Prognostic value of preoperative mechanical hyperalgesia and neuropathic pain qualities for postoperative pain after total knee replacement.

BACKGROUND: Total knee replacement (TKR) is the gold standard treatment for end-stage chronic osteoarthritis pain, yet many patients report chronic postoperative pain after TKR. The search for preoperative predictors for chronic postoperative pain following TKR has been studied with inconsistent findings. METHODS: This study investigates the predictive value of quantitative sensory testing (QST) and PainDETECT for postoperative pain 3, 6 and 12 months post-TKR. We assessed preoperative and postoperative (3 and 6 months) QST measures in 77 patients with knee OA (KOA) and 41 healthy controls, along with neuropathic pain scores in patients (PainDETECT). QST parameters included pressure pain pressure threshold (PPT), pain tolerance threshold (PTT), conditioned pain modulation (CPM) and temporal summation (TS) using cuff algometry, alongside mechanical hyperalgesia and temporal summation to repeated pinprick stimulation. RESULTS: Compared to healthy controls, KOA patients at baseline demonstrated hyperalgesia to pinprick stimulation at the medial knee undergoing TKR, and cuff pressure at the calf. Lower cuff algometry PTT and mechanical pinprick hyperalgesia were associated with preoperative KOA pain intensity. Moreover, preoperative pinprick pain hyperalgesia explained 25% of variance in pain intensity 12 months post-TKR and preoperative neuropathic pain scores also captured 30% and 20% of the variance in postoperative pain at 6 and 12 months respectively. A decrease in mechanical pinprick hyperalgesia from before surgery to 3 months after TKR was associated with lower postoperative pain at the 12 months post-TKR follow-up. CONCLUSION: Our findings suggest that preoperative pinprick hyperalgesia and neuropathic-like pain symptoms show predictive value for the development of chronic post-TKR pain. SIGNIFICANCE STATEMENT: This study's findings hold significant implications for chronic pain management in knee osteoarthritis patients, particularly those undergoing total knee replacement surgery (TKR). Mechanical hyperalgesia and neuropathic pain-like characteristics predict postoperative pain 1 year after TKR, emphasizing the importance of understanding pain phenotypes in OA for selecting appropriate pain management strategies. The normalization of hyperalgesia after surgery correlates with better long-term outcomes, further highlighting the therapeutic potential of addressing abnormal pain processing mechanisms pre- and post-TKR.

Mechanical hyperalgesia and neuropathic pain qualities impart risk for chronic postoperative pain after total knee replacement.

Total knee replacement (TKR) is the gold-standard treatment for end-stage chronic osteoarthritis pain, yet many patients report chronic postoperative pain after TKR. The search for preoperative predictors for chronic postoperative pain following TKR has been studied with inconsistent findings. This study investigates the predictive value of quantitative sensory testing (QST) and PainDETECT for postoperative pain 3, 6, and 12 months post-TKR. We assessed baseline and postoperative (3- and 6-months) QST measures in 77 patients with knee OA (KOA) and 41 healthy controls, along with neuropathic pain scores in patients (PainDETECT). QST parameters included pressure pain pressure threshold (PPT), pain tolerance threshold (PTT), conditioned pain modulation (CPM), and temporal summation (TS) using cuff algometry, alongside mechanical hyperalgesia, and mechanical temporal summation to repeated pinprick stimulation. Compared to healthy controls, KOA patients at baseline demonstrated hyperalgesia to pinprick stimulation at the medial OA-affected knee and cuff pressure on the ipsilateral calf. Lower cuff algometry PTT and mechanical pinprick hyperalgesia were associated with baseline KOA pain intensity. Moreover, baseline pinprick pain hyperalgesia explained 25% of variance in pain intensity 12 months post-TKR and preoperative neuropathic pain scores also captured 30% and 20% of the variance in postoperative pain at 6- and 12-months, respectively. A decrease in mechanical pinprick hyperalgesia from before surgery to 3 months after TKR was associated with lower postoperative pain at the 12 months post-TKR follow-up, and vice-versa. Our findings suggest that preoperative pinprick hyperalgesia and PainDETECT neuropathic-like pain symptoms show predictive value for the development of chronic post-TKR pain.

Closed Suction Drainage after Total Knee Arthroplasty with Concomitant Intravenous Tranexamic Acid Administration.

Drain use in total knee arthroplasty (TKA) remains controversial. Use has been associated with increased complications, particularly postoperative transfusion, infection, increased cost, and longer hospital stays. However, studies examining drain use were performed before widespread adoption of tranexamic acid (TXA), which markedly reduces transfusion without increasing venous thromboembolism events. We aim to investigate incidence of postoperative transfusion and 90-day return to the operating room (ROR) for hemarthrosis in TKA with use of drains and concomitant intravenous (IV) TXA. Primary TKAs from a single institution were identified from August 2012 to December 2018. Inclusion criteria were primary TKA, age 18 years and over where use of TXA, drains, anticoagulant, and pre- and postsurgical hemoglobin (Hb) were documented during the patient's admission. Primary outcomes were 90-day ROR specifically for hemarthrosis and rate of postoperative transfusion. A total of 2,008 patients were included. Sixteen patients required ROR, three of which were due to hemarthrosis. Drain output was statistically higher in the ROR group (269.3 vs. 152.4 mL, p = 0.05). Five patients required transfusion within 14 days (0.25%). Patients requiring transfusion had significantly lower presurgical Hb (10.2 g/dL, p = 0.01) and 24-hour postoperative Hb (7.7 g/dL, p < 0.001). Drain output between the transfusion and no transfusion groups varied significantly (p = 0.03), with transfusion patients having higher postoperative day 1 drain output of 362.6 mL and total drain output of 376.6 mL. In this series, postoperative drain use with concomitant weight-based IV TXA is shown to be safe and efficacious. We observed exceedingly low risk of postoperative transfusion compared with prior reports of drain use alone as well as preserved low rate of hemarthrosis that has previously been positively linked to drain use.

Outcomes of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis.

The purpose of this study was to examine current literature regarding the efficacy of total knee arthroplasty for patients with rheumatoid arthritis. Studies that assessed total knee arthroplasty outcomes in patients with rheumatoid arthritis were identified on MEDLINE from January 2009 to November 2018. All 4 studies that assessed knee pain and 9 of 11 studies that assessed knee function noted significant improvement in average knee score. However, between 10% and 47% of patients had significant knee pain at final follow-up. Total knee arthroplasty provides significant improvement in knee pain and function for patients with rheumatoid arthritis. However, the rates of postoperative pain vary widely. [Orthopedics. 2021;44(5):e626-e632.].

Assessment of Psychological Factors in Short-Stay Total Hip Arthroplasty Protocol.

BACKGROUND: Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol. METHODS: We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol. RESULTS: Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment. CONCLUSION: Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization.

Outcomes of Elective Total Hip Arthroplasty in Nonagenarians and Centenarians.

BACKGROUND: Nonagenarians and centenarians are among the fastest growing demographics in the United States. Although consequent demand for joint replacement is projected to rise precipitously, outcomes of total hip arthroplasty (THA) have seldom been studied in this population. METHODS: A retrospective cohort of patients undergoing primary THA was established using the 2008-2017 American College of Surgeons National Quality Improvement Program. Propensity scores were used to match 858 patients aged 90 or older to 858 patients aged 65-89, controlling for demographic factors and comorbidities. Thirty-day outcomes were compared between matched age cohorts using multiple regression modeling. RESULTS: Statistically equivalent 30-day rates of surgical infection (P = .73), pneumonia (P = .39), deep venous thrombosis/thrombophlebitis (P = .55), pulmonary embolism (P = .69), stroke (P = .73), myocardial infarction (P = .44), cardiac arrest (P = .69), and sepsis (P = .77) were observed between matched age cohorts, although nonagenarians and centenarians were significantly more likely to experience urinary tract infection (2.8% vs 0.9%, P = .004). In addition, matched patients aged 90 or older were more likely to have longer hospital stays (3.52 vs 2.81 days, P < .001) and be discharged to a nonhome facility (75.4% vs 34.6%, P < .001) but were at no higher than 30-day risk of reoperation (P = .45), readmission (P = .23), or mortality (P = .59). CONCLUSION: Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. Patient comorbidity profiles, rather than age, should principally guide shared clinical decision making.

Which Postoperative Day After Total Joint Arthroplasty Are Catastrophic Events Most Likely to Occur?

BACKGROUND: Despite lacking granularity, large database registries can help provide important information on rare outcomes following total joint arthroplasty (TJA). In an era of short stay and outpatient arthroplasty, an awareness of the timeframe for most common catastrophic complications can help providers maintain an appropriate degree of suspicion for these significant events. METHODS: Patients undergoing primary TJA between 2011 and 2016 were identified in the National Surgical Quality Improvement Program and queried for 4 adverse postoperative outcomes: pulmonary embolism (PE), myocardial infarction or cardiac arrest, cerebrovascular accident, and death. The timing of postoperative events was compared, and also their association with medical comorbidities and timing in inpatient vs outpatient arthroplasty. RESULTS: A total of 341,601 patients met inclusion criteria. Of them, 1631 (0.48%) patients sustained a postoperative PE, 1033 (0.3%) patients had a cardiac event, 304 patients had a cerebrovascular accident (0.09%), and 608 (0.18%) patients expired. Greater than 60% of all these complications occurred between postoperative days 0 and 5, including 65% of PE. On postoperative day 0, a catastrophic event is 13 times more likely to be a cardiac event (80.7%) compared to a PE (6%). However, by postoperative day 1, a cardiac event (41.2%) is only 1.03 times more likely than a PE (40%) and by postoperative day 2, a PE (62%) is twice as likely as a cardiac event (30%). CONCLUSION: Risk assessment for catastrophic event and timeliness of occurrence may guide providers to recommend enhanced observation for specific patients undergoing TJA.

Differences in Post-Operative Outcome Between Conversion and Primary Total Hip Arthroplasty.

BACKGROUND: The demand for conversion of prior hip surgery to total hip arthroplasty (conversion THA) is likely to increase as a function of increasing US hip fracture burden in addition to its application in managing other conditions. Thus, outcome analysis is warranted to better inform value-based reimbursement schemes in the era of bundled payments. METHODS: Via Current Procedural Terminology codes, the National Surgical Quality Improvement Project data files were queried for all patients who underwent primary THA and conversion of previous hip surgery to THA from 2005 to 2014. To better understand the isolated effect of procedure type on adverse outcomes, primary and conversion cohorts were then propensity-score matched via logistic regression modeling. Comparisons of the study's primary outcomes were drawn between matched cohorts. Statistical significance was defined by a P-value less than or equal to .05. RESULTS: Relative to the primary THA group, the conversion THA group had statistically greater rates of Center Medicare and Medicaid Services (CMS) complications (7.5% vs 4.5%), non-home bound discharge (19.6% vs 14.7%), and longer length of hospital stay. Conversion THA was associated with increased likelihood of CMS complications (odds ratio 1.68, confidence interval 1.39-2.02) and non-home bound discharge (odds ratio 1.41, confidence interval 1.25-1.58). No statistically significant differences in mortality and readmission were detected. CONCLUSION: The elevated risk for CMS-reported complications, increased length of hospital stay, and non-home bound discharge seen in our study of conversion THA indicates that it is dissimilar to elective primary THA and likely warrants consideration for modified treatment within the Comprehensive Care for Joint Replacement structure in a manner similar to THA for fracture.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Differences in Postoperative Outcomes Between Total Hip Arthroplasty for Fracture vs Osteoarthritis.

BACKGROUND: Hip fracture is an increasingly common expanded indication for total hip arthroplasty (THA) and warrants outcome analysis so as to best inform risk assessment models, public reporting of outcome, and value-based reimbursement schemes. METHODS: The National Surgical Quality Improvement Program data file from 2011 to 2014 was used to identify all patients undergoing THA via current procedural terminology code 27130. Propensity score matching in a 1:5 fashion was used to compare 2 cohorts: THA for osteoarthritis and THA for fracture. Primary outcomes included Centers for Medicare and Medicaid Services (CMS) reportable complications, unplanned readmission, postsurgical length of stay, and discharge destination. χ2 tests for categorical variables and Student t test for continuous variables were used to compare the 2 cohorts and adjusted linear regression analysis used to determine the association between hip fracture and THA outcomes of interest. RESULTS: A total of 58,302 patients underwent elective THA for osteoarthritis and 1580 patients underwent THA for hip fracture. Rates of CMS-reported complications (4.0% vs 10.7%; P < .001), non-homebound discharge (39.8% vs 64.7%; P < .001), readmission (4.7% vs 8.0%; P < .001), and mean days of postsurgical hospital stay (3.2 vs 4.4; P < .001) were greater in the hip fracture cohort. THA for hip fracture was significantly associated with increased risk of CMS-reportable complications (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.17-3.28), non-homebound discharge (OR, 1.73; 95% CI, 1.39-2.15), and readmission (OR, 2.78; 95% CI, 2.46-3.12). CONCLUSION: Our findings support recent advocacy for the exclusion of THA for fracture from THA bundled pricing methodology and public reporting of outcomes.

The Impact of Metabolic Syndrome on 30-Day Complications Following Total Joint Arthroplasty.

BACKGROUND: The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed. RESULTS: Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups. CONCLUSION: MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases.

Risk Factors for Postoperative Urinary Tract Infections in Patients Undergoing Total Joint Arthroplasty.

Background. Urinary tract infections (UTIs) are the most common minor complication following total joint arthroplasty (TJA) with incidence as high as 3.26%. Bladder catheterization is routinely used during TJA and the Centers for Medicare and Medicaid Services (CMS) has recently identified hospital-acquired catheter associated UTI as a target for quality improvement. This investigation seeks to identify specific risk factors for UTI in TJA patients. Methods. We retrospectively studied patients undergoing TJA for osteoarthritis between 2006 and 2013 in the American College of Surgeon's National Surgical Improvement Program Database (ACS-NSQIP). A univariate analysis screen followed by multivariate logistic regression identified specific patient demographics, comorbidities, preoperative laboratory values, and operative characteristics independently associated with postoperative UTI. Results. 1,239 (1.1%) of 115,630 TJA patients we identified experienced a postoperative UTI. The following characteristics are independently associated with postoperative UTI: female sex (OR 2.1, 95% CI 1.6-2.7), chronic steroid use (OR 2.0, 95% CI 1.2-3.2), ages 60-69 (OR 1.5, 95% CI 1.0-2.1), 70-79 (OR 2.0, 95% CI 1.4-2.9), and ≥80 (OR 2.3, 95% CI 1.5-3.6), ASA Classes 3-5 (OR 1.5, 95% CI 1.2-1.9), preoperative creatinine >1.35 (OR 1.8, 95% CI 1.3-2.6), and operation time greater than 130 minutes (OR 1.8, 95% CI 1.3-2.4). Conclusions. In this large database query, postoperative UTI occurs in 1.1% of patients following TJA and several variables including female sex, age greater than 60, and chronic steroid use are independent risk factors for occurrence. Practitioners should be aware of populations at greater risk to support efforts to comply with CMS initiated quality improvement.

A case of extensive hyperostosis frontalis interna in an 87-year-old female human cadaver.

Hyperostosis frontalis interna (HFI) is a condition that involves thickening of the inner surface of the frontal bone with sparing of the midline. Little is known about the etiology and clinical presentation of HFI. We report unusual findings in a woman with extensive Type D hyperostosis of the frontal bone and a large hyperostotic nodule in the parietal bone with impingement on the precentral gyrus, distinguishing this from the common form of HFI. The scalp was dissected from the cranial vault, and the calvaria and brain were removed and digitally imaged. Bone specimens were embedded in methyl methacrylate plastic, sectioned, and stained using the Von Kossa Method with MacNeal's tetrachrome. Medical records were reviewed, and additional history was obtained through interviews with the donor's family. The calvaria had extensive, bilateral thickening of the frontal bone with irregular topography and clearly demarcated borders. The dura was adherent to all hyperostotic regions. A 3.5-cm nodule was visible on the inner table of the left parietal bone. The dura and cerebrum showed compression in this region, but it was unclear if this resulted in clinical ramifications. Microscopic analysis revealed a larger proportion of cancellous bone was present in regions of macroscopic hyperostosis. Quantitative analysis of sections through areas of gross hyperostosis demonstrated a lower proportion of lamellar bone than in the control. The patient exhibited symptoms that have been correlated to HFI in previous studies. We suggest that the HFI disease process was responsible for the manifestation of these symptoms in this patient.