Psychological determinants of problematic outcomes following Total Knee Arthroplasty The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty Prospective relation between catastrophizing and residual pain following knee arthroplasty: two-year follow-up. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Preoperative predictors of pain following total knee arthroplasty. Individuals’ experience of living with osteoarthritis of the knee and perceptions of total knee arthroplasty Are psychological predictors of chronic postsurgical pain dependent on the surgical model? A comparison of total knee arthroplasty and breast surgery for cancer. Patient-Specific CT-Based Instrumentation versus Conventional Instrumentation in Total Knee Arthroplasty: A Prospective Randomized Controlled Study on Clinical Outcomes and In-Hospital Data Knee pain during the first three months after unilateral total knee arthroplasty: a multi-centre prospective cohort study. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain Mediolateral oversizing influences pain, function, and flexion after TKA Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty: A Multisite Randomized Clinical Trial The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty Patient and intraoperative factors influencing satisfaction two to five years after primary total knee arthroplasty.
ABSTRACT The primary objective of the present study was to examine the role of pain‐related psychological factors in predicting pain and disability following Total Knee Arthroplasty ( TKA ) . The study sample consisted of 75 ( 46 women , 29 men ) individuals with osteoarthritis of the knee who were scheduled for TKA .  Measures of pain severity , pain catastrophizing , depression , and pain‐related fears of movement  were completed prior to surgery . Participants completed measures of pain severity and self‐reported disability 6 weeks following surgery . Consistent with previous research , cross‐sectional analyses revealed significant correlations among measures of pre‐surgical pain severity , pain catastrophizing , depression and pain‐related fears of movement . Prospect i ve analyses revealed that pre‐surgical pain severity and pain catastrophizing were unique predictors of post‐surgical pain severity ( 6‐week follow‐up ) . Pain‐related fears of movement were predictors of post‐surgical functional difficulties in univariate analyses , but not when controlling for pre‐surgical co‐morbidities ( e.g. back pain ) . The results of this study add to a growing literature highlighting the prognostic value of psychological variables in the prediction of post‐surgical health outcomes . The results support the view that the psychological determinants of post‐surgical pain severity differ from the psychological determinants of post‐surgical disability . The results suggest that interventions design ed to specifically target pain‐related psychological risk factors might improve post‐surgical outcomes Summary Patients ’ behavioral outcome expectancies assessed presurgically predicted pain severity and physical function 1 year after total knee arthroplasty ( TKA ) and partially mediated the relation between catastrophizing and TKA outcomes . Abstract The present study examined the prospect i ve value of response expectancies ( ie , pain , sleep ) and behavioral outcome expectancies ( ie , return to function ) in the prediction of pain severity and functional limitations 12 months after total knee arthroplasty ( TKA ) . The study sample consisted of 120 individuals ( 73 women , 47 men ) with osteoarthritis of the knee who were scheduled for TKA .  Measures of expectancies , pain severity , pain catastrophizing , pain‐related fears of movement , and depression  were completed prior to surgery . Participants also completed measures of pain severity and functional limitations 12 months following surgery . Analyses revealed that behavioral outcome expectancies were stronger predictors of follow‐up pain and functional limitations than response expectancies . Consistent with previous research , analyses also revealed that pain catastrophizing , pain‐related fear of movement , and depression predicted follow‐up pain and function . In a multivariate analysis , only pain catastrophizing contributed significant unique variance to the prediction of follow‐up pain and function . Behavioral outcome expectancies partially mediated the relation between catastrophizing and follow‐up pain and function . The relation between catastrophizing and follow‐up pain severity and functional limitations remained significant even when controlling for behavioral outcome expectancies . The results suggest that interventions design ed to specifically target behavioral outcome expectancies and catastrophizing might improve post‐surgical outcomes BACKGROUND Pain is the primary indication for both primary and revision total knee arthroplasty ( TKA ) ; however , most arthroplasty outcome measures do not take pain into account . OBJECTIVE To document the prospect i ve pain experience following TKA , with subjective pain-specific question naires to determine if comorbidities , preoperative pain or preoperative pain catastrophizing scores are predictive of long-term pain outcomes . METHODS Fifty-five patients with a primary diagnosis of osteoarthritis of the knee , who were scheduled to undergo TKA , were asked to fill out the McGill Pain Question naire ( MPQ ) and the Pain Catastrophizing Scale ( PCS ) preoperatively and at three , 12 and 24 months follow-up . Comorbidities were extracted from the Queen Elizabeth II Health Sciences Centre health information system . RESULTS The overall response rate ( return of completed question naires ) was 84 % . There was a significant decrease in the MPQ scores ( P<0.05 ) postoperatively . PCS scores did not change over time . Receiver operating characteristic curves revealed the number of comorbidities per patient predicted the presence of pain postoperatively , as documented by the numerical rating subscale of the MPQ at 24 months ( P<0.05 ) . Receiver operating characteristic curves for preoperative PCS and rumination subscale scores predicted the presence of pain , as measured by the Pain Rating Index subscale of the MPQ at 24 months ( P<0.05 ) . Preoperative PCS scores and comorbidities were significantly higher in the persistent pain group ( P<0.05 ) . CONCLUSIONS The number of comorbidities predicted the presence of pain at 24 months follow-up and , for the first time , preoperative PCS scores were shown to predict chronic postoperative pain . This may enable the identification of knee arthroplasty patients at risk for persistent postoperative pain , thus allowing for efficient administration of preoperative interventions to improve arthroplasty outcomes Several recent reports suggest that pain-related catastrophizing  is a risk factor for poor acute pain outcomes following surgical interventions . However , it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes . Data were analyzed from a relatively small number ( n=43 ) of patients who underwent total knee replacement and were followed for 12 months after their surgery . Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery . In this sample ,  catastrophizing and depression at each of the assessment points were studied as prospect i ve predictors of pain ( both global pain ratings and pain at night ) at the subsequent assessment point over the course of one year . The predictive patterns differed somewhat across measures of pain reporting ; depressive symptoms were unique predictors of greater global pain complaints , while catastrophizing was a specific and unique predictor of elevated nighttime pain . While surgical outcomes following total knee replacement are , on average , quite good , a significant minority of patients continue to experience long-term pain . The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels , indicating that interventions design ed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes Total knee arthroplasty has provided dramatic improvements in function and pain for the majority of patients with knee arthritis , yet a significant proportion of patients remain dissatisfied with their results . We performed a prospect i ve analysis of 215 patients undergoing TKA who underwent a comprehensive array of evaluations to discover whether any preoperative assessment could predict high pain scores and functional limitations postoperatively . Patients with severe pain with a simple knee range-of-motion test prior to TKA had a 10 times higher likelihood of moderate to severe pain at 6 months . A simple test of pain intensity with active flexion and extension preoperatively was a significant predictor of postoperative pain at 6 months after surgery . Strategies to address this particular patient group may improve satisfaction rates of TKA This study investigated the physical and psychosocial consequences of living with osteoarthritis ( OA ) in daily life and peoples ’ views of total knee arthroplasty ( TKA ) and the role of physiotherapy . In-depth interview data were used from a prospect i ve qualitative study conducted by the senior author ( KY ) . Participants were 15 volunteers with knee OA who were awaiting TKA at a specialized orthopaedic tertiary care facility in Toronto . A modified grounded theory method approach was used to analyze the interview data . The findings showed that experiences for the participants with OA were conceptualized as a “ breakpoint . ” The breakpoint was centred on the experiences/processes of living with unremitting pain , the limitations of mobility , leisure and social activities , and the result ing consequences to the participant 's physical and psychological well-being . In addition to the above experiences , participants also discussed their perceptions of  TKA surgery .  The findings showed that expectations of TKA were linked to participants ’ knowledge of the procedure and its outcomes . The participants listed acquaintances , friends , family members , and doctors as the main sources of knowledge for TKA . On the basis of the above analysis , recommendations are made for developing a preoperative physiotherapy program that would focus on minimizing preoperative disability and maximizing postoperative recovery UNLABELLED Anxiety , depression , and catastrophizing are generally considered to be predictive of chronic postoperative pain , but this may not be the case after all types of surgery , raising the possibility that the results depend on the surgical model . We assessed the predictive value of these factors for chronic postsurgical pain in 2 different surgical models : total knee arthroplasty for osteoarthritis ( 89 patients , 65 % women , age = 69 ± 9 years , baseline pain intensity = 4.7 ± 2.1 ) and breast surgery for cancer ( 100 patients , 100 % women , age = 55 ± 12 years , no preoperative pain ) . Data were collected before surgery , then 2 days and 3 months after surgery . Anxiety , depression , and catastrophizing were measured with the Spielberger State-Trait Anxiety Inventory , Beck Depression Inventory , and Pain Catastrophizing Scale , respectively . Pain was assessed with the  Brief Pain Inventory  . Neuropathic pain was detected with the DN4 question naire . Multivariate logistic regression analyses for the total knee arthroplasty and breast surgery models considered together indicated that the presence of clinical ly meaningful chronic pain at 3 months ( pain intensity ≥3/10 ) was predicted independently by age ( P = .04 ) , pain intensity on day 2 ( P = .009 ) , and state anxiety ( P = .001 ) . Linear regression models also showed that pain magnification , one of the dimensions of catastrophizing , independently predicted chronic pain intensity ( P = .04 ) . These results were not affected by the surgical model or by the neuropathic characteristics of the pain . Thus , state anxiety and pain magnification seem to constitute psychological risk factors for chronic postsurgical pain relevant in all surgical models . PERSPECTIVE This prospect i ve study performed in patients with total knee arthroplasty or breast surgery for cancer shows that state anxiety , amplification of pain , and acute postoperative pain independently predict postsurgical pain at 3 months and that this does not depend on the surgical model Total knee arthroplasty ( TKA ) is a frequently performed procedure in orthopaedic surgery . Recently , patient-specific instrumentation was introduced to facilitate correct positioning of implants . The aim of this study was to compare the early clinical results of TKA performed with patient-specific CT-based instrumentation and conventional technique . A prospect i ve , r and omized controlled trial on 112 patients was performed between January 2011 and December 2011 . A group of 112 patients who met the inclusion and exclusion criteria were enrolled in this study and r and omly assigned to an experimental or control group . The experimental group comprised 52 patients who received the Signature CT-based implant positioning system , and the control group consisted of 60 patients with conventional instrumentation .  Clinical outcomes were evaluated with the KSS scale , WOMAC scale , and VAS scales to assess knee pain severity and patient satisfaction with the surgery . Specified in-hospital data were recorded . Patients were followed up for 12 months . At one year after surgery , there were no statistically significant differences between groups with respect to clinical outcomes and in-hospital data , including operative time , blood loss , hospital length of stay , intraoperative observations , and postoperative complications . Further high- quality investigations of various patient-specific systems and longer follow-up may be helpful in assessing their utility for TKA Many patients have an unfavourable pain outcome post total knee arthroplasty ( TKA ) . This multi-centre prospect i ve cohort study recorded weekly pain scores one week before TKA and 12 weeks post TKA . 96 patients were enrolled into the study . Patients kept a record of their weekly scores pre-operation and post-operation by using the visual acuity score . Pain was divided into " best " pain score ( lowest pain score ) and " worst " pain score ( highest pain score ) . Patients with a pre-operative pain scores ≤ 4 were identified as an at risk group for poor pain outcome . Female gender , age and anaesthetics type were not identified as risk factors for poor pain outcome . Pain trajectory analysis also identified general patterns of pain response post TKA Purpose The purpose of the study was to investigate if changes in psychological variables are related to the outcome in pain and disability in patients with chronic anterior knee pain . Methods A longitudinal observational study on 47 patients with chronic anterior knee pain was performed in a secondary healthcare setting .  Pain was measured with the visual analogue scale and disability with the Lysholm scale . The psychological variables , such as anxiety , depression , pain coping strategies , catastrophizing and fear to movement beliefs , were studied by using self-administered question naires . Results Among the pain coping strategies , only the catastrophizing subscale showed a significant reduction . Similarly , anxiety , depression and kinesiophobia were significantly reduced after treatment . Those patients who decreased the catastrophizing , kinesiophobia , anxiety and depression showed a greater improvement in pain and disability after a purely biomedical treatment . A multiple regression analysis revealed that changes in catastrophizing predicted the amount of improvement in pain severity and that changes in both catastrophizing and anxiety predicted changes in disability after treatment . Conclusion What has been found suggests that clinical improvement in pain and disability is associated with a reduction in catastrophizing and kinesiophobia . Therefore , co- interventions to reduce catastrophizing thinking and kinesiophobia may enhance the results .Level of evidence Prospect i ve Cohort Study , Level I for prognosis Purpose Manufacturers of total knee arthroplasty ( TKA )  have introduced narrower femurs to improve bone-implant fit . However , few studies have reported the clinical consequences of mediolateral oversizing . Our hypothesis was that component oversizing negatively influences the results after TKA . Methods One hundred and twelve prospect ively followed patients with 114 consecutive TKA ( 64 females and 50 males ) were retrospectively assessed . The mean age of the patients was 72 years ( range , 56 to 85 years ) . The dimensions of the femur and tibia were measured on a preoperative CT-scan and were compared with those of the implanted TKA . The influence of size variation on the clinical outcomes 1 year after surgery was assessed . Results Mediolateral overhang was observed in at least one area in 66 % of the femurs ( 84 % in females and 54 % in males ) and 61 % of the tibia ( 81 % in females and 40 % in males ) . Twenty-two patients presented no overhang in any area and 16 had overhang in all studied zones . The increase in the Pain and KOOS scores were 43 ± 21 and 36 ± 18 in the patients without overhang and 31 ± 19 and 25 ± 13 in patients with overhang ( p = 0.033 ; p = 0.032 ) . Knee flexion was 127 ° ± 7 and 121 ° ± 11 , respectively . Regression and latent class analysis showed a significant negative correlation between overall oversizing and overall outcome . Conclusions This study confirms that oversizing may lead to worse clinical results in TKA . The clinical consequences are that surgeons should pay attention not to oversize implants during implantation nd that oversizing should be ruled out in case of so called unexplained pain . Level of evidence IV In this prospect i ve r and omized study , patients undergoing total hip ( THA ) or knee arthroplasty ( TKA ) were r and omized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block ( TKA patients ) . All patients received a comprehensive multimodal perioperative protocol .  Pain , recovery of functional milestones , and overall satisfaction were assessed . The THA study group demonstrated significantly lower average pain scores and higher overall satisfaction than the control group . There was no significant difference in pain scores between the study and control groups in the TKA cohort . Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery . Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities OBJECTIVE To quantify the magnitude of change seen with pain , function , and quality of life outcomes 6 months after  total hip and knee arthroplasties ( THA , TKA )  within a community based cohort of a regional health district . METHODS An inception cohort of 504 patients who received primary THA ( 228 ) or TKA ( 276 ) was prospect ively followed . All patients resided in the community and were assessed within one month prior to surgery and 6 months postoperatively . Health related quality of life measures were evaluated with the Western Ontario and McMaster Universities ( WOMAC ) Osteoarthritis Index and the Medical Outcome Survey Short Form SF-36 . Perioperative factors were extracted from medical charts . Health services utilization data were collected from regional health data bases . RESULTS Over 75 % of patients reported improvement in joint-specific pain and function , regardless of the type of joint replaced . Other health dimensions such as social function , bodily pain , physical function , vitality , and general health showed significant improvement after surgery . Those psychosocial dimensions with modest changes had baseline values comparable to age and sex adjusted normal values ; whereas , bodily pain and physical function , which had large changes , had values lower than the normal values . Ninety-one percent of patients receiving THA were satisfied with their surgery , whereas 77 % were satisfied with their TKA . The average length of stay was 7 days and the in-hospital complication rate was 0.34 per patient . CONCLUSION Large improvements were reported for pain and function after joint arthroplasties , while small to moderate changes were seen in other areas related to quality of life .  Patients with hip arthroplasties showed greater improvement in pain and function and were more satisfied with their outcomes than patients with knee arthroplasties . Although pain and function show large improvements , bodily pain and physical function were less than the values reported in the general population OBJECTIVE To evaluate the relationship between patient expectations of  total joint arthroplasty ( TJA ) and health related quality of life plus satisfaction 6 months after surgery . Methods . This prospect i ve cohort study included patients undergoing primary total hip ( THA ) and knee arthroplasty ( TKA ) .  Patients were evaluated with  self-report question naires prior to surgery and 6 months post-surgery . Medical Outcomes Study Short Form 36 ( SF-36 ) , the Western Ontario McMaster Universities Osteoarthritis Index ( WOMAC ) , and a satisfaction scale were used to evaluate outcomes at final followup . Multivariate regression models were used to evaluate the impact of expectations on outcomes . RESULTS There were 102 patients with THA and 89 with TKA . Mean age was 66 years . All patients achieved significant improvements in their WOMAC and SF-36 scores following surgery . Patient expectations regarding surgery were not associated with their age , gender , index joint of surgery , marital status , or race . Expectations were not correlated with pre-operative functional health status . Expectation of complete pain relief after surgery was an independent predictor of better physical function and improvement in level of pain at 6 months post-surgery . Expectation of low risk of complications from TJA was an independent predictor of greater satisfaction . CONCLUSIONS Patient expectations were important independent predictors of improved functional outcomes and satisfaction following TJA . Greater underst and ing of the relationship between expectations and outcomes may improve the process of care and outcomes of TJA Background : Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty .  Interventions to address pain catastrophizing , to our knowledge , have not been tested in patients undergoing knee arthroplasty . The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education . Methods : A multicenter , 3-arm , single-blinded , r and omized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States . There were 402 r and omized participants . The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) Pain Scale , measured at baseline , 2 months , 6 months , and 12 months following the surgical procedure . Results : Participants were recruited from January 2013 to June 2016 . In 402 participants , 66 % were women and the mean age of the participants ( and st and ard deviation ) was 63.2 ± 8.0 years . Three hundred and forty-six participants ( 90 % of those who underwent a surgical procedure ) completed a 12-month follow-up . All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences ( p > 0.05 ) among the 3 treatment arms . No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups ( adjusted mean difference , 0.3 [ 95 % confidence interval ( CI ) , −0.9 to 1.5 ] ) or between the pain coping and usual-care groups ( adjusted mean difference , 0.4 [ 95 % CI , −0.7 to 1.5 ] ) . Secondary outcomes also showed no significant differences ( p > 0.05 ) among the 3 groups . Conclusions : Among adults with pain catastrophizing undergoing knee arthroplasty  , cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care . Future research should develop interventions for the approximately 20 % of patients undergoing knee arthroplasty who experience persistent function-limiting pain . Level of Evidence : Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence Abstract The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased . We hypothesized same-day discharge following either a unicompartmental ( UKA ) or total knee arthroplasty ( TKA ) in an unselected group of patients would not result in a higher perioperative complication rate than st and ard-length hospitalization when following a comprehensive perioperative clinical pathway , including preoperative teaching , regional anesthesia , preemptive oral analgesia , preemptive antiemetics , and a rapid rehabilitation protocol . We prospect ively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospect ively ; 25 had UKA and 86 TKA . Of the 111 patients , 104 ( 94 % , 24 with UKA and 80 with TKA ) met discharge criteria and were discharged directly to home the day of surgery . Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge . There were four ( 3.6 % ) readmissions ( all with TKA ) and one emergency room visit without readmission ( in a patient with a TKA ) within the first week after surgery , while there were four subsequent readmissions ( 3.6 % ) and one additional emergency room visit without readmission within three months of surgery , all among patients undergoing TKA . There were no deaths , cardiac events , or pulmonary complications during this study . Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization . Level of Evidence : Level IV , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence The purpose of this study was to compare patient demographics and factors recorded at the time of surgery between patients that were either satisfied or dissatisfied with their TKA at mid-term follow-up . From our prospect i ve outcomes data base , 989 primary TKAs with complete preoperative and intraoperative data were identified . At mean follow-up of 3.5 years , 94/989 TKAs ( 9.5 % ) were not satisfied with their TKA . African American patients were 3.0 times more likely to be dissatisfied than Caucasians ( 95 % CI = 1.5 - 6.0 , P = .003 ) . Patients with less severe degenerative changes  were 2.1 times more likely to be dissatisfied ( 95 % CI = 1.3 - 3.2 , P = .001 )
This study provides moderate-level evidence for pain catastrophizing as an independent predictor of chronic pain post-TKA .
BACKGROUND Total knee arthroplasty ( TKA ) is a common and costly surgical procedure .
Despite high success rates , many TKA patients develop chronic pain  in the months and years following surgery , constituting a public health burden .
Pain catastrophizing is a construct that reflects anxious preoccupation with pain , inability to inhibit pain-related fears , amplification of the significance of pain vis-à-vis health implication s , and a sense of helplessness regarding pain .
Recent research suggests that it may be an important risk factor for untoward TKA outcomes .
To clarify this impact , we systematic ally review ed the literature to date on pain catastrophizing as a prospect i ve predictor of chronic pain following TKA .