Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review

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For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of peri-operative care may be associated with the adverse event of chronic pain six months or longer after surgery; effects may be direct, e.g. through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical peri-operative interventions prevent long-term pain after TKR.
We conducted a systematic review of peri-operative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searched The Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL to February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.
Peri-operative non-surgical interventions; control receiving no intervention or alternative treatment.
Primary and secondary outcome measures
Pain or score with pain component assessed at six months or longer post-operative.
44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (3 studies), ketamine infusion (1 study), pregabalin (1 study) and supported early discharge (1 study) compared with no intervention. For electric muscle stimulation (2 studies), anabolic steroids (1 study) and walking training (1 study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.
To prevent chronic pain after TKR, several peri-operative interventions show benefits and merit further research. Good quality studies assessing long-term pain after peri-operative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.
Original languageEnglish
Article numbere028093
Number of pages14
JournalBMJ Open
Publication statusPublished - 6 Sep 2019

Structured keywords

  • Centre for Surgical Research


  • Long-term pain
  • Perioperative care
  • Randomised controlled trial
  • Systematic review
  • Total knee replacement


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