A state-of-the-art pain protocol for total knee replacement.
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ABSTRACT:
SUBMITTER: Dalury DF
PROVIDER: S-EPMC4957167 | biostudies-literature | 2016 Mar
REPOSITORIES: biostudies-literature
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A state-of-the-art pain protocol for total knee replacement.
Arthroplasty today 20160212 1
Total knee replacement is acknowledged as a successful and durable operation, but recovery from this surgery is often lengthy and painful. A great deal of attention has recently been directed at enhancing this recovery, most of which has focused on improvements in perioperative pain control. Various protocols have been suggested. This article discusses a pain management program that uses local infiltrative analgesia with a specific "cocktail" which, when combined with an oral multimodal pain reg ...[more]
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Project description:Pain is the main impetus for osteoarthritis (OA) patients to seek healthcare including joint replacement. The pain experience in OA is heterogeneous and affected by factors across multiple domains-peripheral, psychological, and neurological. This indicates the existence of homogenous subgroups/phenotypes within OA patients with pain. We recently identified three pain phenotypes using a wide spectrum of pain-related factors, including structural damage on magnetic resonance imaging (MRI), emotional problems, number of painful sites, sex, body mass index, education level and comorbidities (i.e., Class 1: high prevalence of emotional problems and low prevalence of structural damage (25%); Class 2: low prevalence of emotional problems and high prevalence of structural damage (20%); Class 3: low prevalence of emotional problems and low prevalence of structural damage (55%)). This study was to examine whether the total knee replacement (TKR) risk over 12 years was different among these three pain phenotypes. Data on 963 participants (mean age 62.8 ± 7.4 years) from a population-based cohort study were utilised. Data on socio-demographic, psychological and comorbidities were collected. MRI of the right knee structural pathology was performed. TKR history was ascertained by linking to the Australian Orthopedic Association National Joint Replacement Registry. Latent class analysis and the Cox proportional hazards model were applied for the analysis. During the follow-up period, 41 right and 44 left TKRs in 67 participants were identified. In multivariable analyses, participants in Class 1 and 2 had a higher risk of having a TKR (Class 1 vs. Class 3, HR (hazard ratio) 4.81, 95%CI (confidence interval) 2.33-9.93; Class 2 vs. Class 3, HR 9.23, 95%CI 4.66-18.30). These associations were stronger in the imaged right knee but were also significant in the left knee. Participants within distinct pain phenotypes have different risks of TKR, suggesting that the identified phenotypes reflect distinct clinical subgroups with different prognoses. The risk for TKR was higher in Class 1 than that in Class 3, suggesting that pain/emotional status is a stronger driver for TKR than structural damage, and that selecting patients for TKR needs to be optimized in clinical practice.
| S-EPMC7141124 | biostudies-literature
Project description:BackgroundTotal knee arthroplasty is a common surgery for end-stage knee osteoarthritis. Partial knee arthroplasty is also a treatment option for patients with arthritis present in only one or two knee compartments. Partial knee arthroplasty can preserve the natural knee biomechanics, but these replacements may not last as long as total knee replacements. Robotic-assisted orthopedic techniques can help facilitate partial knee replacements, increasing accuracy and precision. This trial will investigate the feasibility and assess clinical outcomes for a larger definitive trial.MethodsThis is a protocol for an ongoing parallel randomized pilot trial of 64 patients with uni- or bicompartmental knee arthritis. Patients are randomized to either receive robot-assisted partial knee arthroplasty or manual total knee arthroplasty. The primary outcome of this pilot is investigating the feasibility of a larger trial. Secondary (clinical) outcomes include joint awareness, return to activities, knee function, patient global impression of change, persistent post-surgical pain, re-operations, resource utilization and cost-effectiveness, health-related quality of life, radiographic alignment, knee kinematics during walking gait, and complications up to 24 months post-surgery.DiscussionThe RoboKnees pilot study is the first step in determining the outcome of robot-assisted partial knee replacements. Conclusions from this study will be used to design future large-scale trials. This study will inform surgeons about the potential benefits of robot-assisted partial knee replacements.Trial registrationThis study was prospectively registered on clinicaltrials.gov (identifier: NCT04378049) on 4 May 2020, before the first patient was randomized.
| S-EPMC10880336 | biostudies-literature
Project description:Background and purpose - Meaningful interpretation of postoperative Oxford Knee Score (OKS) levels is challenging. We established Patient Acceptable Symptoms State (PASS) and Treatment Failure (TF) values for the OKS in patients undergoing primary total knee replacement (TKR) in Denmark.Patients and methods - Data from patients undergoing primary TKR between February 2015 and January 2019 was extracted from the arthroplasty registry at the Copenhagen University Hospital, Hvidovre in Denmark. Data included 3, 12, and 24 months postoperative responses to the OKS and 2 anchor questions asking whether they considered their symptom state to be satisfactory, and if not, whether they considered the treatment to have failed. PASS and TF threshold values were calculated using the adjusted predictive modeling method. Non-parametric bootstrapping was used to derive 95% confidence intervals (CI).Results - Complete 3, 12, and 24 months postoperative data was obtained for 187 of 209 (89%), 884 of 915 (97%), and 575 of 586 (98%) patients, with median ages from 68 to 70 years (59 to 64% female). 72%, 77%, and 79% considered as having satisfactory symptoms, while 6%, 11%, and 11% considered the treatment to have failed, at 3, 12, and 24 months postoperatively, respectively. OKS PASS values (CI) were 27 (26-28), 30 (29-31), and 30 (29-31) at 3, 12, and 24 months postoperatively. TF values were 27 (26-28) and 27 (26-29) at 12 and 24 months postoperatively.Interpretation - The OKS PASS values can be used to guide the interpretation of TKR outcome and support quality assessment in institutional and national registries.
| S-EPMC7919874 | biostudies-literature
Project description:Background:Pain control after total knee replacement (TKR) is pivotal in postoperative rehabilitation. Usage of epidural analgesia or parenteral opioids can cause undesirable side effects hampering early recovery and rehabilitation. These side effects can be avoided by infiltration of an analgesic cocktail locally. Our study was performed to evaluate the benefits of a particular cocktail combination in patients undergoing TKR with respect to pain and knee motion recovery. Methods:One hundred consecutive patients who underwent simultaneous bilateral TKR were enrolled and received an intraoperative periarticular cocktail injection in the right knee (intervention) and normal saline in the left knee (control). Postoperative pain was recorded using the visual analog scale for each knee, and the time taken to achieve 90° of knee flexion was noted for each side. Results:The cocktail injected knee had significantly less pain when compared with the control knee during the first 48 hours and significantly shorter period to achieve 90° of knee flexion. Conclusions:The use of intraoperative periarticular cocktail injection significantly reduces early postoperative pain and provides better early knee motion.
| S-EPMC6728801 | biostudies-other
Project description:BACKGROUND:Total knee replacement is a common operative procedure to improve pain, function, and quality of life in patients with end stage knee osteoarthritis. The current study aimed to compare simultaneous bilateral versus unilateral total knee replacement on pain intensity and recovery of function. METHODS:A total of 80 patients (bilateral 50, unilateral 30) aged 63.28 (9.4) years undergone total knee replacement participated in the current study. The participants were admitted for 5-7?days in the hospital. Participants in both the group received similar inpatient and outpatient physiotherapy sessions. Pain intensity and function capacity were assessed at baseline, day 7, and day 30 postoperatively using visual analogue scale and lower extremity functional scale, respectively. Repeated measures analysis of variance was used to analyze the data. RESULTS:Both groups showed a significant reduction of pain intensity (Day 0, mean 8.9, SD 1.0; Day 30, mean 2.2, SD 1.3 in bilateral total knee replacement; Day 0, mean 8.8, SD 1.1; Day 30, mean 2.0, SD 1.5 in unilateral total knee replacement; p <?0.001) and improvement in the functional capacity (Day 0, mean 16.2, SD 10.1; Day 30, mean 55.6, SD 14.6 in bilateral total knee replacement; Day 0, mean 19.1, SD 9.1; Day 30, mean 56.7, SD 15.8 in unilateral total knee replacement; p <?0.001) following total knee replacement at 30?days post-operatively. However, there was a non-significant difference noted between bilateral versus unilateral total knee replacement on the reduction of pain intensity (mean changes, 6.9 versus 6.8) and improvement in the functional capacity (mean changes, 39.4 versus 37.6) at 30?days post-operatively (p?>?0.05). CONCLUSION:Simultaneous bilateral total knee replacement was associated with a similar reduction of pain intensity and recovery of function compared to unilateral total knee replacement, suggesting the use of simultaneous bilateral total knee replacement in patients with bilateral knee osteoarthritis since its costs and rehabilitation process could be reduced compared to staged bilateral total knee replacement.
| S-EPMC7161292 | biostudies-literature
Project description:BackgroundChronic postoperative pain affects approximately 20% of patients with knee osteoarthritis after total knee replacement. Circulating microRNAs can be found in serum and might act as biomarkers in a variety of diseases. The current study aimed to investigate the preoperative expression of circulating microRNAs as potential predictive biomarkers for the development of chronic postoperative pain in the year following total knee replacement.MethodsSerum samples, collected preoperatively from 136 knee osteoarthritis patients, were analyzed for 21 circulatory microRNAs. Pain intensity was assessed using a visual analog scale before and one year after total knee replacement. Patients were divided into a low-pain relief group (pain relief percentage <30%) and a high-pain relief group (pain relief percentage >30%) based on their pain relief one year after total knee replacement, and differences in microRNAs expression were analyzed between the two groups.ResultsWe found that three microRNAs were preoperatively dysregulated in serum in the low-pain relief group compared with the high-pain relief group. MicroRNAs hsa-miR-146a-5p, -145-5p, and -130 b-3p exhibited fold changes of 1.50, 1.55, and 1.61, respectively, between the groups (all P values < 0.05). Hsa-miR-146a-5p and preoperative pain intensity correlated positively with postoperative pain relief (respectively, R = 0.300, P = 0.006; R = 0.500, P < 0.001).DiscussionThis study showed that patients with a low postoperative pain relief present a dysregulation of circulating microRNAs. Altered circulatory microRNAs expression correlated with postoperative pain relief, indicating that microRNAs can serve as predictive biomarkers of pain outcome after surgery and hence may foster new strategies for preventing chronic postoperative pain after total knee replacement (TKR).
| S-EPMC7543153 | biostudies-literature
Project description:BackgroundA major limitation of total knee replacement (TKR), as with other joint replacements, is the risk of revision. Revision TKR is associated with high risk and economic burden to patients, healthcare providers, and societies. It will be worthwhile to assess the economic burden of revision TKR across countries or different study settings. This study aims to review the literature on the cost of revision TKR to assess costs across countries and studies, estimate a pooled cost estimate for homogenous data, and identify major cost components that contribute to the cost burden.MethodsWe will conduct a search of the MEDLINE (OvidSp), EMBASE, Web of Science, Cochrane Library, EconLit, and Google Scholar databases to identify relevant studies, and will use an optimally designed search approach to search for relevant studies. EndNote library will be used to manage the searched studies. Selection will be undertaken in two phases-screening and eligibility. Study selection, data extraction, and assessment of the risk of bias will be performed in duplicate, after which the data will be analysed narratively and a meta-analysis performed for homogenous studies, if possible.DiscussionThis protocol provides a proposed stepwise plan for conducting a systematic review and meta-analysis of the cost of revision TKR. Findings from this systematic review will provide information about the cost across settings and identify the major cost drivers of revision TKR, which will, in turn, stimulate efforts to minimize the cost.Systematic review registrationPROSPERO CRD42020171988.
| S-EPMC8160044 | biostudies-literature
Project description:IntroductionThis study is designed to determine whether a full randomised controlled trial (RCT) examining the clinical effectiveness and safety of total knee replacement surgery with or without a tourniquet is warranted and feasible.Method and analysisSingle centre, patient-blinded and assessor-blinded RCT. A computer-generated randomisation service will allocate 50 participants into one of two trial treatments, surgery with or without a tourniquet. The primary objective is to estimate recruitment, crossovers and follow-up of patients. All patients will have an MRI scan of their brain preoperatively and day 1 or 2 postoperatively to identify ischaemic cerebral emboli (primary clinical outcome). Oxford Cognitive Screen, Montreal Cognitive Assessment and Mini-Mental State Examination will be evaluated as outcome tools for measuring cognitive impairment at days 1, 2 and 7 postoperatively. Thigh pain, blood transfusion requirements, venous thromboembolism, revision surgery, surgical complications, mortality and Oxford knee and five-level EuroQol-5D scores will be collected over 12 months. Integrated qualitative research study: 30 trial patients and 20 knee surgeons will take part in semistructured interviews. Interviews will capture views regarding the pilot trial and explore barriers and potential solutions to a full trial. Multicentre cohort study: UK National Joint Registry data will be linked to Hospital Episode Statistics to estimate the relationship between tourniquet use and venous thromboembolic event, length of hospital stay, risk of revision surgery and death. The study will conclude with a multidisciplinary workshop to reach a consensus on whether a full trial is warranted and feasible.Ethics and disseminationNational Research Ethics Committee (West Midlands-Edgbaston) approved this study on 27 January 2016 (15/WM/0455). The study is sponsored by University of Warwick and University Hospitals Coventry and Warwickshire. The results will be disseminated via high-impact peer-reviewed publication.Trial registration numberISRCTN20873088; Pre-results.
| S-EPMC5900804 | biostudies-literature
Project description:It is unclear whether mobile-bearing (MB) total knee arthroplasties reduce the risk of tibial component loosening compared to fixed-bearing (FB) designs. This randomized study investigated implant migration, periprosthetic bone mineral density (BMD), and patient-reported outcomes (Oxford knee score)-all at 2 years-for the P.F.C. Sigma Cruciate Retaining total knee arthroplasty.50 osteoarthritis patients were allocated to either FB or MB tibial articulation.At 2 years, the mean total translation (implant migration) was higher for the FB implant (0.30 mm, SD 0.22) than for the MB implant (0.17 mm, SD 0.09) (p = 0.04). BMD decreased between baseline and 1-year follow-up. At 2-year follow-up, BMD was close to the baseline level. The knee scores of both groups improved equally well. The FB tibial implant migrated more than the MB, but this was not clinically significant. The mobile polyethylene presumably partly absorbs the force transmitted to the metal tibial tray, thereby reducing micromotion.
| S-EPMC4404772 | biostudies-literature
Project description:ObjectiveTo identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR).DesignThe systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3?months postoperatively and pain at 6?months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6?months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR.ResultsAfter removal of duplicates, 16?430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres.ConclusionThis systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients' outcomes after TKR.
| S-EPMC5695416 | biostudies-literature