Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review

Abstract

ObjectivesFor many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR.MethodsWe conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searchedThe Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.InterventionsPerioperative non-surgical interventions; control receiving no intervention or alternative treatment.Primary and secondary outcome measuresPain or score with pain component assessed at 6 months or longer postoperative.Results44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.ConclusionsTo prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.

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

“…The protocol for this systematic review was registered with PROSPERO 49. We formulated the research question according to the participants, intervention(s), comparator(s), outcomes (PICO) principle50 and used methods based on those recommended by Cochrane 51.…”

“…We established a database of all randomised controlled trials in knee replacement, in preparation for a suite of systematic reviews in chronic pain after TKR 47 48. Relevant trials were identified through searches (last updated on 18 December 2018) in: MEDLINE, Embase and PsycINFO on OvidSP; CINAHL on EBSCOhost; and The Cochrane Library .…”

“…A sensitivity analysis excluding those comparisons for which we had imputed data and/or studies we had assessed as being at overall high risk of bias was conducted. At protocol stage,49 we planned to generate funnel plots, if ten or more studies with similar interventions and controls were identified, as a method of estimating the risk of publication bias. In the event, data were not sufficient to do so.…”

“…Previous reviews have largely focused on specific interventions but we have opted for a temporal framework and sought to include any intervention conducted before surgery. This review is part of a broad suite of reviews considering the timing of intervention throughout the TKR care trajectory 47 48…”

Anesthesia Method, Tourniquet Use, and Persistent Postsurgical Pain after Total Knee Arthroplasty: A Prespecified Secondary Analysis of a Randomized Trial

“…11 Several studies have investigated factors that may affect the risk of persistent postsurgical pain. [7][8][9][12][13][14][15][16][17][18][19] However, data on the effects of spinal and general anesthesia on persistent pain after total knee arthroplasty are highly limited. A retrospective, multicenter study including patients who underwent hip or knee arthroplasty found no difference in the prevalence of persistent postsurgical pain between the regional and general anesthesia groups.…”