BACKGROUND: High pain levels immediately after surgery have been associated with persistent postsurgical pain. Still, it is uncertain if analgesic treatment of immediate postsurgical pain prevents the development of persistent postsurgical pain.
METHODS: We searched MEDLINE, CENTRAL, and Embase up to September 12, 2023, for randomized controlled trials investigating perioperative analgesic interventions and with reported pain levels 3 to 24 months after total hip or knee arthroplasty in patients with osteoarthritis. The primary outcome was pain score 3 to 24 months after surgery, assessed at rest and during movement separately. Two authors independently screened, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. We conducted meta-analyses and tested their robustness with trial sequential analyses and worst-best and best-worst case analyses.
RESULTS: We included 49 trials with 68 intervention arms. All but 4 trials were at high risk of bias for the primary outcome. Moreover, the included trials were heterogeneous in terms of exclusion criteria, baseline pain severity, and which cointerventions the participants were offered. For pain at rest, no interventions demonstrated a statistically significant difference between intervention and control. For pain during movement, perioperative treatment with duloxetine (7 trials with 641 participants) reduced pain scores at 3 to 24 months after surgery (mean difference -4.9 mm [95% confidence interval {CI}, -6.5 to -3.4] on the 0-100 visual analog scale) compared to placebo. This difference was lower than our predefined threshold for clinical importance of 10 mm.
CONCLUSIONS: We found no perioperative analgesic interventions that reduced pain 3 to 24 months after total hip or knee arthroplasty for osteoarthritis. The literature on perioperative analgesia focused little on potential long-term effects. We encourage the assessment of long-term pain outcomes.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
This meta-analysis compared a range of interventions for pain lasting 3-24 months post-total hip or knee replacement in patients with osteoarthritis. The intervention arms included steroids, gabapentinoids, ketamine, local anaesthetic infiltration, varying regional anaesthesia techniques, NSAIDs, intraarticular injection, and epidurals. They assessed both pain at rest and on movement. The only intervention with significant benefit was duloxetine on movement in a comparison of 641 patients, which although statistically significant, did not meet the authors' threshold for clinical significance. Although this meta-analysis has yielded little for clinical practice, it has highlighted the paucity of evidence and the ongoing need for further trials and proposals of hypothesis to reduce this prevalent and debilitating condition. The authors should be commended for their efforts to bring together all the available evidence for a heterogeneous group of patients.
, McMaster University