Case of the Month #13: Persistent pain following total knee replacement

Published: 28/02/2022

Persistent Post-surgical Pain

Persistent post-surgical pain

This month’s recommended reading is on persistent post-surgical pain.  This case report is a typical example of the impact such pain can have on the patient population.  Persistent pain after surgery is described as a source of pain by up to a fifth of patients attending a chronic pain service1. Unrealistic expectations of what surgery can achieve is undoubtedly a contributor to this issue. 

High levels of catastrophisation have also been shown to be associated with report of higher levels of pain and indeed Forsythe2 and his colleagues showed this to be true in a group of patients who had undergone knee replacement surgery for osteoarthritis and were followed up two years following surgery. Catastrophisation associated with chronic pain leads to heightened levels of distress and emotional pain. 
Catastrophizing, mental health, preoperative knee pain, and pain at other sites are the strongest independent predictors of persistent pain after TKA3.

The patient responded very well to a holistic package of care from a multidisciplinary pain team.  

Bearing in mind predictors of chronic post-surgical pain shared not only by patients undergoing knee replacement surgery but other procedures as well, one cannot emphasise enough the importance of addressing some of these issues pre and perioperatively in order to minimise the risk of post-surgical pain. Patient education including ensuring that there are realistic expectations of long-term outcomes are of prime importance and this should be an integral aspect of the consent process.  Use of patient clinical measures to assess levels of catastrophisation, anxiety, depression and their impact on patient’s level of function is also crucial. NICE guidelines4 published in 2020 recommend further research in the long term management of patients undergoing major joint arthroplasty.

How as anaesthetics and pain clinicians can we work with our surgical colleagues to achieve this?