Many Patients with Persistent Pain 1 Year After TKA Report Improvement by 5 to 7 Years

Sellevold, Vibeke Bull RN, MSc1,2; Steindal, Simen A. RN, PhD1,3; Lindberg, Maren Falch RN, PhD4,5; Småstuen, Milada Cvancarova PhD2,6; Aamodt, Arild MD, PhD4; Lerdal, Anners RN, PhD6,7; Dihle, Alfhild RN, PhD2Author Information

doi: 10.1097/CORR.0000000000002183

Clinical Orthopaedics and Related Research: March 21, 2022 – Volume – Issue – 10.1097/CORR.0000000000002183

Abstract

Background 

Knee Replacement Pain after surgery is common. Approximately 20% of patients report pain 12 months after TKA. No studies have investigated patients’ experiences of living with persistent postsurgical pain 5 to 7 years after TKA by combining a qualitative and quantitative methodology.

Question/purpose 

In a mixed methods study, we explored patients’ experiences of living with persistent pain up to 7 years after primary TKA. We asked: In a subgroup analysis of patients who reported persistent pain 1 year after TKA surgery, how do patients live with persistent pain at the 5- to 7-year postoperative timepoint?

Methods 

This follow-up study was part of a longitudinal study of pain, symptoms, and health-related quality of life in patients who underwent TKA for osteoarthritis. The present study targeted a subgroup of patients (22% [45 of 202]) identified in the longitudinal study who reported no improvement in pain interference with walking at 12 months after surgery. Inclusion criteria were: All 31 patients in this subgroup who attended their 5-year follow-up at the hospital and lived within a 2-hour drive from the hospital. Eight patients declined or were unable to participate due to illness or death. Hence, the final sample consisted of 23 patients (13 women and 10 men). The participants’ mean age at surgery was 66 ± 10 years. There were no differences in sociodemographic baseline data between the 23 included and the 22 excluded participants. A mixed-methods approach was employed, in which the quantitative data were followed up and investigated with qualitative interviews. Instruments used were the Brief Pain Inventory preoperatively, 12 months, and 5 years after surgery, as well as a semistructured interview guide. The individual interviews were conducted at one-time point 5 to 7 years post-surgery to capture how pain was experienced at that timepoint. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Meaning units were identified, condensed, and sorted into subthemes that were interpreted and abstracted into themes, guided by the research question. With a small sample, the quantitative analysis focused on descriptive statistics and nonparametric statistics when comparing demographics of included and non-included patients. In addition, two multivariate mixed models for repeated measures were employed to estimate within patient and between patients’ variations as well as to assess the effect of time on the pain outcomes.

Results 

Pain with walking decreased from 12 months to 5 years postoperatively (estimated mean scores 7 versus 4, difference of means -3 [95% CI -5 to -2]; p < 0.001). Pain with daily activity decreased from 12 months to 5 years postoperatively (estimated mean score 6 versus 3, difference of means -3 [95% CI -4 to -1]; p < 0.001). Pain intensity (average pain) decreased from 12 months to 5 years postoperatively (estimated mean score 5 versus 4, difference of means -1 [95% CI -3 to 0]; p = 0.03). The results are presented as point estimates rounded up to whole numbers. The qualitative data analysis yielded three themes: persistent limitations after TKA, regained wellness over time, and complexity in physical challenges. Intermittent pain with certain movements resulted in limitations with some activities in everyday life and seemed to persist beyond 5 years. Multiple painful body sites and presence of comorbidities seemed to interfere with regained wellness over time.

Conclusion 

In this subgroup of patients experiencing postsurgical persistent pain 12 months after primary TKA, persistent postsurgical pain still limited certain activities for the participants, although pain seemed to be less influential in their everyday lives after 5 years to 7 years. Clinicians may use these findings to inform and guide patients with delayed improvements in pain into more realistic expectations for recovery, rehabilitation, and strategies for coping with pain, and impaired function. However, it is imperative to rule out other reasons for pain in patients reporting pain 12 months and longer after surgery and to be attentive of possible changes in pain over time.

Level of Evidence 

Level III, therapeutic study.

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Reliability of pain scores during a body weight support protocol in individuals with knee osteoarthritis

Disability and Rehabilitation

Rebecca Greenwood, Jennifer Ellison, Peggy Gleeson, Katy Mitchell

Disabil Rehabil. 2021 Dec 21 1-6 [Epub ahead of print]

PURPOSE To explore the reliability of percentage of Body Weight Support (BWS) needed for maximal pain relief and of pain scores across 12 walking conditions including pre and post-over-ground walking and an unweighting protocol from 0% to 40% BWS on a lower-body positive pressure (LBPP) treadmill for individuals with knee osteoarthritis (OA).

MATERIALS AND METHODS Twenty individuals (64 ± 9.44 years) with knee OA completed over-ground walking and an unweighting protocol on an LBPP treadmill. The amount of BWS started at 0% and increased by 5% increments until it reached 40%. Pain scores were recorded at the end of each increment.

RESULTS The reliability of pain scores was assessed using a Spearman’s rho. This study found moderate reliability of the percentage of BWS for maximal pain relief. Additionally, there was good reliability of pain scores with pre and post-over-ground walking and from 0% BWS to 30% BWS, but moderate reliability of pain scores was found at 35% and 40% BWS.

CONCLUSION This study supports the use of pain scores as a reliable measure during an unweighted walking session on an LBPP treadmill.

IMPLICATIONS FOR REHABILITATION Both the OARSI and ACR recommend exercise in the treatment of individuals with knee OA but acknowledge that pain during exercise and exercise preference/accessibility are important when considering the type of exercise for an individual.LBPP treadmills decrease pain in individuals with knee OA during walking. Pain scores during unweighted walking show moderate to good reliability for individuals with knee OA. This study provides an unweighting protocol to use clinically to determine the Body Weight Support needed to decrease pain.

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Compression Stocking Help Reduce Blood Volumes in Leg Veins

Abstract

Objectives

This study was designed to explore venous deformation of the lower extremities and the changes in venous hemodynamics in supine position before and after wearing graduated elastic stockings in patients awaiting total knee arthroplasty (TKA).

Method

The leg veins of 21 elderly patients awaiting TKA were imaged in the supine position with and without knee-length graduated compression stockings (GCS) according to a fixed protocol. Measured parameters including the lateromedial (LM) diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) of the great saphenous vein (GSV), gastrocnemius vein (GV), soleus vein (SV), posterior tibial vein (PTV), fibular vein (FV), and anterior tibial vein (ATV). In addition, the mean and maximum velocities of the popliteal vein (PV) and superficial femoral vein (FSV) were measured.

Results

GCS-related compression was observed for all the measured veins. Maximal reduction was observed for the GV and SV, whereas the GSV exhibited the lowest degree of GCS-related compression. The mean cross-sectional area reduction values associated with GCS were 33.1 ± 41.2 % for the GSV, 94.8 ± 11.1 % for the GV, and 85.6 ± 20.3 % for the SV, while the mean reduction of anteroposterior diameter was 18.1 ± 34.5 % for the GSV, 89.0 ± 22.5 % for the GV, and 72.9 ± 35.1 % for the SV, and the mean reduction of the lateromedial diameter was 25.9 ± 36.4 % for the GSV, 89.6 ± 19.6 % for the GV, 78.2 ± 28.3 % for the SV. No significant GCS-related changes in blood velocity in the superficial femoral veins or popliteal veins were detected.

Conclusions

For elderly patients awaiting TKA, knee-length GCS can significantly reduce calf vein dilation while at rest in the supine position, with the greatest reductions being observed for the soleus and gastrocnemius veins. These data might help provide a theoretical basis for the GCS in reducing incidence of deep vein thrombosis in patients undergoing TKA.Keywords: Graduated compression stockings, Vein diameter, Blood velocity, Venous thrombosis, Thromboprophylaxis

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The impact of tourniquet on tibial bone cement penetration in different zones in primary total knee arthroplasty: a meta-analysis

Abstract: Background:Cement mantle penetration and the cement–bone interface strength were critical to a successfulprimary total knee arthroplasty (TKA). It remained unclear whether decreased blood and fat in the cancellous boneachieved with the use of a tourniquet increases tibial cement mantle penetration in different zones on AP andlateral view in TKA according to criteria defined by the Knee Society Scoring System (KSS). The purpose of thisstudy was to determine whether tourniquet use influences tibial cement mantle penetration in different zones onAP and lateral view in TKA according to KSS.

Methods: We conducted a meta-analysis to identify studies involving the impact of tourniquet use and no tourniquet use on tibial bone cement penetration in primary TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, VIP, Wanfang database, up to January 2021. Finally, we identified 1231 patients (1231 knees) assessed in twelve studies.

Conclusion: The application of a tourniquet increases the thickness of the tibial bone cement penetration—the increase in the thickness of bone cement penetration mainly located in zone 3 on the anteroposterior (AP) view.

Results: Tourniquet use increases the cumulative cement mantle penetration (P< 0.00001), mean cement mantle penetration (P= 0.004), and cement mantle in zone 3(P< 0.0001) on AP view. However, there were no significant differences in cement mantle in zone 1(P= 0.5), zone 2(P=0 .54), zone 4(P= 0.07) on AP view, and zone 1(P=0.32), zone 2(P= 0.38) on lateral view between two groups. There were also no significant differences in length of surgery(P= 0.7), change in hemoglobin(P= 0.4), transfusion rates(P= 0.47), and complications such as muscular calfvein thrombosis(P= 0.21), superficial infection (P= 0.72), and deep vein thrombosis (P= 0.66) between two groups.

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Vitamin D Supplementation

High-Dose Vitamin D Supplementation May Have Beneficial Effect on Bone Microarchitecture in Seniors

By Danny Kucharsky

MONTREAL — October 3, 2018 — Long-term, high-dose vitamin-D supplementation of 2,000 IU daily may have a slight beneficial effect on bone microarchitecture in seniors, according to results of a double-blind study presented at the 2018 Annual Meeting of the American Society for Bone and Mineral Research (ASBMR).

The trial evaluated the effect of 2-year long supplementation of 800 IU versus 2,000 IU daily of vitamin D on bone microarchitecture in patients aged 60 years or greater using high-resolution peripheral quantitative computed tomography (HR-pQCT).

HR-pQCT, a non-invasive imaging method, allows for in vivo 3-dimensional characterisation of human bone microstructure. Most trials use the 2-dimensional dual-energy x-ray absorptiometry (DXA) to assess bone outcomes, but DXA cannot resolve bone microstructure, explained lead author Ursina Meyer, PhD, Centre on Aging and Mobility, University Hospital Zurich, Zurich Switzerland, speaking here on September 28.

Dr. Meyer and colleagues recruited 273 patients undergoing unilateral total-knee replacement due to severe knee osteoarthritis. The team randomised patients to receive daily doses of either 2,000 IU vitamin D or the standard-dose of 800 IU vitamin D. All patients received 500 mg of calcium supplements daily.

After 2 years, the group receiving 2,000 IU vitamin D daily had higher 25(OH)D levels compared with the group receiving 800 IU vitamin D (35.7±6.8 vs 28.8±6.1 ng/ml; P≤ .001).

DXA showed similar small increases in mean areal bone mineral density (aBMD) at 2 years, but when investigators used HR-pQCT to assess bone outcomes at the tibia, there was a significant increase in trabecular number (TbN) (beta = 0.05mm-1 [95% confidence interval: 0.004 to 0.09]) at the tibia in the 2,000 IU group compared to the 800 IU vitamin D group. The increase in TbN was accompanied by a statistically trending lower rate of TbN bone loss in the 2,000 IU group.

The investigators observed no other statistically significant differences in other microstructural parameters of the tibia and radius.

In a preliminary subanalysis, a higher 2-year dose of vitamin D did not translate into increases in bone strength as represented by changes in stiffness or failure load compared with the 800 IU vitamin D group.

[Presentation title: Effect of High-Dose Vitamin D on Bone Microarchitecture assessed via High Resolution Peripheral Quantitative Computed Tomography (HR-pQCT): a Double-Blind RCT. Abstract FRI-0827]

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Large Knee Swelling may be a Reason to Operate

Association of Changes in Effusion‐Synovitis and Progression of Cartilage Damage Over 18 Months in Patients with Osteoarthritis and Meniscal Tear

Cover image

First published: 22 August 2018   https://doi.org/10.1002/art.40660

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/art.40660

Abstract

Objective

Synovitis is a feature of knee osteoarthritis (OA) and meniscal tear and has been associated with articular cartilage damage. Our study examined the associations between baseline and changes in effusion‐synovitis and changes in cartilage damage in a cohort with OA and meniscal tear.

Methods

We analyzed data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of surgery vs. physical therapy for treatment of meniscal tear. We performed semiquantitative grading of effusion‐synovitis and cartilage damage on magnetic resonance imaging (MRI), and dichotomized effusion‐synovitis as none/small (‘minimal’) and medium/large (‘extensive’). We assessed the association between baseline and changes in effusion‐synovitis on changes in cartilage damage size and depth over 18 months, using Poisson regression models. Analyses were adjusted for demographics, treatment, and baseline cartilage damage.

Results

We analyzed 221 participants. Over 18 months, effusion‐synovitis was persistently minimal in 45.3% and persistently extensive in 21.3%. The remaining 33.5% had minimal synovitis on one occasion and extensive on the other. In adjusted analyses, extensive effusion‐synovitis at baseline was associated with a relative risk (RR) of 1.7 (95% CI 1.1, 2.6) for progression of cartilage damage depth. Compared to those with persistently minimal effusion‐synovitis, persistently extensive effusion‐synovitis had a statistically significant increased risk of progression of cartilage damage depth (RR 2.0 95% CI 1.1, 3.4).

Conclusions

The presence of extensive effusion‐synovitis is associated with subsequent progression of cartilage damage over 18 months. Persistence of extensive effusion‐synovitis over time was associated with the greatest risk of concurrent cartilage damage progression.

This article is protected by copyright. All rights reserved.

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Injection of your own serum gives better relief than steroids.

OC38 EFFICACY STUDY OF THE TREATMENT OF OSTEOARTHRITIS-INDUCED KNEE PAIN WITH AUTOLOGOUS CONDITIONED SERUM: A COMPARATIVE, PROSPECTIVE AND RANDOMIZEDSTUDY D. W. Hang1 1Shin Kong Orthopedic Sports Medicine Institute, Taipei, Taiwan, Province of China Objective: To compare the efficacy of the standardized injection therapies of (1) autologous conditioned serum (ACS) against (2) corticosteroid in patients with bilateral knee pain secondary to osteoarthritis. Material and Methods:34patients(N=68knees)withbilateral knee pain secondary to osteoarthritis were followed prospectively after intra-articular knee injection of either corticosteroid (group 1) or ACS (group 2). Every patient received a series of six intra-articular injections with ACS into one of the randomly selected knee over a three week period. The other contra-lateral knee received a one-time only standard regime of corticosteroid injections (dexamethasone). Results: In group 1, 23.5 % of the 34 knees experienced 50100 % pain reduction at 12 months after injection. Average VAS pain relief was 41.0 %. The WOMAC score showed significant (p Conclusion: Therapy with both steroid and ACS effectively reduces pain in osteoarthritic knees. Both treatments have beneficial effects on pain, function, and mobility in osteoarthritic knees. In addition, the risk profile is minimal for both treatment regimens.

A Comparative, Prospective and Randimised Study with Autologous Conditioned Serum (Interleukin-1 Receptor Antagonist Containing Serum) and Corticosteroid for Treatment of Osteoarthritic Knee. Abstract OC38

MILAN, Italy — April1, 2015 — Intra-articular injections of autologous conditioned serum (ACS) are effective and safe compared with a corticosteroid for the treatment of mild to moderate knee osteoarthritis, according to prospective trial results presented at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (WCO).

Interleukin-1 (IL-1) is the main cytokine responsible for the pathophysiological processes underlying cartilage destruction. Conversely, an IL-1 receptor antagonist is a naturally occurring 25-kDa glycoprotein cytokine that can decrease cartilage destruction through antagonism of IL-1 effects. Based on this knowledge, “a new technique was developed to produce a serum containing high concentrations of autologous IL-1 receptor antagonist,” stated lead investigator David W. Hang, MD, Shin Kong Orthopaedic Sports Medicine Institute, Taipei, Taiwan, China, speaking here on March 29.

The production of this IL-1 antagonist-containing serum, or ACS, is based on the concept of cell adherence, in which direct contact between monocytes in the blood and specially etched glass beads stimulates production of the autologous cytokine by monocytes.

Dr. Hang and colleagues produced ACS by the glass-bead treatment of 60 mL of blood from 34 patients with bilateral knee pain secondary to osteoarthritis (mean age, 61.3 years), providing 68 knees for evaluation. Production of ACS resulted in increased mean IL-1 receptor antagonist levels in this serum from 270 pg/mL at baseline to 4,051.3 pg/mL after 24 hours (mean ratio: 15.9).

For each patient, the researchers randomised 1 knee to 2 ml ACS as 6 biweekly intra-articular injections. The contralateral knee, as a comparator, received a single injection of 5 mg 5% dexamethasone (1 mL) and 2% xylocaine (1 mL).

Efficacy (defined at 12 months as >50% reduction in visual analogue scale [VAS] pain score) was achieved in 67.6% of ACS-injected knees, compared with 23.5% of corticosteroid-injected knees. Similarly, the mean percentage reduction in VAS pain scores at 12 months demonstrated greater benefit for ACS-injected knees (56.2% vs 41.0%).

For the VAS and Western Ontario McMaster (WOMAC) scores assessed over 3, 6, and 12 months, at all times there were significant improvements over baseline for ACS (P < .0001 for all) and corticosteroid (P < .001 for all). ACS generally provided significant benefits over corticosteroid across these assessments for VAS pain score and WOMAC function and pain scores (P < .05).

In the safety analysis, Dr Hang noted that, “The average side effects were 26% for the steroid group and 7% for the ACS group, but [side effects] were all transient, and were resolved in a few hours.”

Dr Hang also noted possible synergistic effects on the contralateral knee that he feels require further study. “The long-term effectiveness and the histological effects of ACS on cartilage remain to be determined,” he stated.

WCO is sponsored by the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

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Knee Injections No benefit to Exercise

This paper shows that the use os knee injections

JAMA Intern Med. Published online March 30, 2015. doi:10.1001/jamainternmed.2015.0461

Go To The Abstract on Line

to treat Osteoarthritis has no effect on exercise tolerance

Evaluation of the Benefit of Corticosteroid Injection Before Exercise Therapy in Patients With Osteoarthritis of the KneeA Randomized Clinical Trial ONLINE FIRST

Marius Henriksen, PT, MSc, PhD1; Robin Christensen, PhD1; Louise Klokker, MSc1; Cecilie Bartholdy, MSc1; Elisabeth Bandak, MSc1; Karen Ellegaard, PhD1; Mikael P. Boesen, PhD1,2; Robert G. Coumine Riis, MD1,2; Else M. Bartels, PhD1; Henning Bliddal, DMSc1

Importance to Kneejoint pain

Osteoarthritis (OA) of the knee is the most frequent form of arthritis and a cause of pain and disability. Combined nonpharmacologic and pharmacologic treatments are recommended as the optimal treatment approach, but no evidence supports the recommendation.

Objective of Investigation

To assess the clinical benefits of an intra-articular corticosteroid injection given before exercise therapy in patients with OA of the knee.

Design, Setting, and Participants

We performed a randomized, blinded, placebo-controlled clinical trial evaluating the benefit of intra-articular corticosteroid injection vs placebo injection given before exercise therapy at an OA outpatient clinic from October 1, 2012, through April 2, 2014. The participants had radiographic confirmation of clinical OA of the knee, clinical signs of localized inflammation in the knee, and knee pain during walking (score >4 on a scale of 0 to 10).

Interventions  Participants were randomly allocated (1:1) to an intra-articular 1-mL injection of the knee with methylprednisolone acetate (Depo-Medrol), 40 mg/mL, dissolved in 4 mL of lidocaine hydrochloride (10 mg/mL) (corticosteroid group) or a 1-mL isotonic saline injection mixed with 4 mL of lidocaine hydrochloride (10 mg/mL) (placebo group). Two weeks after the injections, all participants started a 12-week supervised exercise program.

Main Outcomes and Measures  The primary outcome was change in the Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (range, 0-100; higher scores indicate greater improvement) at week 14. Secondary outcomes included the remaining KOOS subscales and objective measures of physical function and inflammation. Outcomes were measured at baseline, week 2 (exercise start), week 14 (exercise stop), and week 26 (follow-up).

Results  One hundred patients were randomized to the corticosteroid group (n = 50) or the placebo group (n = 50); 45 and 44 patients, respectively, completed the trial. The mean (SE) changes in the KOOS Pain subscale score at week 14 were 13.6 (1.8) and 14.8 (1.8) points in the corticosteroid and placebo groups, respectively, corresponding to a statistically insignificant mean difference of 1.2 points (95% CI, −3.8 to 6.2; P = .64). We found no statistically significant group differences in any of the secondary outcomes at any time point.

Conclusions and Relevance  No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee. Further research is needed to establish optimal and potentially synergistic combinations of conservative treatments.

Trial Registration  clinicaltrialsregister.eu Identifier: 2012-002607-18; clinicaltrials.gov Identifier:

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