. The present study examined the effects of 4 sessions of tDCS on post-TKA pain and opioid consumption. Forty patients undergoing unilateral TKA were randomly assigned to receive a total of 80 minutes of real (n=20) or sham tDCS (n=20) with the anode over the knee representation of the motor strip (C1h or C2h corresponding to the target knee) and cathode over the right dorsolateral prefrontal cortex (F3; located by the EEG 10-20 System). Patient-controlled analgesia ( hydromorphone) use was tracked during the ∼48 hours postsurgery. Patients in the real tDCS group used an average of 6.6 mg (SD=5.3) of patient-controlled analgesia hydromorphone, whereas those in the sham group used 12.3 mg (SD=6.6; t37=2.93, P=0.006). Despite using less opioid medication, participants in the real tDCS group reported no pain exacerbation or worse mood with respect to those in the sham tDCS group. Results from this pilot feasibility study suggest that tDCS may be able to reduce post-TKA opioid requirements. Although these results are preliminary, the data support further research in the area of adjunctive cortical stimulation in the management of postsurgical pain.

Single-injection femoral nerve block lacks preemptive effect on postoperative pain and morphine consumption in total knee arthroplasty

ObjectivePostoperative pain is severe after total knee arthroplasty (TKA). Therefore, femoral nerve block (FNB) is commonly used as an adjuvant to spinal anesthesia for TKA. Some anesthesia providers perform this preoperatively, while others perform it postoperatively. To our knowledge, no study has compared the relative benefits of the timing of performing the procedure. In this study, we investigated whether preoperative FNB would provide better analgesic effects than postoperative FNB in patients undergoing unilateral TKA. MethodsIn this double-blind, randomized, controlled trial, we divided 82 patients (ASA physical status I–III) undergoing unilateral TKA into four groups: (1) a pre-treatment group, in which FNB was performed with 0.4 mL/kg 0.375% bupivacaine plus 1:200,000 epinephrine after spinal anesthesia but before the operation; (2) a post-treatment group, in which FNB was performed with the same drugs at similar dosages immediately after the operation; (3) a pre-control group, in which FNB was performed with normal saline in the same volume as the tested drugs before the operation; and (4) a post-control group, in which FNB was performed with normal saline in the same volume as the tested drug after the operation. At 2, 4, 6, 24, 48 and 72 postoperative hours, we recorded cumulative morphine consumption, visual analog pain scales (VAS), the time of first request for morphine and its side effects. We also measured knee maximum flexion range of motion once a day for 3 days. Our primary aim was to obtain cumulative morphine consumption in 24 hours. ResultsWithin the postoperative 24 hours, we found significant differences in cumulative morphine consumption between patients who received true FNB and those who did not (at 24 hours, treatment groups = 45.6 ± 31.7 and 33.5 ± 20.6 mg vs. controls = 70.8 ± 31.2 and 78.8 ± 37.7 mg, p < 0.001). We also found significant differences in VAS (at 24 hours, p < 0.001) and time to first request of morphine (p = 0.005) between the treatment group and the sham group. However, there were no significant differences in these values between the pre-surgical treatment group and the post-surgical treatment group. Beyond 24 hours, there were no significant differences in morphine consumption or maximum flexion range on day 2 and day 3 among the four groups. ConclusionPatients who received FNB used for total knee arthroplasty consumed significantly less postoperative morphine and had significant relief of post-TKA pain on postoperative day 1 than those who did not have FNB. However, at follow-up we found no significant differences in these values between those receiving FNB before surgery and those receiving it after surgery.

Reduction in Narcotic Use After Primary Total Knee Arthroplasty and Association with Patient Pain Relief and Satisfaction

We examined the prevalence of narcotic use before and after total knee arthroplasty (TKA) and its association with post-TKA pain relief and satisfaction. Data on 6364 primary, unilateral TKA patients in a national registry were analyzed. Before TKA, 24% of patients were prescribed one form of narcotic. Of these, 14% reported continued narcotic use at 12 months after TKA, whereas the majority discontinued use. Only 3% of patients who did not use narcotics before TKA had a narcotics prescription at 12 months. Patients who used narcotics before TKA were more likely to have a narcotic prescription at 12 months post-TKA, reported greater pain at 12 months, and were more likely to be dissatisfied with TKA outcome. These findings have implications for patient pre-TKA counseling.