Several nonsurgical perioperative interventions may help prevent the development of chronic pain after primary total knee replacement (TKR) for osteoarthritis, according to a systematic review published in BMJ Open.

In this review, randomized controlled trials (RCTs) in which the efficacy of perioperative nonsurgical treatments in adult patients with osteoarthritis scheduled to undergo unilateral primary TKR were examined. Only trials that compared active interventions with usual care, placebo, or an alternative therapy, and in which patients were followed for ≥6 months were included in the review. Patient-reported joint-specific pain intensity, pain dimensions, or pain evaluated on a visual analog scale comprised the outcomes of interest in RCTs examined.

A total of 44 RCTs with an estimated low risk for bias were included in the review. In 20 trials that assessed components of multimodal pain management, there was an overall cohort of 2393 participants. The included trials reported on pain management (n=20), blood conservation (n=7), tourniquets (n=5), rehabilitation (n=4), continuous passive motion (CPM, n=2), electrical stimulation (n=2), compression bandages (n=1), denosumab (n=1), wound management (n=1), and anabolic steroids (n=1). A total of 10 studies examined the effects of femoral nerve blocks.

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Generally weak evidence from good-quality research suggested small long-term pain reductions using: local infiltration analgesia (3 trials), ketamine infusion (1 trial), pregabalin (1 trial). Anabolic steroids and walking training were associated with a clinically important pain management benefit in this patient population. No study reported any long-term adverse events related to any of the interventions, and none of the interventions were associated with unfavorable pain outcomes.

Study limitations include the lack of a meta-analysis and the inclusion of studies that assessed pain using questionnaires.

 “High-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR,” noted the review authors.

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Beswick AD, Dennis J, Gooberman-Hill R, Blom AW, Wylde V. Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review. BMJ Open. 2019;9(9):e028093.