Victoria A. Brander

Predicting total knee replacement pain: a prospective, observational study.

To describe the natural history of pain after total knee arthroplasty and to identify factors predicting excessive postoperative pain, we used a prospective, observational study assessing clinical and radiographic variables preoperatively and at 1, 3, 6, and 12 months after knee replacement. Data sources included the visual analog pain scale and other measures of patient health, psychologic state, and component reliability. Regression analyses were conducted to identify specific factors predictive of postoperative pain, controlling for inequality of variables, and confirmed using regression diagnostics. For 116 patients (149 knees; mean age, 66 years; 55.2% women), significant pain was reported by 72.3%, 44.4%, 22.6%, 18.4%, and 13.1%, respectively. No intergroup differences existed for anesthesia, weight, age, or gender. Patients with greater preoperative pain had more postoperative pain, used more home therapy, and postoperative manipulations. Preoperative depression and anxiety were associated with heightened pain at 1 year. Pain after knee replacement resolves quickly, declining to approximately 1/2 by 3 months. However, one in eight patients report moderate to severe pain 1 year after surgery despite an absence of clinical or radiographic abnormalities. Development of office-based preoperative screening tools and interventions for these patients may reduce postoperative costs and improve patient-perceived outcomes.

Pain and depression influence outcome 5 years after knee replacement surgery.

We previously reported preoperative depression, anxiety, and pain were associated with greater pain, more utilization of healthcare resources, and worse outcome 1 year after total knee arthroplasty. We asked whether these outcomes persisted over time and whether patients with unexplained heightened pain early after surgery were ultimately satisfied. We prospectively followed and evaluated 83 patients (109 TKAs) 5 years postoperative. The mean age was 66 years; 55% were women. Preoperative pain and depression predicted lower Knee Society score mostly related to lower function subscores. Although anxiety was associated with greater pain, worse function, and more use of resources in the first year after surgery, anxiety did not affect ultimate outcome. Most patients required a full year to recover from surgery but with negligible improvements in most parameters afterward. However, patients with heightened, unexplained pain at 1 year had progressive improvement in pain over several years. By 5 years, nearly all of these patients were satisfied. Therefore, assuming good range of motion and well-aligned implants, most patients with pain 1 year after surgery can be reassured pain ultimately improves. Depression drives long-term outcomes; the Knee Society score is influenced by psychologic variables and does not solely reflect issues related to the knee. Expansion of this tool to include measures sensitive to psychologic and other health factors should be considered.Level of Evidence: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study

&NA; We hypothesized that preoperative emotional distress and pain intensity would predict the occurrence of signs and symptoms of complex regional pain syndrome (CRPS) following total knee arthroplasty (TKA). Depression (Beck Depression Inventory, BDI), anxiety (State Trait Anxiety Inventory, STAI), pain (McGill Pain Questionnaire–Short Form, MPQ), and signs/symptoms meeting IASP criteria for CRPS were assessed preoperatively, and at 1‐, 3‐, and 6‐months postoperatively in 77 patients undergoing TKA. The prevalence of subjects fulfilling CRPS criteria was 21.0% at 1 month, 13.0% at 3 months, and 12.7% at 6 months postoperative. Higher preoperative scores on the STAI predicted positive CRPS status at 1‐month follow‐up (P<0.05), with a similar non‐significant trend for preoperative BDI scores (P<0.10). Diagnostic sensitivity for the STAI was good (0.73), with moderate specificity (0.56). Neither measure predicted CRPS at later follow‐up (P>0.10). Greater preoperative pain intensity predicted positive CRPS status at 3‐month (MPQ‐Sensory and MPQ‐Affective; P<0.01) and 6‐month (MPQ‐Sensory) follow‐up (P<0.01), but not at 1‐month (P>0.10). Diagnostic sensitivity was high (0.83–1.00), with moderate specificity (0.53–0.60). Post‐TKA patients with CRPS were more depressed at 1‐month follow‐up (P<0.05) and more anxious at 6‐month follow‐up (P<0.05) than patients with ongoing non‐CRPS pain (all other comparisons non‐significant, P>0.10). Overall, results indicate that CRPS‐like phenomena occur in a significant number of patients early post‐TKA; however, it is not associated with significantly greater complaints of postoperative pain. There appears to be a modest utility for preoperative distress and pain in predicting CRPS signs and symptoms following TKA, although false positive rates are relatively high.

Outcome of hip and knee arthroplasty in persons aged 80 years and older

Recent studies have established the cost effectiveness and safety of total joint arthroplasties. As the population ages, it is important to determine whether these procedures are equally beneficial in the elderly. The short term safety and efficacy of total hip and knee arthroplasties in subjects 80 years of age and older was evaluated. Between 1988 and 1993, preoperative and postoperative physical and functional information was collected on 99 consecutive elective hip and knee arthroplasties in subjects 80 years of age or older. These data were compared with those derived from a younger otherwise matched control group. Data collected included subject demographics and characteristics, information concerning the acute and postacute hospital stay, comorbid conditions, postoperative complications, discharge disposition, Hospital for Special Surgery knee and Harris hip scores, pain scores, and functional capacity. The average age of the subjects was 83 years; osteoarthritis was the most common diagnosis; and the average followup was 25 months. Complication rates and length of stay in acute care facilities were not significantly different than for the control group. Mean preoperative Hospital for Special Surgery knee and Harris hip scores were 58 and 60, respectively, with postoperative scores of 77 and 88, respectively. Pain dramatically improved with 98% of total knee arthroplasty and 100% of total hip arthroplasty subjects reporting mild or no pain at followup. Preoperatively, none of the knee or hip subjects could walk unlimited distances. Postoperatively 51% of the total knee arthroplasty and 54% of the total hip arthroplasty subjects could walk more than five blocks; 71% of the total knee arthroplasty and 86% of the total hip arthroplasty subjects walked with a cane or no assistive device. The most dramatic postoperative functional gains were seen in the most disabled subjects. Total charges of care for patients 80 years of age and older was slightly greater than for a younger group. It was established that total joint arthroplasty can be performed safely in patients 80 years of age and older, promising excellent pain relief and improved functional outcome.

Selective muscle activation following electrical stimulation of the collateral ligaments of the human knee joint

The objective of this study was to establish the presence of a local neurosensory reflex are from mechanoreceptors in human collateral ligaments and joint capsule to knee muscles and to determine if these muscles could be selectively activated as varus or valgus stabilizers using randomized trials. All studies were performed in the research department laboratories. Eleven subjects were recruited from the university staff and students based on no prior history of knee ailments. Subjects laid supine on an experimentation table as a current-modulated electrical stimulation was provided through the medial (MCL) or lateral collateral (LCL) knee ligaments. Latency of activation was measured for seven muscles, four by surface electrodes (semitendinosus, biceps femoris long head, vastus medialis, and lateralis), and three by intramuscular electrodes (sartorius, gracilis, tensor fascia lata). In the protocol, selective activation was defined as the relative increase in the activity of four muscles with medial moment arms following MCL stimulation compared with corresponding activity following LCL stimulation. For lateral muscles, the opposite was assumed (ie, that more activity would follow LCL than MCL stimulation). Monte Carlo simulations were performed on the data to determine significant selective muscle activation (p < .05). Statistically significant increases in activation were observed, most consistently, in the vastus medialis following MCL stimulation and in the vastus lateralis following LCL stimulation. These results suggest that a neurosensory reflex are from ligament mechanoreceptors may provide varus and valgus stabilization and knee muscles may be selectively activated to counter varus or valgus loads.

Efficacy and Safety of Hylan G-F 20 for Symptomatic Glenohumeral Osteoarthritis: A Prospective, Pilot Study

To determine the safety and efficacy of 2 intra‐articular, fluoroscopically guided hylan G‐F 20 injections for painful glenohumeral osteoarthritis.

Hylan G-F 20 Improves Hip Osteoarthritis: A Prospective, Randomized Study

Abstract We compared the efficacy and safety of intra-articular hylan G-F 20 with methylprednisolone acetate (MPA) for treating symptomatic Kellgren-Lawrence grade (KLG) 2 or 3 hip osteoarthritis in a prospective, randomized, multicenter, double-blind trial (N = 313). Two injections of hylan G-F 20 were administered 2 weeks apart (n = 150), or 1 injection of 40 mg MPA and 1 sham injection 2 weeks later (n = 155). The Western Ontario and McMaster Universities Arthritis Index (WOMAC) (total and subscale), clinician observations, and patient global assessments were collected at baseline and at weeks 4, 8, 12, 16, 20, and 26 (intent-to-treat population was analyzed; n = 305). Responder rates were assessed by WOMAC domain A, and criteria were established by the Outcome Measures in Rheumatology Clinical Trials–Osteoarthritis Research Society International (OMERACT-OARSI). At week 26, WOMAC A improved by 16.6 mm for hylan G-F 20 versus 13.6 mm for MPA. Response rates were higher with hylan G-F 20 versus MPA in patients with more advanced disease (KLG 3) and were similar between hylan G-F 20 and MPA in patients with less advanced disease (KLG 2). Adverse events were similar between groups and between patients with KLG 2 or 3. Hylan G-F 20 provided clinically meaningful improvements in pain and function, comparable with those of MPA, with good safety and tolerability. Thus, we conclude it is an appropriate option for treating hip osteoarthritis.

Functional Improvement with Hylan G-F 20 in Patients with Knee Osteoarthritis

Abstract A systematic review of randomized, controlled, prospective clinical studies is described (8 trials; N = 1674 patients), with > 100 patients in each, which evaluated functional outcomes with hylan G-F 20 in secondary analyses. Hylan G-F 20 significantly improved Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function versus appropriate/conventional care or corticosteroid, it significantly improved loss of activity versus saline, and it had similar functional improvements compared with progressive knee exercises or nonsteroidal anti-inflammatory drugs. Functional improvements with hylan G-F 20 also improved with pain relief. Hylan G-F 20 should be considered as part of a multimodal arthritis treatment regimen that focuses on improving function.

REHABILITATION ADVANCES IN THE TREATMENT OF ARTHRITIS AND MUSCULOSKELETAL DISEASE

The current literature is reviewed related to three disease processes commonly encountered by the physiatrist, rheumatologist, and internist in clinical practice, including osteoarthritis, rheumatoid arthritis, and osteoporosis. These diseases often have effects beyond the pathology that has an impact on the individuals function and integration into society. Emphasis is on the specific rehabilitative approach to the individual.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Musculoskeletal disorders

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytrens disease.