ORIGINAL ARTICLE

Chronic Postoperative Pain After Primary and Revision Total Knee Arthroplasty Kristian K. Petersen, MSc,*w Ole Simonsen, MD, PhD,w Mogens B. Laursen, MD, PhD,w Thomas A. Nielsen, BSc,* Sten Rasmussen, MD,*w and Lars Arendt-Nielsen, PhD*

Objectives: Clinical experience suggests that patients with osteoarthritis (OA) undergoing revision total knee arthroplasty (TKA) experience more chronic complications after surgery compared with patients receiving primary TKA. This study aimed to investigate the difference in pain, mobility, and quality of life (QoL) in patients after revision TKA compared with patients after primary TKA. Methods: A total of 99 OA patients after revision TKA surgery and 215 patients after primary TKA surgery were investigated in a cross-sectional study using: a pain description of current pain (nonexistent, mild, moderate, severe, or unbearable), the pain intensity visual analogue scale, the Knee Society Score, and the Osteoarthritis Research Society International questionnaire. Results: Nineteen percent after primary TKA surgery and 47% after revision TKA surgery experienced severe to unbearable chronic postoperative pain. After revision TKA surgery patients reported higher pain intensities during rest (P = 0.039), while walking (P = 0.008), and on average over the last 24 hours (P = 0.050) compared with the patients after primary TKA surgery. Patients after revision TKA surgery had reduced walking distance (P = 0.001), increased use of walking aids (P = 0.015), and showed an overall decreased QoL (P < 0.001) compared with patients after primary TKA surgery. No significant improvement was found in walking distance (P = 0.448) for patients before revision TKA surgery compared with after revision TKA surgery. Discussion: More than twice as many patients have pain after revision surgery compared with patients after primary TKA. Patients after revision TKA surgery have reduced function, poorer QoL, and higher pain intensity compared with patients after primary TKA surgery. Key Words: osteoarthritis, chronic pain, quality of life, total knee arthroplasty, revision arthroplasty

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O

steoarthritis (OA) is the most frequent musculoskeletal diagnosis in the elderly population and the most common cause of disability.1 Forty percent of women and Received for publication September 16, 2013; revised September 3, 2014; accepted January 16, 2014. From the *Department of Health Science and Technology, Faculty of Medicine, Center for Sensory-Motor Interaction (SMI); and wOrthopaedic Surgery Research Unit, Aalborg University Hospital, Aalborg, Denmark. Funded by “Lions Danmark,” (Copenhagen); “Gigtforeningen,” (Copenhagen); “Savværksejer Jeppe Juhl og hustru Ovita Juhls Mindelegat, (Kolding);” and The Danish Council for Technology and Innovation, (Copenhagen); (09-052174). The authors declare no conflict of interest. Reprints: Lars Arendt-Nielsen, PhD, Department of Health Science and Technology, Faculty of Medicine, Center for Sensory-Motor Interaction (SMI), Aalborg University, Frederik Bajers Vej 7, D3, DK-9220 Aalborg, Denmark (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins DOI: 10.1097/AJP.0000000000000146

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25% of men aged 60 to 70 years are diagnosed with OA.2 With the expected global growth in the elderly population and concomitant rise in stationary lifestyle choices, the incidence of OA is predicted to increase in the coming years.3–5 In 2007 nearly half a million total knee arthroplasty (TKA) implant surgeries were performed in the United States alone.6 Unfortunately, approximately 13% of the TKA patients will report severe chronic postoperative pain.7 For total hip replacement the number is 14% to 32%.8 Further, in fibromyalgia patients, in whom pain sensitization is prominent, chronic postoperative pain after TKA reaches 44%.9 Patients with a large number of comorbidities have been found to have less pain relief from revision TKA surgery10 indicating that additional pain comorbidities may worsen the outcome. Evidence suggests that sensitization and neuropathic descriptors apply to a subgroup of OA patients,7,11–14 and widespread hyperalgesia has been documented in a number of studies.13,15 Such factors may further increase the incidence of postoperative chronic pain after TKA. OA patients demonstrating >1 location of pain often express pain symptoms being more diffuse and spreading to larger areas16 supporting the notion that spreading sensitization may be present in these patients.17 Recently, pain intensity and duration of knee OA have been found to be associated with the degree of sensitization,15 but no studies have quantitatively investigated the effect of sensitization in OA for the outcome of TKA. Pre-TKA and post-TKA treatment with pregabalin seems to inhibit the development of chronic postoperative pain,18 which may indicate that sensitization plays a key role in determining the outcome of TKA. Other risk factors such as sex, age, preoperative and postoperative pain levels, repeated surgery, surgical procedure, depression, anxiety, and catastrophizing have been found to be predictive factors for the development of chronic postoperative pain.8,9,19,20 Chronic postoperative pain after primary TKA is often an indication for performing revision surgery, as minor mechanical dysfunctions in the prosthesis are believed to be the cause of pain, although this cannot be verified by standard radiologic examinations. In a meta-analysis Callahan et al21 showed that the rate of revision knee arthroplasty is 3.8%. Revision TKA is technically more difficult, has a higher rate of failure, and is associated with a higher complication rate than the primary TKA.22 Revision TKA performed for unexplained pain is reported to be associated with a low probability of success with continued symptoms of pain and impaired function.5 In general, little is known about the outcome of TKA revisions. The aim of the present cross-sectional cohort study was to investigate the incidence of chronic postoperative www.clinicalpain.com |

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pain after primary and revision TKA and the implications on function and quality of life (QoL).

MATERIALS AND METHODS All TKA patients who had undergone surgery in 2004 to 2005 at 3 hospitals in Northern Denmark were contacted by letter 3 years after the surgery and were invited to join the study. If the patients accepted the invitation, they were contacted by telephone and interviewed. The OA severity was scored by the Kellgren-Lawrence Grading Scale and Joint Space Width in the primary group as a measure of the radiologic severity of the OA. The patients were excluded if they could not cooperate, did not understand Danish, or had cognitive deficits. Clinical OA was defined following the American College of Rheumatology criteria and patients with previously diagnosed rheumatoid arthritis, fibromyalgia, and patients with a fractured knee were excluded from the study. The study was approved by the local ethics committee (N-20070064), approved by the Danish Data Protection Agency, and followed the rules of the Declaration of Helsinki.

Pain The patients were asked to rate the averaged 24 hours pain intensity of the index knee as not existing, mild, moderate, severe, or unbearable. Further, the patients were asked to score their pain intensity of the index knee during rest, during night, after 50 m of walk, and the worst pain within the last 24 hours on a continuous visual analogue scale (VAS 0 to 10 scale).



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that these patients were not a selected group, we randomly recontacted a group of 15% of the nonresponding patients and asked them about their function and pain at rest, in the night, after 50 m of walk, and the worst pain within the last 24 hours. These items were scored according to the KSS function and a VAS (0 = no pain, 10 = worst imaginable pain), respectively. The data from the responders and the nonresponders were compared to identify whether these patient groups were different.

RESULTS Of 500 primary and 99 revision surgery patients, 215 primary surgery patients (43%) and 90 revision surgery patients (91%) agreed to participate in the study. The primary surgery group had a mean Kellgren-Lawrence Grading Scale of 3.88 ± 0.34 SD (range, 2 to 4) and a Joint Space Width of 1.37 mm ± 1.63 SD (range, 0 to 7 mm) before surgery. Revision surgery was performed due to pain attributed by infections (17%), aseptic loosening (35%), mechanical instability (18%), pain without obvious cause (20%), and other reasons (10%). A nonresponder cohort analysis showed no significant differences to the responder group with respect to sex ratio, OA severity, preoperative and postoperative function, or pain parameters (P > 0.10).

Demographics

The Knee Society Score (KSS) function was available from the Danish Knee Arthoplasty Registry, in which all TKA patients are recorded before and collected 3 years after surgery. The KSS function was used to determine the patient mobility of the index knee in terms of walking distance, the ability to walk on stairs, and use of walking aids.

The revision patient group (on average 59 y; range, 37 to 82 y) was younger compared with the primary TKA patient group (65 y; range, 48 to 83 y) (P < 0.001). However, there was no difference in BMI between the primary and revision patient groups (primary: 29.7 kg/m2; range, 18.7 to 40.7 kg/m2; revision: 29.7 kg/m2; range, 15.7 to 43.7 kg/m2). The revision group consisted of 40% male patients, and the primary group consisted of 35% male patients (P = 0.329). Average time between primary and first revision surgery was 34.3 (± 9.0) months. The revision TKA patients had 2.2 (± 1.8) surgeries on average after their primary TKA surgery.

QoL

Pain

The Osteoarthritis Research Society International questionnaire14 was used to rate the impact of pain on the QoL of the patients in the following categories: pain intensity, sleep disorder, frustrations, anxiety, and everyday QoL.

In the revision group, 47% of the patients reported severe to unbearable pain 3 years after surgery, whereas only 19% of the patients from the primary TKA group reported a comparable pain intensity (P = 0.006) (Fig. 1). After surgery the revision group more often reported pain in the last 24 hours (P = 0.050), pain during rest (P = 0.039), and pain after 50 m of walking (P = 0.008) as compared with the primary group as shown in (Table 1).

Function

Satisfaction With the Surgery Patients rated their satisfaction with the surgery on a categorical scale: very satisfied, satisfied, not completely satisfied, and not satisfied.

Data Analysis Statistical analyses were performed in IBM SPSS Statistics (ver. 19). A t test was used to compare the VAS scores, whereas binary logistic regression was applied to analyze the categorical measures. All data were normalized by converting them into percentage because of unequal sample sizes, and P < 0.05 was considered significant. Pearson correlations were applied to assess the association between pain (during night, during rest, after 50 m of walk, and the worst pain within the last 24 h) and the KSS function scores (walking distance, ability to walk on stairs, and use of walking aids) for both the primary and revision TKA patients. Five-hundred primary TKA patients were contacted but only 43% responded (215 patients). To demonstrate

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Function Longer walking distance (P = 0.001) and less use of walking aids (P = 0.015) were found for the primary group after TKA in comparison with the revision TKA group (Fig. 2).

Function—Primary TKA Patients A significant increase was found in walking distance before and after surgery (P < 0.001) and the ability to walk on stairs (P < 0.001) for the primary group, but no difference was found in the use of walking aids (P = 0.309). A total of 27% of the primary TKA patients were unable to walk, walked indoors only, or were unable to walk >0.5 km before their primary TKA surgery. This number was reduced to 16% after primary TKA (P = 0.497). The number of primary TKA patients able to walk >0.5 km r

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FIGURE 1. Pain intensities for patients after primary and revision TKA surgery. After revision TKA surgery patients had increased pain intensity (P = 0.006) compared with patients after primary surgery. A total of 19% of the primary patients and 47% of the revision TKA patients reported severe to unbearable pain 3 years after surgery. TKA indicates total knee arthroplasty.

was 73% before primary TKA surgery and 84% after primary surgery (P < 0.001).

Function—Revision TKA Patients Comparing the revision group before and after revision surgery showed no differences in the walking distance (P = 0.448) or the use of walking aids (P = 0.162). However, the revision group had a significantly reduced ability to walk on stairs (P = 0.014) after revision surgery as compared with before revision surgery. In the revision group, 20% of the patients were not able to walk, were walking indoors only, or were not able to walk >0.5 km before revision surgery. After revision surgery this number increased to 37% (P = 0.123). The number of revision surgery patients able to walk >0.5 km was 80% before revision surgery and 63% after revision surgery (P = 0.081).

Function—Group Comparison Comparison of the KSS scores recorded before primary and before revision surgery showed no difference in mobility with respect to walking distance (P = 0.344), the ability to walk up stairs (P = 0.842), or the use of walking aids (P = 0.621). Comparison of the KSS scores, as

FIGURE 2. Knee Society Score (KSS) function funtion before and after primary and revision TKA surgery. Patients after revision surgery have reduced walking distance (P = 0.001) and increased use of walking aids (P = 0.015) compared with patients in the primary group. TKA indicates total knee arthroplasty.

recorded after surgery, between the groups revealed that mobility with respect to walking distance was decreased (P = 0.001) and the use of walking aids was increased (P = 0.015) for revision surgery patients as compared with primary surgery patients. However, no difference was found in the ability to walk up stairs (P = 0.775).

TABLE 1. Pain Scores (VAS) During Night, During Rest, After 50 m of Walk, and the Worst Pain in the Last 24 Hours for Patients After Primary and Revision TKA Surgery

VAS Category During night During rest After 50 m of walk Worst in the last 24 h

Group

Mean

SD

Primary Revision Primary Revision Primary Revision Primary Revision

2.03 2.56 1.68 2.49 2.28 3.29 3.14 4.77

2.64 2.81 2.34 2.62 2.86 3.26 3.21 3.67

P 0.130 0.039 0.008 0.050

TKA indicates total knee arthroplasty; VAS, visual analogue scale.

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TABLE 2. Pearson Correlations (r) Between Pain and Function for Primary and Revision TKA Patients

Walking Distance Primary TKA VAS: During r = 0.360** night P < 0.001 VAS: During rest r = 0.380** P < 0.001 VAS: After 50 m r = 0.591** of walk P < 0.001 VAS: Worst r = 0.433** within the last P < 0.001 24 h Revision TKA VAS: During r = 0.319** night P = 0.004 VAS: During rest r = 0.361** P = 0.001 VAS: After 50 m r = 0.459** of walk P < 0.001 VAS: Worst r = 0.342** within the last P = 0.002 24 h

Ability to Walk on Stairs

Walking Aids

r = 0.395** P < 0.001 r = 0.475** P < 0.001 r = 0.515** P < 0.001 r = 0.474** P < 0.001

r = 0.094 P = 0.174 r = 0.027 P = 0.698 r = 0.149* P = 0.032 r = 0.066 P = 0.338

r = 0.167* P = 0.136 r = 0.199 P = 0.074 r = 0.248* P = 0.025 r = 0.221* P = 0.047

r = 0.311** P = 0.006 r = 0.202 P = 0.078 r = 0.286* P = 0.012 r = 0.337** P = 0.003



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QoL After surgery the revision group had a significantly increased intensity of pain (P < 0.001), degree of sleep disorder (P < 0.001), impact on the QoL (P < 0.001), frustrations due to the pain (P < 0.001), and anxiety of pain (P < 0.001) as compared with the primary group after surgery (Table 3).

Satisfaction With the Surgery The revision group was significantly less satisfied with the treatment as compared with the primary group (P < 0.001) (Fig. 3).

DISCUSSION

**P < 0.01. *P < 0.05. TKA indicates total knee arthroplasty; VAS, visual analogue scale.

Correlations Between Pain and Function Scores The correlation coefficients are presented in Table 2. Significant correlations were found between pain and the KSS function scores for both primary and revision patients (P < 0.05).

The main clinical outcomes (QoL, mobility, and pain) assessed in the present study revealed that revision TKA surgery does not give the same benefits as normally gained from primary TKA as more patients experience chronic postoperative pain with reduced QoL as a result. Studies evaluating the clinical outcomes after revision TKA surgery are sparse. Improvements in function and pain as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index20 as well as increased QoL23 have been demonstrated after primary TKA surgery. Improvements in function, pain, and QoL are the main clinical objectives of TKA and are comparable to the data from the present study in patients without pain after TKA. In the present study, primary TKA surgery led to improved walking distance, whereas revision TKA surgery showed no such general improvements. A positive association has been shown to exist between increased comorbidities and lower functional outcome after revision surgery,10,24 and an increased number of comorbidities can

TABLE 3. Quality of Life for Patients With Constant and Intermittent Pain After Primary and Revision TKA Surgery

OARSI Category Constant pain Pain intensity Impaired sleep Quality of life Frustrations Anxiety Intermittent pain Frequency Pain intensity Impaired sleep Quality of life Frustrations Anxiety

Group

None (%)

Mild (%)

Moderate (%)

Severe (%)

Extreme (%)

Primary Revision Primary Revision Primary Revision Primary Revision Primary Revision

47.2 0.0 62.6 0.0 54.0 0.0 52.8 0.0 54.7 0.0

12.7 11.9 15.2 20.4 11.4 3.4 13.7 5.2 11.3 5.3

28.8 40.7 14.7 14.3 19.9 17.2 18.4 13.8 20.3 14.0

9.4 40.7 6.2 51.0 12.8 34.5 10.8 22.4 9.4 22.8

1.9 6.8 1.4 14.3 1.9 44.8 4.25 58.8 4.2 57.9

Primary Revision Primary Revision Primary Revision Primary Revision Primary Revision Primary Revision

46.2 0.0 44.8 0.0 66.5 0.0 57.5 0.0 57.1 0.0 60.4 0.0

17.0 7.5 16.5 4.3 13.7 18.6 12.7 3.1 12.3 4.8 11.8 3.3

30.7 22.4 28.3 27.1 10.8 15.3 19.3 10.9 18.9 11.3 16.5 11.7

5.2 37.3 7.5 38.6 8.0 25.4 9.4 20.3 9.9 17.7 9.0 21.7

0.9 32.8 2.8 30.0 0.9 40.7 0.9 65.6 1.9 66.1 2.4 63.3

P

< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001

OARSI indicates Osteoarthritis Research Society International; TKA, total knee arthroplasty.

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FIGURE 3. Satisfaction with the surgery as rated by the patients after primary and revision TKA surgery. Patients after revision surgery are less satisfied compared with patients after primary TKA surgery (P < 0.001). TKA indicates total knee arthroplasty.

lead to more chronic postoperative pain in general.25 In postoperative TKA patients with pain, it could be assumed that more concomitant ongoing nociceptive generators were active leading to more postoperative pain problems when revision surgeries were implemented. In addition, revision surgery is normally more complicated,22 and even when optimally performed, it is associated with significant postoperative pain and loss of mobility,10 following the notion that repeated surgery is generally shown to increase the risk for chronic postoperative pain.25 Further, numerous surgeries have an impact on the individual patient, such as fear and anxiety, with a substantial impact on health care costs.26 Many factors can intensify chronic postoperative pain such as impaired sleep27 and anxiety,28 and the present findings showed that the chronic pain after revision TKA resulted in impaired sleep, frustrations caused by pain, anxiety of pain, and overall QoL. Kehlet et al29 found that the level of the acute postoperative pain was related to the development of persisting pain in general, and we found that this seems to be the case for both TKA and TKA revision patients. The incidence of reported severe pain after knee TKA is in the range from 12.7%7 to 17%.30 The present study was in line with those studies finding that 19% of the patients have severe knee pain 3 years after primary TKA surgery. The slight difference in incidence can be explained by the different times on which the various studies perform the follow-up after surgery, as the chronic postoperative pain tend to decrease as function of years after surgery.31–33 Data from national registers in Australia and Sweden3,34 have shown that men have a higher risk for revision surgery than women and at the same time women seem to benefit more from multimodal pain treatments as compared with men.35 In the present study, the majority of patients were women; however, the revision TKA group had a higher percentage of men as compared with the primary TKA group. The higher percentage of men, although not significant, may to some degree explain the poor outcome seen in the revision group. Julin et al19 found that young age is associated with increasing revision rate and r

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complications, and the data of the present study showed that the patients in the revision group were significantly younger than in the primary group, which again may contributes to the higher level of complications seen in the revision group. In the present study 43% of the patients in the primary group responded to the complete questionnaire assessment. To counterbalance this, 15% of the nonresponders were randomly recontacted and were asked to answer a short questionnaire during the telephone call. Comparison of the responses between responders and nonresponders did not differ significantly. Liu et al36 described response rates of 32% in a study focusing on postoperative health state after TKA and total hip replacements. In a recent small study (n = 45), 18% of painful knee arthroplasties were due to referred pain from a degenerative lumbar spine and 16% were due to ipsilateral hip OA.37 These confounding factors were not included as covariates in the present study but could also contribute to the persistent pain in the revision group. Finally, the present study found correlations between pain and function for both primary and revision patients. The fear-avoidance model by Lethem et al28 explains that patients in pain will often avoid movement to protect the injured knee, which could explain these correlations. In conclusion, patients after revision TKA surgery report from more frequent chronic postoperative pain, significantly higher pain levels, lower QoL, and a lower function level compared with patients who have pain after primary TKA. In general, revision surgery patients do not benefit significantly from the repeated surgery and careful selection of patients for revision surgery is recommended. If the indication for revision is based only on pain reports, alternative treatment modalities should be seriously considered.

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23. March LM, Cross MJ, Lapsley H, et al. Outcomes after hip or knee replacement surgery for osteoarthritis. Med J Aust. 1999;171:235–238. 24. Singh JA, Gabriel S, Lewallen D. The impact of gender, age, and preoperative pain severity on pain after TKA. Clin Orthop Relat Res. 2008;466:2717–2723. 25. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology. 2000;93:1123–1133. 26. Carr AJ, Robertsson O, Graves S, et al. Knee replacement. Lancet. 2012;379:1331–1340. 27. Moldofsky H. Sleep and pain. Sleep Med Rev. 2001;5:385–396. 28. Lethem J, Slade P, Troup J, et al. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther. 1983;21:401–408. 29. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–1625. 30. Elson DW, Brenkel IJ. Predicting pain after total knee arthroplasty. J Arthroplasty. 2006;21:1047–1053. 31. Aasvang E, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia. 2006;10:316–321. 32. Macdonald L, Bruce J, Scott N, et al. Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome. Br J Cancer. 2005;92:225–230. 33. Kristensen A, Pedersen T, Hjortdal V, et al. Chronic pain in adults after thoracotomy in childhood or youth. Br J Anaesth. 2010;104:75–79. 34. Lidgren L, Sundberg M, Dahl AW, et al. Swedish Knee Arthroplasty Register, Annual Report. Lund, Sweden: Wallin & Dalholm AB; 2010. 35. Pieh C, Altmeppen J, Neumeier S, et al. Gender differences in outcomes of a multimodal pain management program. Pain. 2011;153:197–202. 36. Liu SS, Buvanendran A, Rathmell JP, et al. A cross-sectional survey on prevalence and risk factors for persistent postsurgical pain 1 year after total hip and knee replacement. Reg Anesth Pain Med. 2012;37:415–422. 37. Al-Hadithy N, Rozati H, Sewell MD, et al. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012;36: 1185–1189.

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Chronic postoperative pain after primary and revision total knee arthroplasty.

Clinical experience suggests that patients with osteoarthritis (OA) undergoing revision total knee arthroplasty (TKA) experience more chronic complica...
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