Persistent post-surgical pain and neuropathic pain after total knee replacement

Table 1 Total knee replacement and chronic (persistent) post-surgical pain

Ref.	Design/patients	Aim of the study	Scores-scales	Follow-up	Pain	Factors
Brander et al[19]	Prospective n = 116	To describe the natural history of pain after TKR To identify factors predicting excessive post-surgical pain	VAS and other measures of patient health	Pre-op. Post-op.: (1) 1 mo; (2) 3 mo; (3) 6 mo; and (4) 12 mo	Pre-op.: 72.3% Post op.: (1) 44.4%; (2) 22.6%; (3) 18.4%; and (4) 13.1%, respectively	Factors related with post-op pain at 12 mo (1) Pre-operative pain; and (2) Pre-operative depression and anxiety
Forsythe et al[20]	Prospective n = 55	To document: the prospective pain experience following TKR To determine if: (1) comorbidities; (2) preoperative pain; or (3) preoperative pain catastrophizing scores are predictors of chronic pain after TKR	MPQ PCS	Pre-op. Post-op.: (1) 3 mo; (2) 12 mo; and (3) 24 mo	Significant reduction only between pre-op and 3-mo post-op values. After 3-mo pain had reached a plateau Pain catastrophizing scores didn’t show any significant differences	Predictive of chronic postoperative pain: (1) No. of comorbidities; and (2) Pre-operative pain catastrophizing scores
Ritter et al[24]	Retrospective n = 7326	To quantify the effect of sex on the clinical outcome and survivorship of a specific TKR (AGC, Biomet, Warsaw, Ind)	KSS PS FS	Clinical scores: Throughout 5 yr Survival data: Up to 17 yr	Pain after TKR was less for men but there was no statistically significant difference between men and women	Improvement after TKR is similar for men and women No significant difference in post-operative pain between men and women
Wylde et al[9]	Retrospective n = 632	To assess the (1) prevalence; (2) severity; (3) sensory qualities; and (4) postoperative determinants of persistent pain after primary THR and TKR	WOMAC Pain Scale SFMPQ pD-Q Two-item Patient Health Questionnaire (PHQ-2)	Median: 41 mo Range: 34-49 mo	Persistent post-surgical pain (PPSP): 44% Severe-extreme PPSP: 15% Constant PPSP: 5% Likely neuropathic pain: 6%	Significant and independent postoperative determinants of number of PPSP: (1) No. of pain problems elsewhere; and (2) The presence of major depression
Polkowski et al[23]	Prospective n = 309	To explore the relationship between early-grade preoperative OA with pain and dissatisfaction after TKR	Group A: Pain after TKR Group B: Consecutive series of 100 TKR’s performed the same period by the same surgeon Group C: Asymptomatic TKR Group D: Symptomatic TKR performed the same period	1-5 yr	Early-grade OA pre-op: Group A: 49% Group B: 5% Group C: 6% Group D: 10%.	A high percentage of patients referred for unexplained pain after TKR had early-grade OA pre-operatively
Noiseux et al[21]	Prospective n = 215	Τo discover whether any preoperative assessment could predict high pain scores and functional limitations postoperatively	Pain Intensity rating: NRS QST Anxiety Form of the State Trait Anxiety Inventory GDS PCS	Pre-op. Post-op.: 6 mo	Moderate to severe pain At rest: Pre-op.: 17% Post-op.: 5% With range-of-motion: Pre-op.: 52% Post-op.: 16%	Significant predictors (for moderate or severe TKR pain with knee motion after 6 mo): (1) Severe preoperative knee pain with range-of motion; and (2) Anxiety
Pérez-Prieto et al[22]	Prospective n = 716 Depressed: n = 200	To evaluate quality of life, function, pain and satisfaction outcomes in patients, with and without depression, undergoing TKR	GDS KSS Medical Outcomes Study 36-Item Short Form Health (SF-36) MCS VAS	12 mo	Depressed patients reported significant higher pain scores than non-depressed patients pre- and post-operatively Net changes (postoperative - preoperative): No significant difference	Depression leads to (1) Poorer preoperative and postoperative scores in all but the mental domains; and (2) But similar net score changes (improvement) with a high rate of patient satisfaction
W-Dahl et al[25]	Non-depressed: n = 516 retrospective	To evaluate how the instruments used to measure pain affected the number of patients who reported no relief of pain or worse pain, and the relative effect of potential risk factors	Osteoarthritis Outcome Score (KOOS) VAS EQ-5D	Pre-operatively 1 year post-operatively	No pain relief: 10.1% Only KOOS pain: 25% Only VAS knee pain: 52% Both: 23%	The observed proportion of patients with unchanged or worse pain one year after TKR differed depending on the method of pain measurement used Risk factors for no pain relief are: (1) less pre-operative pain; and (2) higher degree of anxiety Charnley category C was a risk factor for unchanged or worse pain as measured by the VAS but not for the KOOS

OA: Osteoarthritis; TKR: Total knee replacement; Pre-op: Preoperatively; Post-op: Postoperatively; PPSP: Persistent post-surgical pain; VAS: Visual Analogue Scale; EQ-5D: Euro-Qol 5 Dimension; MCS: Mental Composite Score; KSS: Knee Society Score; GDS: Geriatric Depression Scale; PCS: Pain Catastrophizing Scale; QST Quantitative Sensory Testing; NRS: Numerical Rating Scale; SFMPQ: Short-Form McGill Pain Questionnaire; pD-Q: PainDETECT Questionnaire; WOMAC: Western Ontario and McMaster Universities Index of Osteoarthritis; FS: Function score; PS: Pain score; KSS: Knee Society knee score; MPQ: McGill Pain Questionnaire.

Table 2 Total knee replacement and neuropathic pain

Ref.	Design	No. of patients	Aim of the study	Scores-scales	Follow-up	Pain	Factors
Harden et al[28]	Prospective	77	Preoperative emotional distress and pain intensity and would predict the occurrence of signs and symptoms of CRPS following TKR	CRPS: IASP criteria (signs/symptoms) Beck Depression Inventory State Trait Anxiety Inventory McGill Pain Questionnaire-Short Form	Pre-op. Post-op.: (1) 1 mo; (2) 3 mo; and (3) 6 mo	1 mo: 21.0% 3 mo: 13.0% 6 mo: 12.7%	CRPS-like phenomena: (1) In a significant number of patients after TKR; and (2) No association with significantly greater complaints of postoperative pain Prediction by preoperative distress and pain: Modest utility
Buvanendran et al[30]	Prospective	Control: 120 Pregabalin: 120	To examine if perioperative treatment with pregabalin, would reduce the incidence of postsurgical NP	11-point NRS LANS scale Osteoarthritis Outcome Score–Physical function Short-form (KOOS-PS)	Pre-op. Post-op.: (1) 3 mo; and (2) 6 mo	Study group: 0% Placebo group: (1) 3 mo: 8.7%; (2) 6 mo: 5.2%	Perioperative pregabalin administration reduces the incidence of chronic NP after TKR In the doses tested, it is associated with a higher risk of early postoperative sedation and confusion
Wylde et al[9]	Retrospective	632	To assess: (1) prevalence; (2) severity; (3) sensory qualities; and (4) postoperative determinants of persistent pain after primary THR and TKR	WOMAC Pain Scale SF-MPQ PainDETECT Questionnaire Two-item PHQ-2	Median: 41 mo Range: 34-49 mo	Persistent postsurgical pain (PPSP): 44% Severe-extreme PPSP: 15% Constant PPSP: 5% Likely NP: 6%	Significant and independent postoperative determinants of number of PPSP: (1) No. of pain problems elsewhere; and (2) The presence of major depression
Phillips et al[29]	Prospective	94	To record the prevalence of pain and NP To establish predictive factors that could be used to identify patients who were likely to have high levels of pain or NP	VAS HADS score pD-Q score OKS	Pre-op. Post-op.: (1) 3-5 d; (2) 6 wk; (3) 3 mo; (4) 6 mo; (5) 9 mo; (6) 1 yr; and (7) 46 mo	VAS (value) Pre-op.: 5.8 Post-op.: (1) 3-5 d: 4.5; (2) 6 wk: 3.2; (3) 3 mo: 2.4; (4) 6 mo: 2.0; (5) 9 mo: 1.7; (6) 1 yr: 1.5; and (7) 46 mo: 2.0 Frequency (%) VAS moderate-severe/ painDETECT possible -likely Pre-op.: 41-50/5-1 Post-op.: (1) 3-5 d: 47-19/5-3; (2) 6 wk: 39-9/27-8; (3) 3 mo: 21-10/19-4; (4) 6 mo: 16-6/17-3; (5) 9 mo: 16-4/13-6; (6) 1 yr: 14-3/9-2; and (7) 46 mo: 15-7/7-6	High correlation between the mean VAS scores for pain and the mean painDETECT scores at 3 mo, 1 yr and 3 yr post-operatively No correlation between the pre-operative scores and any post-operative scores at any time point NP is an underestimated problem in patients after TKR

CRPS: Complex regional pain syndrome; NP: Neuropathic pain; Pre-op: Preoperatively; Post-op: Postoperatively; LANS: Leeds Assessment of Neuropathic Symptoms and Signs; NRS: Numerical Rating Scale; WOMAC: Western Ontario and McMaster Universities Index of Osteoarthritis; SF-MPQ: Short-Form McGill Pain Questionnaire; PHQ-2: Patient Health Questionnaire; VAS: Visual Analogue Score; HADS: Hospital Anxiety and Depression; pD-Q: PainDETECT; OKS: Oxford Knee score.

Table 3 Studies including total knee replacement patients concerning the prevalence and etiology of neuropathic pain

Ref.	Design	No. of patients	Aim of the study	Scores-scales	Follow-up	Pain	Factors
Wylde et al[9]	Retrospective	632	To assess: (1) prevalence; (2) severity; (3) sensory qualities; and (4) postoperative determinants of persistent pain after primary THR and TKR	Western Ontario and McMaster Universities Index of Osteoarthritis Pain Scale Short-Form McGill Pain Questionnaire PainDETECT Questionnaire Two-item Patient Health Questionnaire	Median: 41 mo Range: 34-49 mo	PPSP: 44% Severe-extreme PPSP: 15% Constant PPSP: 5% Likely NP: 6%	Significant and independent postoperative determinants of number of PPSP: (1) No. of pain problems elsewhere; and (2) The presence of major depression
Masselin-Dubois et al[31]	Prospective	TKR patients: 89 breast cancer surgery patients: 100	To assess the predictive value of: (1) Anxiety; (2) Depression; (3) Pain catastrophizing; and (4) Baseline pain intensity for chronic post-surgical pain. The existence of neuropathic pain	BPI NRS Neuropathic Pain Diagnostic Questionnaire (DN4) Spielberger STAI 13-item BDI PCS	Pre-op. Post-op: (1) 2 d (2) 3 mo	TKR patients: (1) Pre-op: 84% at least moderate pain (2) 2 d: 46.9%; and (3) 3 mo: 50.6% Neuropathic pain TKR patients: (1) Pre-op: 30.7% (2) 3 mo: 42.2%	Regardless the type of surgery, state anxiety, pain catastrophizing (especially pain magnification) and acute post-surgical pain are predictive of persistent post-surgical pain Acute post-surgical pain was also predictive of NP pain. Baseline pain intensity, trait anxiety and depression had no independent impact on post-surgical pain (considering low baseline scores for depression in this study)
Lavand’homme et al[33]	Prospective	TKR and UKR patients: 120	To examine the relationship between postoperative pain trajectories and persistent pain, specifically neuropathic pain.	NRS Neuropathic Pain Diagnostic Questionnaire (DN4) PCS Spielberger STAI for Adults	Pre-op. Post-op: (1) Day 1 to day 8; (2) 3 mo	At 3 mo post-op: (1) 42% patients were pain free (2) 47% patients with persistent pain without NP pain; and (3) 11% patients with persistent pain involving neuropathic component	Patients with neuropathic pain displayed higher pain scores, particularly during mobilization No differences found among pain trajectories for pain at rest
Attal et al[32]	Prospective	TKR patients: 89 breast cancer surgery patients: 100	If: (1) cognitive functioning (2) emotional functioning and pain coping are predictors of persistent post-surgical pain and neuropathic pain	BPI Neuropathic Pain Diagnostic Questionnaire (DN4) TMT A TMT B ROCF-copy ROCF-immediate recall BDI Spielberger STAI CSQ Brief Version of the SOPA-B	Pre-op: (1) 1 mo; and (2) 1 d Post-op: (1) 2 d; (2) 6 mo, 12 mo	TKR patients (1) Pre-op: 84%; (2) 6 mo: 39%; and (3) 12 mo: 38% Neuropathic pain TKR patients: (1) Pre-op: 75 patients; (2) 6 mo: 32 patients; and (3) 12 mo: 26 patients	Cognitive functioning, emotional functioning and pain coping made an independent contribution to the prevalence and severity of persistent post-surgical pain, as well as its neuropathic quality. Results at ROCF-copy and ROCF- immediate recall test seemed to be predictors of pain with neuropathic nature

PPSP: Persistent postsurgical pain; BPI: Brief Pain Inventory; NRS: Numerical Rating Scale; STAI: State-Trait Anxiety Inventory; PCS: Pain Catastrophizing Scale; BDI: Beck Depression Inventory; TMT A: Trail-Making Test A; ROCF-copy: Rey-Osterrieth Complex Figure-copy; ROCF-immediate recall: Rey-Osterrieth Complex Figure-immediate recall; CSQ: Coping Strategies Questionnaire; SOPA-B: Survey of Pain Attitudes.