Predictors for moderate to severe acute postoperative pain after total hip and knee replacement
Open accessAbstract
Purpose The ability to identify and focus care to patients at higher risk of moderate to severe postoperative pain should improve analgesia and patient satisfaction, and may affect reimbursement. We undertook this multi-centre cross-sectional study to identify preoperative risk factors for moderate to severe pain after total hip (THR) and knee (TKR) replacement. Methods A total of 897 patients were identified from electronic medical records. Preoperative information and anaesthetic technique was gained by retrospective chart review. The primary outcomes were moderate to severe pain (pain score ≥ 4/10) at rest and with activity on postoperative day one. Logistic regression was performed to identify predictors for moderate to severe pain. Results Moderate to severe pain was reported by 20 % at rest and 33 % with activity. Predictors for pain at rest were female gender (OR 1.10 with 95 % CI 1.01-1.20), younger age (0.96, 0.94-0.99), increased BMI (1.02, 1.01-1.03), TKR vs. THR (3.21, 2.73-3.78), increased severity of preoperative pain at the surgical site (1.15, 1.03-1.30), preoperative use of opioids (1.63, 1.32-2.01), and general anaesthesia (8.51, 2.13-33.98). Predictors for pain with activity were TKR vs. THR (1.42, 1.28-1.57), increased severity of preoperative pain at the surgical site (1.11, 1.04-1.19), general anaesthesia (9.02, 3.68-22.07), preoperative use of anti-convulsants (1.78, 1.32-2.40) and anti-depressants (1.50, 1.08-2.80), and prior surgery at the surgical site (1.28, 1.05-1.57). Conclusions Our findings provide clinical guidance for preoperative stratification of patients for more intensive management potentially including education, nursing staffing, and referral to specialised pain management.
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Since the previous review's publication nearly a decade ago, many additional studies have been published with improved methodological rigour.
“Since its publication was nearly a decade ago, many additional studies have been published with improved methodological rigour;21–24 thus, providing a new opportunity to provide an updated summary of the literature and to generate pooled estimates of risk.”
From Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis (2019) · cites this paper as [23]
The use of preoperative analgesia, especially opioid therapy, has been linked to poor postoperative pain control in numerous studies.
“The use of preoperative analgesia, especially opioid therapy, has been linked to poor postoperative pain control in numerous studies.23 68”
From Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis (2019) · cites this paper as [23]
The association between preoperative analgesia and poor postoperative pain control may be due to greater preoperative severity of pain, opioid-induced hyperalgesia and central or peripheral sensitisation to pre-existing nociception.
“This may be due to greater preoperative severity of pain, opioid-induced hyperalgesia and central or peripheral sensitisation to pre-existing nociception.23 69”
From Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis (2019) · cites this paper as [23]
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“We are aware of studies concerning postarthroplasty acute pain either on TKA31–40 or on THA.28,29 Three other studies centered on the comparison between TKA and THA,41,42 but did not perform multivariate predictive analyses.”
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Risk Factors for Acute Postsurgical Pain: A Narrative Review
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“30,38,66 Two prospective cohort studies have shown that current smoking fails to predict APSP intensity, but some psychological factors can.”
InfluentialFeczko, P., Jutten, L. M. C., van Steyn, M. V., Deckers, P., Emans, P., & Arts, J. (2017) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-017-1635-9 · Cited by 25 · see citing works
Incidence and predictive factors for additional opioid prescription after endoscopic sinus surgery
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“005) and were prescribed more opioid tablets on discharge postoperatively (median [IQR], 30 [20-30] vs 30 [30-40]; p < 0.”
BackgroundKeulen, M. H. F., Asselberghs, S., Bemelmans, Y. F. L., Hendrickx, R. P. M., Schotanus, M. G. M., & Boonen, B. (2020) · The Journal of Arthroplasty · doi:10.1016/j.arth.2020.04.064 · Cited by 24 · see citing works
García‐Lopez, J., Polanco-García, M., & Montes, A. (2021) · The Journal of Arthroplasty · doi:10.1016/j.arth.2021.02.005 · Cited by 25 · see citing works
Soffin, E. M., Wilson, L. A., Liu, J., Poeran, J., & Memtsoudis, S. G. (2021) · British Journal of Anaesthesia · doi:10.1016/j.bja.2020.12.046 · Cited by 24 · see citing works
Gerber, S., & Saeed, N. (2021) · British Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.bjoms.2021.11.010 · Cited by 24 · see citing works
Comprehensive Analysis of Pain Management after Total Knee Arthroplasty
Lee, Y. S. (2017) · Knee Surgery and Related Research · doi:10.5792/ksrr.16.024 · Cited by 24 · see citing works
Cui, H., Sun, Z., Ruan, J., Yu, Y., & Fan, C. (2019) · International Journal of Surgery · doi:10.1016/j.ijsu.2019.06.010 · Cited by 21 · see citing works
Acute postoperative pain impact trajectories and factors contributing to trajectory membership
Giordano, N. A., Kent, M. L., Kroma, R. B., Rojas, W., Lindl, M. J., Lujan, E., Buckenmaier, C. C., & Highland, K. B. (2022) · Pain Medicine · doi:10.1093/pm/pnac203 · Cited by 23 · see citing works
Perioperative or Postoperative Nerve Block for Preventive Analgesia
Richebé, P., Rivat, C., & Liu, S. S. (2013) · Anesthesia & Analgesia · doi:10.1213/ane.0b013e31828843c9 · Cited by 20 · see citing works
Self-citationPain management in total knee arthroplasty: efficacy of a multimodal opiate-free protocol
Canata, G. L., Casale, V., & Chiey, A. (2016) · Joints · doi:10.11138/jts/2016.4.4.222 · Cited by 19 · see citing works
“in particular, preoperative psychological comorbidities, such as anxiety, depression or negative mood, have been significantly associated with acute postoperative pain after tKA (12); furthermore, preoperative antidepressant use and opioid use have each been shown to be among the significant predictors of moderate to…”
BackgroundLatijnhouwers, D. A. J. M., Martini, C. H., Nelissen, R. G. H. H., Verdegaal, S. H. M., Vlieland, T. P. M. V., Gademan, M. G. J., the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS) Group, van der Linden, H. M. J., Kaptein, B. L., Damen, P. J., et al. (2022) · Rheumatology International · doi:10.1007/s00296-022-05094-4 · Cited by 19 · see citing works
“Nevertheless, the effect of acute postoperative pain may be different in hip and knee arthroplasty patients compared to other surgical fields, as the majority of OA patients experienced pain for years before arthroplasty surgery [15].”
BackgroundWolmeister, A. S., Schiavo, C. L., Nazário, K. C. K., Castro, S. M. D. J., de Souza, A., Caetani, R. P., Caumo, W., & Stefani, L. P. C. (2020) · PLoS ONE · doi:10.1371/journal.pone.0227441 · Cited by 19 · see citing works
“Nevertheless, analyzing, in a practical and consistent way, a patient’s psychological profile in the preoperative period constitutes a challenging task, even considering the existing evidence of worst rehabilitation outcomes related to catastrophizing levels [6], anxiety [7], surgical fear [8] and preoperative pain [8…”
BackgroundJohnston, D. F., Sondekoppam, R. V., Giffin, J. R., Litchfield, R. B., & Ganapathy, S. (2017) · Regional Anesthesia & Pain Medicine · doi:10.1097/aap.0000000000000638 · Cited by 18 · see citing works
Perioperative insomnia trajectories and functional outcomes after total knee arthroplasty
Hamilton, K. R., Hughes, A. J., Campbell, C. M., Owens, M. A., Pester, B., Meints, S. M., Taylor, J. L. W., Edwards, R. R., Haythornthwaite, J. A., & Smith, M. T. (2023) · Pain · doi:10.1097/j.pain.0000000000002977 · Cited by 17 · see citing works
Pain Management After Total Joint Arthroplasty
McDonald, L. T., Corbiere, N. C., DeLisle, J. A., Clark, A. M., & Kuxhaus, L. (2016) · AORN Journal · doi:10.1016/j.aorn.2016.04.003 · Cited by 17 · see citing works
Preoperative Risk Factors of Persistent Pain following Total Knee Arthroplasty
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“Female gender was found to be a risk factor of CPSP by Puolakka et al. and Liu et al. [33, 34].”
Lambert, T. L., & Cata, D. M. (2014) · Orthopaedic Nursing · doi:10.1097/nor.0000000000000065 · Cited by 16 · see citing works
“Some orthopaedic postsurgical pain studies have suggested that gender differences may also infl uence postoperative pain with women tending to report higher pain scores than men after TKA ( Liu et al., 2012 ).”
Lizaur-Utrilla, A., González-Parreño, S., Miralles-Muñoz, F. A., Lopez‐Prats, F. A., & Gil-Guillén, V. F. (2014) · The Journal of Arthroplasty · doi:10.1016/j.arth.2014.07.011 · Cited by 14 · see citing works
“These studies [5,10,12] have found the influence of different factors such as that age, gender, preoperative pain, poor function, lowmental health, or multiple comorbid conditions are predictors of poorer outcomes.”
BackgroundResultInfluentialThe effects of preoperative chronic opioid use in total hip arthroplasty
Kim, K. Y., Chen, K. K., Roof, M. A., Anoushiravani, A. A., Vigdorchik, J. M., & Schwarzkopf, R. M. (2019) · Journal of Clinical Orthopaedics and Trauma · doi:10.1016/j.jcot.2019.04.027 · Cited by 14 · see citing works
Enhanced Recovery after Surgery for Knee Arthroplasty in the Era of COVID-19
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Morimoto, M., Nawari, A. N., Savić, R. M., & Marmor, M. T. (2024) · Sensors · doi:10.3390/s24155024 · Cited by 13 · see citing works
“…resting pain [36]. depression, and age for predicting postsurgical severe resting pain [35]; and (2) sex, age, BMI, surgery type (total hip or knee replacements), preoperative pain, preoperative opioid use, and general anesthesia for predicting moderate-to-severe postsurgical resting pain [36].”
BackgroundMaidment, Z. L., Hordacre, B. G., & Barr, C. (2014) · Australian Health Review · doi:10.1071/ah13232 · Cited by 13 · see citing works
den Hartog, Y. M., Hannink, G., van Dasselaar, N. T., Mathijssen, N. M. C., & Vehmeijer, S. B. W. (2017) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-017-1725-8 · Cited by 13 · see citing works
“Preoperative use of pain medication provides information on the preoperative pain levels of patients and has been shown to be associated with more severe postoperative pain [26, 27].”
BackgroundYe, X., Gao, Y., Xu, Z., Liu, Q.-X., & Zhan, C.-J. (2019) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2019/2979780 · Cited by 13 · see citing works
“Hence, medical workers and patients face the challenge of postoperative pain [10].”
BackgroundAlloplastic temporomandibular joint replacement—what does the future hold?
Mercuri, L. G. (2020) · Frontiers of Oral and Maxillofacial Medicine · doi:10.21037/fomm-2020-tjddm-02 · Cited by 12 · see citing works
“Predictors of post-implant pain with activity were severity of the pain pre-implant, the use of anticonvulsants and anti-depressants, and prior hip/ knee surgery (85).”
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Complications Associated with TMJ TJR: Management and Prevention
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Predictors of postoperative pain using PROMIS pain interference two-years following knee surgery
Karsalia, M., Zhang, T., Aneizi, A. A., Foster, M. J., Schneider, M. B., Sajak, P. M. J., Nadarajah, V., Meredith, S. J., & Henn, R. F. (2021) · Journal of Orthopaedics · doi:10.1016/j.jor.2021.05.017 · Cited by 10 · see citing works
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Factors Influencing the Choice of Anesthetic Technique for Primary Hip and Knee Arthroplasty
Wong, P., McVicar, J. A., Nelligan, K. A., Bleackley, J., & McCartney, C. J. L. (2016) · Pain Management · doi:10.2217/pmt.16.6 · Cited by 9 · see citing works
Self-citationGrant, A. E., Schwenk, E. S., Torjman, M. C., Hillesheim, R. A., & Chen, A. F. (2017) · Anesthesiology and Pain Medicine · doi:10.5812/aapm.46695 · Cited by 9 · see citing works
“There is also evidence for the use of celecoxib alone in improving postoperative analgesia after TKA (18).”
BackgroundNon-pharmacological Methods Used in Pain Control: Are the Evidence About the Efficacy Enough?
GÜNDÜZ, C. S., & Çalışkan, N. (2018) · Journal of Traditional Medical Complementary Therapies · doi:10.5336/jtracom.2018-60643 · Cited by 9 · see citing works
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“This is due to preoperative anxious state has been supported as a factor in lowering pain threshold, assisting overestimation of postoperative pain intensity([34]).”
BackgroundDonahue, R. E., Bradbury, G. R., Zychowicz, M. E., & Muckler, V. C. S. (2017) · Journal of PeriAnesthesia Nursing · doi:10.1016/j.jopan.2016.07.007 · Cited by 9 · see citing works
“mobility, and quality of life related to advanced osteoarthritis, one third of patients report moderate to severe postoperative pain.(3,4) Severe pain is associated with psychological and physiological harm, increased health care costs, and decreased patient satisfaction.”
BackgroundVariations in postoperative opioid prescribing by day of week and duration of hospital stay
Lazar, D. J., Zaveri, S. R., Khetan, P., Nobel, T. B., & Divino, C. M. (2020) · Surgery · doi:10.1016/j.surg.2020.05.047 · Cited by 9 · see citing works
Tran, T. X. M., Wetterslev, M., Nørskov, A. K., Meyhoff, C. S., Olsen, M. H., Itenov, T. S., Mathiesen, O., Karlsen, A. P. H., & The OPI•AID Collaborator Group (2025) · Acta Anaesthesiologica Scandinavica · doi:10.1111/aas.70000 · Cited by 8 · see citing works
“31 These studies also suggest that other factors may impact opioid requirements: female sex, psychological distress, anxiety and smoking , although the impact of female sex seems to be controversial.”
Which Outcomes Related to Regional Anesthesia Are Most Important for Orthopedic Surgery Patients?
Stundner, O., Ortmaier, R., & Memtsoudis, S. G. (2014) · Anesthesiology Clinics · doi:10.1016/j.anclin.2014.08.003 · Cited by 8 · see citing works
Anxiety in patients undergoing fast-track knee arthroplasty in the light of recent literature.
Ziętek, P., Ziętek, J., & Szczypiór-Piasecka, K. (2014) · Psychiatria Polska · doi:10.12740/pp/27173 · Cited by 8 · see citing works
“Educational and motivating interview affects a smaller perception of postoperative pain, higher postoperative satisfaction in patient [5, 46] and may result in a reduction of hospital stay for up to 24 hours [47, 48], although some authors do not have confirmed such a relation [45].”
BackgroundLee, Y., Son, J., & Yoon, H. (2014) · Journal of Korean Biological Nursing Science · doi:10.7586/jkbns.2014.16.3.226 · Cited by 7 · see citing works
“이러한 현상은 전신마취 하의 수술환자가 수술 후 24시간에서 통증 4 이상을 경험할 가능성 이 8.51배와 3.96배 높은 것으로 보고한 선행연구에 의해(Auburn et al., 2008; Liu et al., 2012) 지지되고 있다.”
InfluentialWHAT INFLUENCE ON EARLY POSTOPERATIVE PAIN INTENSITY AFTER TOTAL KNEE ARTHROPLASTY?
Saraev, A. V., Lindberg, M. F., Gay, C., Rosseland, L. A., Lerdal, A., Kornilov, N. N., & Kulyaba, T. A. (2017) · Traumatology and Orthopedics of Russia · doi:10.21823/2311-2905-2017-23-1-45-58 · Cited by 7 · see citing works
Rao, B. M., Cieslewicz, T. J., Sochacki, K. R., Kohlrieser, D., Moylan, D. D., & Ellis, T. J. (2021) · The Journal of Arthroplasty · doi:10.1016/j.arth.2021.03.027 · Cited by 7 · see citing works
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“According most existing studies and meta-analyses, FICB reduces pain intensity, the demand for opioids, and the rates of problems associated with their systemic use in these procedures [18–20].”
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“the first few days after surgery compared to patients who did not take these medications [31, 32].”
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Salazar‐Méndez, J., Gonzalez-Gajardo, K., Muñoz-Tapia, M. F., Sepúlveda-Urrutia, C., Viscay‐Sanhueza, N., & Méndez-Rebolledo, G. (2024) · Journal of Bodywork and Movement Therapies · doi:10.1016/j.jbmt.2024.04.007 · Cited by 5 · see citing works
Komatsu, D. E., Uddin, S. M. Z., Gordon, C., Kanjiya, M. P., Bogdan, D., Achonu, J. U., DiBua, A., Iftikhar, H., Ackermann, A., Shah, R. J., et al. (2022) · PLoS ONE · doi:10.1371/journal.pone.0278632 · Cited by 5 · see citing works
- Authors
- Liu, S. S., Buvanendran, A., Rathmell, J. P., Sawhney, M., Bae, J. J., Moric, M., Perros, S., Pope, A. J., Poultsides, L., Valle, C. J. D., Shin, N. S., McCartney, C. J. L., Ma, Y., Shah, M., Wood, M. J., Manion, S. C., & Sculco, T. P.
- Affiliations
- Hospital for Special Surgery (US)
- Rush University Medical Center (US)
- Harvard University (US)
- Sunnybrook Health Science Centre (CA)
- Cornell University (US)
- Corresponding author
- Liu, Spencer S.
- ORCID
- Venue
- International Orthopaedics
- Published
- 2012-07-29
- Volume
- 36
- Issue
- 11
- Pages
- 2261-2267
- ISSN
- 0341-2695 (ISSN-L)
- 1432-5195
- PMC
- PMC3479283
- OpenAlex
- W1979180225
- Cited by
- 167
- References
- 24
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 13 · 2023: 10 · 2022: 11 · 2021: 17 · 2020: 13 · 2019: 14 · 2018: 9 · 2017: 18 · 2016: 20 · 2015: 8 · 2014: 15 · 2013: 6 · 2012: 1
- FWCI
- 9.80
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- International Orthopaedics (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Hospital for Special Surgery
- National Institutes of Health (RR024996)
- National Center for Research Resources (UL1RR024996)
- Topics
- Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
- Health Sciences › Medicine › Surgery › Total Knee Arthroplasty Outcomes
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Keywords
- postoperative pain, total hip arthroplasty, total knee arthroplasty, preoperative risk factors, general anesthesia, opioid use, antiepileptic drugs, body mass index, preoperative pain, patient stratification, analgesia
- MeSH terms
- Activities of Daily Living, Aged, Cross-Sectional Studies, Female, Hip Joint, Humans, Knee Joint, Male, Middle Aged, Pain Measurement, Pain, Postoperative, Postoperative Pain, Predictive Value of Tests, Prognosis, Retrospective Studies, Risk Factors, Sex Factors, Triage, Treatment Outcome, Practice Guidelines as Topic, Patient Selection, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Pain Management
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