Pain, Postoperative Clinical Trial
Official title:
Postoperative Pain Severity, Incidence Of Chronic Pain And Its Impact On Daily Function Following Total Knee Replacements (TKR) At A Tertiary Cancer Institute
After Institutional Review Board approval, adult patients scheduled for total knee
arthroplasty (TKA) will be enrolled into the study after obtaining informed consent over a 24
month period. Interim analyses of cases who have completed the 6 month follow up as on 31st
October, 2017 will be analyzed as part of the co- principle investigator's thesis. All
consenting patients will be assessed for pain preoperatively, the first 3 post-operative
days, at 1, 4 and 6 months from the date of surgery. Pain scores will be assessed using the
Numerical Rating Scale during the 3 postoperative days. Pain will be managed by the Acute
Pain Service team as per standard protocols.
The Brief pain inventory (BPI) (short form with translations, obtained with permission from
MD Anderson), which assesses pain severity and its impact on daily functions will be
administered to the patient in a language familiar to them, preoperatively, at 1, 4 and 6
months postoperatively.
The Musculoskeletal Tumour Society Score (MSTS) which evaluates the functional condition
(impairment) after completed tumour treatment will be estimated at the end of 6 months from
the date of surgery The painDETECT questionnaire (PD-Q) a quick, simple and reliable
screening tool to identify the likelihood of a neuropathic pain component in patients and
validated in various languages including Hindi and Marathi will be administered
preoperatively and at 1, 4 and 6 months after surgery.
Details of postoperative chemotherapy and radiation will also be obtained from patient's
notes and the electronic medical record. If the patient cannot follow up at the said
intervals, the pain scores would be obtained telephonically and the BPI and PD-Q forms in
prepaid envelopes would be given to them at discharge which they would have to duly fill in
and post them to the given address at the appropriate intervals if they cannot visit the pain
clinic. At the 6th month of follow up, they would be requested to visit the pain clinic for
an assessment of MSTS score and completing the BPI and PD-Q.
INCLUSION CRITERIA:-
- Adult patients above 18 years of age, undergoing TKR
- Literate: able to read and write in at least one of the following languages English,
Hindi and Marathi
- Willing to fill forms and post them and/or answer questions on phone
EXCLUSION CRITERIA:-
- Refusal of consent
- Cognitively impaired
- Revision TKRs (including cases with wound wash and nail spacer cementing)
INTRODUCTION:- A Total Knee Replacement (TKR) or arthroplasty (TKA) is a complex procedure
that requires an Orthopedic Surgeon to make precise measurements and skillfully remove the
diseased portions of the bone, in order to shape the remaining bone to accommodate the knee
implant. Knee Replacement Surgery is most commonly performed in people with advanced
osteoarthritis and should be considered when conservative treatments have been exhausted.
Oncologic TKRs are different from the routine TKRs in a way that the former involves a wide
local resection of the bone and soft tissues, ranging from 10 to 20 cm, resection of muscles
like the head(s) of biceps femoris, the gastrocnemius muscle, the intermuscular septa, the
joint capsule, etc. to ensure negative margins along with the complete resection of the
tumour, followed by a reconstruction of almost the same length as that resected, to restore
function.
The most common indication for doing oncologic TKR is Osteogenic Sarcoma (OGS) of and around
the knee joint. The distal femur and proximal tibia are among the most common sites for
primary bone tumor. OGS is the most common bone cancer in the world in children and
adolescents, and the eighth-most common form of childhood cancer, accounting for 4% of all
childhood cancers worldwide. In India, the incidence varies from 4.7% to 11.6%, where this
malignancy is associated with significant morbidity and mortality. Additional treatment
involves chemotherapy which further delays the healing and recovery of the patient.
Surgery is a known risk factor for development of Chronic Post Surgical Pain(CPSP) which as
per the definition given by Macrae and Davies, is defined by
- Pain developing after a surgical procedure.
- Pain of at least 2 months' duration.
- Other causes of pain excluded (e.g.- malignancy, infection, etc.).
- Pain continuing from a pre-existing pain problem excluded.
CPSP is a well known risk factor in many surgeries like (but not exclusive of)-
- Mastectomy (Incidence of chronic pain = 11-57%)
- Amputation (30-85%)
- Inguinal hernia(5-63%)
- Cholecystectomy (3-50%)
CPSP develops after a surgical procedure or increases in intensity after the surgical
procedure. Literature on TKR surgeries indicated for osteoarthritis, report that although
many patients report a good outcome after their total knee replacement, at a time when
recovery should have been achieved, about 10-34% of patients undergoing TKR for
osteoarthritis report moderate to severe CPSP. In around 30% of patients with CPSP, the
origin of CPSP might be neuropathic. Neuropathic pain is more severe and adversely affects
the quality of life of patients. TKR on its own may cause neuropathic pain postoperatively
due to local nerve damage, often to the infrapatellar branch of the saphenous nerve or due to
local inflammation. Risk factors associated with the operation include increased duration of
surgery and tourniquet time, revision surgery, TKA versus unicompartmental arthroplasty and
intraoperative nerve damage. Oncologic TKRs are more extensive and include much morbid
excisions, and consequently may be presumed to have a similar if not a greater incidence of
CPSP. Some of the risk factors for CPSP include the following (but not exclusive of)-
- Pain, moderate to severe, lasting more than 1 month
- Repeat surgery
- Younger age (adults)
- Surgical approach with risk of nerve damage
- Neurotoxic chemotherapy
Preoperative pain is consistently found to be a predictor for persistent postsurgical pain,
which might reflect an independent risk factor but could well be a manifestation of
predisposing factors.
Tata Memorial Hospital, a tertiary cancer institute is a 629 bedded hospital and conducts
approximately 6000 surgeries per year out of which approximately 100 TKRs are performed per
year. Analgesia peri-operatively is provided by an epidural infusion of a combination of
local anaesthetic and an opioid or intravenous opioids with non-steroidal anti-inflammatory
analgesics and paracetamol as appropriate. Postoperatively, if inserted, epidural analgesia
is continued for up to 3-4 days to help mobilization & physiotherapy. In the absence of an
epidural, around the clock analgesics with or without an opioid administered by means of an
Intravenous Patient Controlled Analgesia (IVPCA) device is instituted. These patients are
visited by the acute pain service team to address pain issues for the first 3 postoperative
days or sometimes longer.
STUDY DESIGN:- Prospective and Observational study
METHODS and MATERIALS:- After Institutional Review Board approval, adult patients scheduled
for TKR surgeries will be enrolled into the study after obtaining their informed consent over
a 24 month period. However, interim analyses of all cases who have completed the 6 month
follow up as on 31st October, 2017 would be analyzed as part of the co- principle
investigator's thesis. All consenting patients will be assessed for their pain preoperatively
and for the first 3 post-operative days, and at 1, 4 and 6 months from the date of surgery.
Pain scores will be assessed using the Numerical Rating Scale during the 3 days after
surgery. Pain will be managed by the Acute Pain Service team as per the standard management
protocols.
The Brief pain inventory (BPI), (short form with translations, obtained with permission from
MD Anderson), which assesses the severity of pain and the impact of pain on daily functions
will be administered to the patient in the language familiar to them, preoperatively, at 1, 4
and 6 months postoperatively. The BPI is a useful instrument to assess the severity of pain
and impact of pain on daily functions in patients with pain from chronic diseases, conditions
such as cancer, osteoarthritis and low back pain, or with pain from acute conditions such as
postoperative pain. The short form comprises of nine questions related to the severity of
pain, impact of pain on daily function, location of pain, pain medications and amount of pain
relief in the past 24 hours or the past week. It has been widely used and validated in
several languages the world over.
The Musculoskeletal Tumour Society Score (MSTS) evaluates the functional condition
(impairment) after completed tumour treatment will be estimated at the end of 6 months from
the date of surgery. It is calculated on the basis of a standardized physical examination by
the physician. This clinical examination assesses six criteria and differs slightly between
the upper and lower limb. For the lower limb, the components are pain, function, emotional
acceptance of the treatment outcome, need for walking aids, walking and gait. For all
criteria, the estimate is made from bad to very good with parallel awarding of points (0 to
5). There is thus a numerical value for each of the six criteria. These six values are added
and divided by the maximum possible number of points (30). The percentage value is obtained
by multiplying the calculated point value by 100.
The painDETECT questionnaire (PD-Q) is a quick, simple and reliable screening tool to
identify the likelihood of a neuropathic pain component in patients with neuropathic pain.
This questionnaire had been prepared by professionals and validated in various languages
including Hindi and Marathi. Its sensitivity and specificity is higher than other screening
questionnaires for neuropathic pain, including the Douleur Neuropathique 4 (DN4), Leeds
Assessment of Neuropathic Symptoms and Signs (LANNS), and the Neuropathic Pain Questionnaire
(NPQ) (Freynhagen et al 2006). The PD-Q has been used to identify neuropathic pain in
patients with knee osteoarthritis (Ohtori et al 2012) and to identify sensory proļ¬les in
patients with diabetic neuropathy and postherpetic neuralgia (Baron et al 2009).This
questionnaire will be administered tot he patients preoperatively , at 1, 4 and 6 months
after surgery.
Details of postoperative chemotherapy and radiation will also be obtained from patient's
notes and the electronic medical record. If the patient cannot follow up at the said
intervals, the pain scores would be obtained telephonically and the BPI and PD-Q forms in
prepaid envelopes would be given to them at discharge which they would have to duly fill in
and post them to the given address at the appropriate intervals if they cannot visit the pain
clinic. At the 6th month of follow up, they would be requested to visit the pain clinic for
an assessment of MSTS score and completing the BPI and PD-Q.
MEASUREMENTS:-
- All demographic, preoperative, intraoperative and postoperative data would be collected
by the investigators.
- Demographic data includes case no, age, sex, ASA (American Society of Anesthesiologists)
grade.
- Preoperative variables include pain score, preoperative analgesics, duration of use, and
the dose.
- Intraoperative variables include duration of surgery, tourniquet time, any nerve or
muscle resection and length of bone resected.
- Postoperative variables include median average and worst pain score for the first 3
postoperative days , 1, 4 and 6 months after surgery.
- Analgesics administered postoperatively, dose & dosing intervals, impact on daily
functions as obtained from the BPI pre-operatively, 1, 4 and 6 months postoperatively.
- The painDETECT score to identify the neuropathic component of pain if any,
preoperatively and at 1, 4 and 6 months after surgery.
- The MSTS score calculated by the physician and obtained from the patient's record at the
6th month after surgery.
STATISTICAL ANALYSIS:- The above mentioned data will be presented as mean (sd), median
(range), and frequency (percentage). Categorical data will be analyzed using the Chi-square
test or Fisher Exact test (for binary data). Continuous variables will be analyzed using
paired t test or Wilcoxon signed rank test as per distribution of data. Repeated measure
ANOVA will be used for pain score analysis. Pearson correlation coefficients will be used for
association. p-value <0.05 will be considered statistical significant.
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