The Role of Preoperative Radiologic Severity, Sensory Testing, and Temporal Summation on Chronic Postoperative Pain Following Total Knee Arthroplasty

Abstract

Objectives: Knee osteoarthritis (KOA) can be associated with local and central sensitization. As an indicator of the central gain, facilitated temporal summation of pain (TSP) has been found in KOA patients. This facilitation is predictive of the development of chronic postoperative pain after total knee arthroplasty (TKA). Other studies have suggested hypoesthesia/hypoalgesia to thermal stimuli as a feature in KOA. This study investigated associations between preoperative TSP, thermal sensitivity, and radiologic severity for the development of chronic postoperative pain after TKA. Methods: Radiologic KOA (Kellgren and Lawrence), TSP, and thermal stimuli were collected, preoperatively. Clinical knee pain intensity (VAS 0-10) was assessed before and 12 months following TKA. Patients were categorized into a chronic postoperative pain group if they experienced <30% pain reduction of the initial pain after 12 months. Results: In total, 19% of the patients were categorized as chronic pain patients and presented facilitated preoperative TSP (P<0.05) and a trend towards increased heat pain threshold (P=0.077) compared with patients with normal recovery. Pearson correlations found that preoperative TSP (R=0.193; P=0.013), Kellgren and Lawrence (R=−0.168; P=0.027), warm detection threshold (R=0.195; P=0.012), and heat pain threshold (R=0.196; P=0.012) were associated with pain intensity 12 months after TKA where TSP was identified as an independent factor. Discussion: This study showed that preoperatively facilitated TSP in KOA patients was predictive of the development of chronic postoperative pain following TKA. Furthermore, this study is the first to find an association between preoperative hypoalgesia to heat and the development of chronic postoperative pain following TKA.

Pain inhibitory mechanisms and response to weak analgesics in patients with knee osteoarthritis

“…Patients with musculoskeletal pain are often pain sensitive to pressure stimuli and not necessarily to heat stimuli (Neziri et al, ; Petersen, Simonsen, Laursen, & Arendt‐Nielsen, ). Offset analgesia can be evoked by heat (Grill & Coghill, ; Ligato et al, ; Petersen, Andersen, et al, ) and electrical stimuli (Petersen, Mørch, et al, ), but currently no study has demonstrated an offset analgesia effect using pressure stimuli.…”

Mechanistic pain profiling as a tool to predict the efficacy of 3-week nonsteroidal anti-inflammatory drugs plus paracetamol in patients with painful knee osteoarthritis

“…The VAS was anchored at 0 cm: no pain and 10 cm: worst pain imaginable. These assessments have been consistently used in similar studies [27,39,[41][42][43].…”

“…Further, mechanistic pain profiling of knee OA patients has found preoperative TSP and PPTs to be predictive of the development of chronic postoperative pain following total joint replacement [27,39,40,42,58]. These parameters are normalized after a successful TKA recovery leading to a painfree outcome [24,31] and this highlights the significance of such mechanisms as targets for pain management.…”

The influence of pre- and perioperative administration of gabapentin on pain 3–4 years after total knee arthroplasty

“…Several pre-and perioperative risk factors for chronic postoperative TKA have been suggested [4,5] where the major risk factors are preoperative, heightened, psychological factors related to pain (e.g. pain catastrophizing, anxiety, or depression) [6], high pre-and perioperative pain intensities [7][8][9] and more recently preoperative pain sensitivity [8,[10][11][12]. Gabapentinoids have an anxiolytic effect [13][14][15] and reduce neuronal hyperexcitability [16], and it has been suggested that preoperative and perioperative administration of gabapentinoids may reduce the incidence of chronic postoperative pain.…”

“…A measure of pain facilitation is temporal summation of pain (TSP), and gabapentin has been shown to decrease TSP in healthy subjects [16]. Preoperatively, facilitated TSP has been linked to the development of chronic postoperative pain following total hip arthroplasty surgery [10], TKA [8,11,12], and acute postoperative pain following thoracotomy [32], indicating that preoperative administration of gabapentinoids could potentially reduce the risk of developing chronic postoperative pain. Since, preoperative administration of pregabalin has been found to diminish neuropathic chronic postoperative pain following TKA [17], the current study hypothesized that different doses of gabapentin would reduce the prevalence of chronic postoperative pain following TKA and aimed to explore the effect of pre-and perioperatively administered gabapentin on the development of chronic postoperative pain in patients undergoing TKA.…”