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Risk factors for pain after total hip arthroplasty: a systematic review

Risk factors for pain after total hip arthroplasty: a systematic review Background Approximately 23% of patients develop hip pain after total hip arthroplasty ( THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgi- cal planning. Methods Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preopera- tive modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently. Results Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes. Conclusions Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management. Keywords Total hip arthroplasty, Systematic review, Pain, Risk factors pain include loosening of implants, infection, peripros- Introduction thetic fracture, and soft-tissue abnormalities [3]. How- Total hip arthroplasty (THA) is highly effective in allevi - ever, many cases cannot be explained by radiographic or ating pain, restoring function, and improving quality of mechanical abnormalities. life in patients with severe hip arthritis. However, approx- Hip pain following THA is often exacerbated by using imately 23% of patients develop hip pain after THA [1– stairs, walking on uneven surfaces, sitting for extended 4]. Some may even experience no improvement or worse periods of time, and standing from a seated position. pain postoperatively [2]. Known causes of postoperative Factors that may influence hip pain involve both modifi - able and non-modifiable risk factors. Modifiable risk fac - *Correspondence: tors include body mass index (BMI), certain medical and Kevin L. Mekkawy psychological comorbidities, and select socioeconomic kevin.mekkawy@gmail.com variables. Non-modifiable risk factors may cover age, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA sex, and race. Identification of these modifiable risk fac - tors of increased postoperative pain is critical in guiding © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Zhang et al. Arthroplasty (2023) 5:19 Page 2 of 12 preoperative optimization. Understanding non-modifia - assess risk factors, pain, risk factors for pain, or specific ble risk factors also has added value in determining sur- THA data were excluded from this analysis. gical expectations, individualizing pain management, and guiding the informed decision-making process. Bias assessment This systematic review aimed to determine preopera - Criteria for bias are not well described for systematic tive risk factors that are associated with post-THA pain. reviews of observational studies. We performed a bias Hernández et  al. reviewed studies prior to 2013 for pre- assessment for each article based on study design and dictive factors in total knee and total hip replacements characteristics. The bias assessment was based on (1) loss [5]. However, THA and TKA are fundamentally distinct to follow-up of <20% before 1  year or <30% after 1  year; surgeries with well-documented differences in outcomes (2) consecutive patient selection; (3) multicenter recruit- [6]. To our knowledge, there has been no systematic eval- ment; and (4) use of univariable or multivariable analysis uation of risk factors for postoperative pain specific to to adjust for confounders. Studies were rated as high risk THA. (meeting zero or one criterion), medium risk (meeting two criteria), or low risk (meeting three or more crite- ria). If it was unclear whether a study met a criterion, we Methods assumed that it did not. Search strategy We developed a comprehensive search strategy according Data to the Preferred Reporting Items for Systematic Reviews Data extracted included study design, patient charac- and Meta-Analyses guidelines with the assistance of a teristics, preoperative risk factors, study duration, out- trained librarian. A systematic search was conducted in come measurements, postoperative pain outcomes, and the PubMed (Medline), Scopus, Web of Science, Cumula- criteria for bias assessment. Results for each factor were tive Index of Nursing and Allied Health Literature Plus compared across the studies. Medical or psychological (EBSCO), Embase, and Cochrane databases by using comorbidities, BMI, preoperative pain, and certain socio- title, abstract, keywords, and medical subject headings economic elements were considered modifiable factors; (MeSH). MeSH terms included arthroplasty, replace- whereas, age, sex, and race were deemed as non-modifi - ment, total hip, THA, follow-up, risk assessment, risk able. A descriptive analysis was performed as the hetero- factors, reinforcing factors, predictors, pain, postopera- geneity of outcome measures and study characteristics tive, chronic, long-term, and pain measurement. Title, prohibited a meaningful meta-analysis. abstract, and keyword search terms were "hip arthro- plasty, THA, THR, hip replacement, OR total hip" AND Patient and public involvement "after, continue, post, recur, ongoing, chronic, persistent, No patients were involved in determining the research OR long term" AND "pain" AND "risk, predict, factor, question, outcome measures, or study design. There associated, correlate, effect, affect, OR influence". The are no plans to involve patients in the dissemination of search strategy was tailored to and optimized for each research findings. database. Results Inclusion and exclusion criteria Study characteristics Our review screened for prospective controlled tri- A total of 11,729 studies were identified, including dupli - als, prospective and retrospective observational cohort cates. The full-text review was performed for 339 pub - studies, and case–control studies. The inclusion criteria lications, and 54 studies satisfied our inclusion criteria were full-text articles published between January 1995 (Fig.  1). Most studies were observational cohort studies. and August 2020 with postoperative pain outcomes in The sample size ranged from 54 to 37,393 patients, and only adult THA cases for osteoarthritis with respect to follow-up ranged from 24  h to 12  years. Other than in preoperative risk factors. Studies of patients undergoing the studies by Busato et al. [7] and Röder et al. [8], THAs THA in combination with other large-joint replacement were performed in 1993 or later. Commonly evaluated surgeries were included if data specific to THA were risk factors for postoperative pain were preoperative provided. The literature review was performed indepen - pain and function (20 studies), medical and psychological dently by three researchers. Search results were reviewed comorbidities (18 studies), BMI (13 studies), socioeco- in order of title, abstract, then full text, and excluded if nomic status and ethnicity (12 studies), sex (11 studies), they did not meet all criteria. Additional relevant studies and radiographic severity of osteoarthritis (4 studies). were identified through a manual search of the bibliog - Functional outcomes were assessed using the West- raphies of selected studies. All other studies that did not ern Ontario and McMaster Universities Arthritis Index Zhang  et al. Arthroplasty (2023) 5:19 Page 3 of 12 Fig. 1 Flow diagram of a systematic review of articles published from January 1995 to May 2018 about adults undergoing total hip arthroplasty. The databases searched were PubMed (Medline), Scopus, Web of Science, Cumulative Index of Nursing and Allied Health Literature Plus (EBSCO), Embase, and Cochrane (WOMAC), Oxford Hip Score (OHS), Harris Hip Score Preoperative pain and hip function (HHS), and Hip Disability and Osteoarthritis Outcome We found that preoperative pain and function were sig- Score (HOOS). nificant predictors of pain or persistent opioid use after According to the bias criteria, 10 studies had a high THA in 16 of 20 studies (Table 3). Of the studies, 2 had a risk of bias, 31 had a medium risk, and 13 had a low risk low risk of bias, 14 had a medium risk, and 4 had a high (Table  1). Most studies adjusted for confounders. How- risk. ever, because of the retrospective design of many studies, selection methods and follow-up rates often could not be Age assessed. We found an association between patient age and pain or opioid use after THA in 9 of 12 studies, but these results were controversial (Table  4). Of these studies, Preoperative BMI 3 showed older age to be predictive of persistent pain, We found that high BMI was associated with worse pain whereas 5 found young age to be predictive. One study outcomes or increased opioid use after THA in 9 of 13 concluded that two opposite age ranges studied were studies, although conclusions varied regarding its clinical associated with worse pain, and three studies found no importance (Table  2). Of the studies, 5 had a low risk of association. Notably, 4 studies had a high risk of bias, 3 bias, 7 had a medium risk, and 1 had a high risk. had a medium risk, and 5 had a low risk. Zhang et al. Arthroplasty (2023) 5:19 Page 4 of 12 Table 1 Risk of bias among 53 studies of adult THA First author Year Consecutive patient Multicenter Adequate follow- Adjustment for Risk of bias selection enrollment up confounders Prentice [9] 2019 Yes Yes Yes Yes Low Goodman [10] 2018 Yes No Yes Yes Low Bedard [11] 2017 - Yes - No High Brembo [12] 2017 Yes Yes Yes Yes Low Li [13] 2017 - Yes - Yes Medium Pinto [14] 2017 Yes - - Yes Medium Dowsey [15] 2016 Yes No Yes Yes Low Goesling [16] 2016 - No Yes Yes Medium Greene [17] 2016 - Yes - Yes Medium Tilbury [18] 2016 Yes No No Yes Medium Lavernia [19] 2015 - No No Yes High Mannion [20] 2015 - - Yes Yes Medium Nam [3] 2015 No Yes No No High Rajamaki [21] 2015 No No Yes Yes Medium Dowsey [22] 2014 - No - Yes High Greene [23] 2014 - Yes No Yes Medium Judge [24] 2014 - Yes - Yes Medium Lavernia [25] 2014 Yes No - Yes Medium Motaghedi [26] 2014 No No Yes No High Petrovic [27] 2014 - Yes Yes Medium Singh [28] 2014 Yes No - Yes Medium Haverkamp [29] 2013 Yes - Yes No Medium Judge [2] 2013 Yes Yes Yes No Low Krupic [30] 2013 - Yes - Yes Medium Neuburger [31] 2013 - Yes - Yes Medium Pinto [32] 2013 Yes No No Yes Medium Singh [33] 2013 Yes No - Yes Medium Singh [34] 2013 Yes No - Yes Medium Jones [35] 2012 Yes Yes Yes Yes Low Liu [36] 2012 No Yes - Yes Medium Smith [37] 2012 Yes - No Yes Medium Allen Butler [38] 2011 Yes - Yes No Medium Clement [39] 2011 Yes No - No High Clement [40] 2011 - No - Yes High Lavernia [41] 2011 - No Yes Yes Medium Lavernia [42] 2011 - Yes Yes Yes Low Johansson [43] 2010 - - - No High Riediger [44] 2010 Yes - No No High Schafer [45] 2010 Yes No No Yes Medium Singh [46] 2010 Yes No - Yes Medium Lavernia [47] 2009 - - - Yes High Quintana [48] 2009 - Yes Yes Yes Low Rolfson [49] 2009 - Yes - Yes Medium Busato [7 ] 2008 - Yes - Yes Medium Kessler [50] 2007 Yes - Yes Yes Low Röder [8] 2007 - Yes - Yes Medium Moran [51] 2005 Yes No Yes Yes Low Fortin [52] 2002 Yes Yes Yes Yes Low Holtzman [53] 2002 - Yes No Yes Medium Zhang  et al. Arthroplasty (2023) 5:19 Page 5 of 12 Table 1 (continued) First author Year Consecutive patient Multicenter Adequate follow- Adjustment for Risk of bias selection enrollment up confounders Nilsdotter [54] 2002 Yes No Yes No Medium Jones [55] 2001 Yes Yes Yes Yes Low Nilsdotter [56] 2001 - No Yes Yes Medium Meding [57] 2000 Yes No Yes Yes Low Fortin [58] 1999 - Yes No Yes Medium “-”: unable to assess Adequate follow-up was defined as a loss to follow-up of < 20% before 1 year or < 30% after 1 year Table 2 Associations of BMI with pain/opioid use after THA First author Year Study design n Follow-up BMI groups (% of patient) Outcome measures Associations of high BMI with postoperative pain/ opioid use Prentice [9] 2019 RC 12,560 1 yr < 30 (60.8); 30–35 (24.5); Opioid usage Greater postoperative opioid > 35 (14.6) use after initial 90-day recov- ery period Li [13] 2017 RC 2040 6 mo 25–29.9 (37); 30–34.9 (22); PCS, HOOS Worse pain at baseline and 35–39.9 (10); ≥ 40 (4) 6 months, more improvement postoperatively Rajamaki [21] 2015 CC 54 1–2 yr < 30 (53); 30–35 (31); > 35 Questionnaire Higher proportion of patients (16) with pain Judge [24] 2014 RS 1431 1 yr < 25 (33); 25–30 (42); 30–35 OHS Worse pain, low clinical dif- (18); ference 35–40 (5.5); > 40 (1.7) Motaghedi [26] 2014 PC 60 1 d < 25 (33); 25–30 (33); > 30 VRS No association (33) Judge [2] 2013 PC 1431 1–5 yr < 25 (33); 25–30 (42); 30–35 OHS Worse pain (18); 35–40 (5.5); > 40 (1.7) Jones [35] 2012 PC 231 3 yr > 35 (14) WOMAC Worse pain at 6 months; no association at 3 years Liu [36] 2012 CC 428 1 d 30 VAS for pain Worse pain, low clinical significance Smith [37] 2012 PC 1318 3 yr NA HHS Worse pain Singh [46] 2010 CC 5707, 3289 2 yr, 5 yr < 25 (24); 25–29.9 (39); Questionnaire Worse pain 30–34.9 (24); 35–39.9 (8); ≥ 40 (1) Busato [7] 2008 RC 20,553 3, 6, 9, 12 yr < 25 (38); 25–30 (44); > 30 Questionnaire No association (18) Kessler [50] 2007 PC 67 10 d, 3 mo < 25 (16); 25–30 (54); > 30 WOMAC No association (30) Moran [51] 2005 PC 800 6, 18 mo 28 (range, 14–49) HHS Worse pain BMI Body mass index, CC Case control, CI Confidence interval, HHS Harris Hip Score, HOOS Hip Disability and Osteoarthritis Outcome Score, NA Not available, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PCS Pain catastrophizing scale, RC Retrospective cohort, SD Standard deviation, VAS Visual analog scale, VRS Verbal rating scale Expressed as mean BMI Sex Radiographic severity of arthritis Female gender was a predictor of worse pain or opioid Of the studies investigated, four examined the asso- use after THA in 9 of 11 studies (Table  5). There were ciation between preoperative radiographic severity of no studies with a high risk of bias, and three had low arthritis and postoperative pain. We noted that 3 of risk. these studies reported better pain outcomes in patients Zhang et al. Arthroplasty (2023) 5:19 Page 6 of 12 Table 3 Associations of preoperative pain medication or opioid use and function with pain medication or opioid use after THA First author Year Study design n Follow-up Outcome measures Associations of poor preoperative pain/function with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 yr Opioid usage Number of preoperative opioid prescriptions, preoperative NSAID use, back pain, and non-specific chronic pain associated with greater postoperative opioid use Bedard [11] 2017 RC 37,393 1 yr Opioid usage rate Greater preoperative opioid use associated with greater postop- erative opioid use Pinto [14] 2017 PC 64 2 d NRS No association Goesling [16] 2016 PC 331 6 mo WOMAC Greater preoperative opioid use associated with greater postop- erative pain and opioid use Dowsey [22] 2014 PC 835 1 yr HHS No association between preoperative pain and postoperative pain; conflicting results for association between preoperative function and postoperative pain Petrovic [27] 2014 CC 90 1 d NRS Higher odds of postoperative pain Singh [28] 2014 RC 3823 2, 5 yr VAS for pain Worse pain in patients using a walking aid Haverkamp [29] 2013 PC 1892.3 yr VAS, WOMAC Worse pain Judge [2] 2013 PC 1431 1–5 yr OHS Worse pain Pinto [32] 2013 CC 48 4–6 mo NRS Higher odds of postoperative pain Singh [33] 2013 RC 3823 2, 5 yr HHS Worse hip pain with preoperative ipsilateral knee pain Liu [36] 2012 CC 428 1 d VAS for pain Higher odds of postoperative pain Smith [37] 2012 PC 1318 3 yr HHS Worse pain Johansson [43] 2010 PC 75 2 yr WOMAC, HHS, SF-36 Worse pain Lavernia [47] 2009 PC 127 3 yr WOMAC Worse pain Röder [8] 2007 RC 13,766 ≤ 10 yr VAS for pain No association Fortin [52] 2002 PC 86 2 yr WOMAC Worse pain Holtzman [53] 2002 PC 1046 1 yr VAS for pain Higher odds of postoperative pain Nilsdotter [56] 2001 PC 162 1 yr WOMAC Worse pain Fortin [58] 1999 PC 116 6 mo WOMAC Worse pain CC Case–control, CI Confidence interval, HHS Harris Hip Score, NRS Numerical rating scale, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PCS Physical component summary, RC Retrospective cohort, RR Risk ratio, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index a † Mean follow-up. Included THA and total knee arthroplasty cases with severe arthritis, while one study found no predic- these, 2 articles had a high risk of bias, 11 had a medium tive value (Table  6). Regarding risk of bias, 2 studies risk, and 5 had a low risk. Psychological comorbidities had a low risk and 2 had a medium risk. were another frequently studied risk factor. Discussion Socioeconomic status and race/ethnicity The most consistent association were found between Associations of various socioeconomic parameters and poor pain outcomes and the female sex, high preopera- race/ethnicity with pain or opioid use after THA were tive pain or low function, and various medical or psy- assessed in 12 studies (Table 7). Three studies had a high chiatric comorbidities. Females not only had worse risk of bias, 6 had a medium risk, and 3 had a low risk. Of pain at both short- and long-term follow-ups but also these studies, 4 found worse pain in African Americans had higher odds of severe acute postoperative pain and at 2–3.5 years postoperatively [10, 19, 38, 42]. Reports on long-term opioid use. Although this should not affect the the educational level were mixed. Three studies reported patient selection, an effort should be made to optimize that low socioeconomic status was a risk factor for poor multimodal pain management in women to achieve bet- pain outcomes after THA [31, 38, 40]. ter short-term pain control, decrease chronic pain, and minimize opioid dependence [59]. Postoperatively, multi- Preoperative comorbidities disciplinary pain therapy has been shown to provide sub- Seventeen of 18 studies found a negative association stantial pain relief and may be a valuable referral [60]. between medical or psychological comorbidities and Preoperative pain and loss of function are two primary pain after THA or postoperative opioid use (Table 8). Of criteria for performing THA; therefore, they cannot be Zhang  et al. Arthroplasty (2023) 5:19 Page 7 of 12 Table 4 Associations of patient age with pain/opioid use after THA First author Year Study design n Age, yr Follow-up Outcome measures Associations of older age with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 67 (59–75) 1 yr Opioid usage Less risk of postoperative opioid use Bedard [11] 2017 RC 37,393 < 50, 2.7% 1 yr Opioid use Less risk of postoperative opioid use Brembo [12] 2017 PC 223 69 (41–91) 3 mo WOMAC Worse pain Nam [3] 2015 PC 196 50 , SD = 7.1 2.9 yr Pain scale of 0–5 Less odds of having pain Dowsey [22] 2014 PC 835 68 SD = 9.9 12 mo HHS Better pain Judge [2] 2013 RC 1431 70 1–5 yr OHS Worse pain in patients aged < 60 or > 70 Liu [36] 2012 CC 428 67 SD = 11 1 d VAS for pain Better pain Smith [37] 2012 PC 1318 68.5 SD = 9.9 3 yr HHS Worse pain Clement [39] 2011 PC 171 > 80 1 yr OHS No association 495 65–74 Quintana [48] 2009 PC 291 > 70 2 yr WOMAC Worse pain 299 ≤ 70 Nilsdotter [54] 2002 PC 124 71 1 yr WOMAC No association Jones [55] 2001 PC 197 55–79 (83%), ≥ 80 (17%) 6 mo WOMAC, SF-36 No association CC Case–control, CI Confidence interval, HHS Harris Hip Score, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, RC Retrospective cohort, SD Standard deviation, SF-36 36-Item Short-Form Health Survey, WOMAC Western Ontario and McMaster Universities Arthritis Index Data presented as mean Data presented as median (interquartile range) Table 5 Associations of female sex with pain/opioid use after THA First author Year Study design n Female sex, % Follow-up Outcome measures Associations of female sex with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 59 1 yr Opioid usage Greater opioid use Brembo [12] 2017 PC 223 71 3 mo WOMAC No association Pinto [14] 2017 PC 64 59 2 d NRS Worse pain Mannion [20] 2015 RC 261 50 1 yr OHS, WOMAC, SF-12 No association Petrovic [27] 2014 CC 90 47 1 d NRS Higher odds of pain Liu [36] 2012 CC 428 58 1 d NRS Worse pain Smith [37] 2012 PC 1318 NA 3 yr HHS Worse pain Lavernia [41] 2011 RC 658 59 2 yr HHS, SF-36, WOMAC Worse pain Singh [46] 2010 PC 5707, 3289 51 2 yr, 5 yr Pain medication use Greater pain medication use Rolfson [49] 2009 RC 6158 57 1 yr VAS Worse pain Quintana [48] 2009 PC 590 49 2 yr WOMAC, SF-36 Worse pain CC Case–control, CI Confidence interval, HHS Harris Hip Score, NA Not available, NRS Numerical rating scale, NSAID Nonsteroidal anti-inflammatory drug, OR Odds ratio, PC Prospective cohort, RC Retrospective cohort, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index treated like other modifiable factors. A difference should without. Other medical comorbidities had a similar be noted for patients using chronic pain medication, who effect. Increased odds of acute and chronic pain, as are at higher risk of postoperative opioid dependence and well as opioid dependence, were repeatedly observed in may benefit from referral to a pain specialist preopera - patients with anxiety or depression. Our data suggest that tively for intervention and a weaning protocol at the cost preoperative medical optimization may be beneficial to of delaying surgery [11, 16]. pain outcomes. Additionally, treating those with active Patients with existing comorbidities are more reluc- psychiatric conditions may also improve perceived pain tant to undergo elective surgeries [61]. In THA, they and satisfaction [63]. also experience increased complications requiring revi- Less consistent association was seen between poor pain sions [62]. Notably, patients with diabetes had eight outcomes and high BMI, low radiographic grade, and low times higher odds of having persistent pain than those socioeconomic status. The difference in pain outcomes Zhang et al. Arthroplasty (2023) 5:19 Page 8 of 12 Table 6 Associations of preoperative radiographic severity of arthritis with pain after THA First author Year Study design n Radiographic grade (% Follow-up Outcome measures Associations of higher- patients) grade osteoarthritis with postoperative pain Tilbury [18] 2016 PC 302 mK-L grade: 1 or 2 (26) mild, 3 1 yr HOOS, OHS, SF-36 Greater pain improvement or 4 (74) Dowsey [15] 2016 CC 382 mK-L grade: 2 (1.4), 3a (6.8), 3b 1 and 2 yr HHS Greater odds of pain (33), 4a (25), 4b (35) improvement Nilsdotter [56] 2001 PC 162 OARSI grade: 3 (70), 2 (29), 1 (1) 1 yr WOMAC, SF-36 No association Meding [57] 2000 PC 1163 -independent scale 32 (6–93) mo HHS Less pain CC Case–control, HHS Harris Hip Score, HOOS Hip Disability and Osteoarthritis Outcome Score, mK-L modified Kellgren and Lawrence grade, OARSI Osteoarthritis Research Society International, OHS Oxford Hip Score, PC Prospective cohort, SF-36 36-Item Short-Form Health Survey, WOMAC Western Ontario and McMaster Universities Arthritis Index Expressed as mean (range) Table 7 Associations of race/ethnicity and SES with pain/opioid use after THA First author Year Study design n Follow-up, yr Outcome measures Associations of race/ethnicity and SES with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 Opioid usage Higher opioid use in African Americans, lower opioid use in Asian (compared to white) Goodman [10] 2018 RC 4170 2 WOMAC Worse pain in African Americans Lavernia [19] 2015 RC 564 3.5 (1–9) VAS, WOMAC, SF-36 Worse pain in African Americans Dowsey [22] 2014 PC 835 1 HHS No association Greene [23] 2014 RC 11,464 1 VAS Worse pain in patients with low education Neuburger [31] 2013 RC 59,680 0.5 OHS Worse pain in low SES Krupic [30] 2013 RC 1216 1 VAS Worse pain in immigrants Allen Butler [38] 2011 PR 119 2 VAS, HHS Worse pain in African Americans, those with low education, and those with low income Lavernia [42] 2011 RC 739 2 WOMAC, SF-36 Worse pain in minority patients, especially African Americans Clement [40] 2011 PC 1359 1 OHS Worse pain in more deprived patients Schafer [45] 2010 CC 1113 0.5 WOMAC Greater odds of poor pain outcome in patients who are single, living alone, on disability Fortin [58] 1999 PC 116 0.5 WOMAC No association with education level CC Case–control, CI Confidence interval, HHS Harris Hip Score, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PR Prospective randomized, RC Retrospective cohort, SES Socioeconomic status, SF-36 36-Item Short-Form Health Survey, THA Total hip arthroplasty, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index Data presented as mean (range) among BMI groups was often small when compared With respect to race and socioeconomic factors, most with the overall improvement. Although most data show studies found worse pain outcomes in African Ameri- worse postoperative pain scores in patients with high cans, immigrants, patients with low educational levels, BMI, this may be due to greater preoperative pain rather and patients with low socioeconomic status. Additionally, than a less surgical benefit. Nevertheless, weight loss African Americans and patients of lower socioeconomic may be beneficial in decreasing baseline pain, ultimately status had worse pain on presentation. A lack of access improving postoperative pain [64]. to resources, along with health care disparities affecting Advanced preoperative radiographic severity of osteo- these populations, likely contribute to a delayed presenta- arthritis was mostly found to be associated with worse tion with greater pain from advanced disease or improper pain outcomes. Although the data were not robust, they non-operative management [66]. Although it is encourag- support the current guidelines of attempting non-oper- ing that these patients achieved similar improvement from ative modalities for those with low-grade radiographic surgery as their counterparts, they may still benefit from arthritis [65]. attention to pain management and preoperative education. Zhang  et al. Arthroplasty (2023) 5:19 Page 9 of 12 Table 8 Associations of preoperative medical/psychological comorbidities with pain/opioid use after THA First author Year Study design n Follow-up Outcome measures Associations of preoperative comorbidities with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 yr Opioid usage Higher postoperative opioid prescriptions with anxiety, chronic pulmonary disease, substance abuse, acquired immunodeficiency syndrome (AIDS), peripheral vascular disease, chronic blood loss anemia, congestive heart failure Bedard [11] 2017 RC 37,393 1 yr Opioid use Higher risk postoperative opioid use with preoperative anxiety, depression, drug use, alcohol use, smoking Brembo [12] 2017 PC 223 3 mo WOMAC Worse pain with increased medical comorbidities Dowsey [15] 2016 PC 382 1 and 2 yr HHS Worse pain with poor mental function Greene [17] 2016 RC 17,147 1 yr VAS for pain Worse pain if using antidepressants Rajamaki [21] 2015 PC 54 1–2 yr NRS Greater odds of pain in diabetes Lavernia [25] 2014 RC 60 11 (3–24) mo HHS Worse pain in vitamin D insufficiency Petrovic [27] 2014 CC 90 1 d NRS Higher odds of pain in type D personality, anxiety, depres- sion Dowsey [22] 2014 PC 835 1 yr HHS Worse pain with increased medical comorbidities Pinto [32] 2017 CC 48 4–6 mo NRS Worse pain with poor disease process perception and emotional representation Judge [2] 2013 PC 1431 1–5 yr OHS Worse pain in medical comorbidities Singh [34] 2013 PC 5707, 3289 2 yr, 5 yr VAS for pain No association Jones [35] 2012 PC 231 3 yr WOMAC Worse pain with cardiac disease Smith [37] 2012 PC 1318 3 yr HHS Worse pain with cardiac disease, hypertension, increase medical comorbidities, NSAID use Allen Butler [38] 2011 PR 119 2 yr VAS, HHS, SF-12 Worse pain with poor mental component score Singh [46] 2010 PC 5707, 3289 2 yr, 5 yr Pain medication use Greater odds of pain, NSAID use, and opioid use in depres- sion Riediger [44] 2010 PC 79 8 wk WOMAC, SF-36 Worse pain in depression and somatoform disorders Rolfson [49] 2009 RC 6158 1 yr VAS for pain Worse pain in anxiety and depression ASA American Society of Anesthesiologists, CAD Coronary artery disease, CC Case–control, CCI Charlson Comorbidity Index, CI Confidence interval, HHS Harris Hip Score, HTN Hypertension, NRS Numerical rating scale, NSAID Nonsteroidal anti-inflammatory drug, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PR Prospective randomized, RC Retrospective cohort, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS 10-cm visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index The relationship between age and pain outcomes is less This is the first systematic review, to our knowledge, clear. Studies showed that older age could be associated that assessed common preoperative risk factors for pain with better, worse, or no difference in postoperative pain. after THA. A strength of this study is that a large num- Possible explanations for worse outcomes in younger ber of studies were included, most of which had a low or patients include an increased level of activity and expec- medium risk of bias. However, there are several limita- tations [67]. Conversely, confounding comorbidities and tions to consider. The majority of outcome-based studies poor recovery may contribute to persistent pain in older are observational cohorts with varying quality and risk of patients. Notably, two studies reported worse outcomes bias. In retrospective studies, appropriate patient selec- in older patients at 3- and 6-month follow-up, whereas, tion and loss of follow-up are difficult to assess. Addi - most studies at later time points showed no effect or tionally, not all studies adjusted for confounding factors. the opposite. This may be attributed to decreased heal - Most studies reported follow-up of < 2  years, and only ing and rehabilitation potential in older patients who are two studies continued beyond 5 years. The effects, if any, less healthy and less active. Although results conflict, that these risk factors may have beyond this time frame data exist showing both ends of the age spectrum hav- are impossible to evaluate. Additionally, it is apparent ing worse pain outcomes. We may consider holding off that there is no consensus on an outcome measure for surgery in young patients due to worse pain outcomes, postoperative pain. The differences in the various ques - in addition to other complications such as early implant tionnaires may also be a source of bias. Although some failure [68]. Older patients, if they meet surgical criteria, studies reported the effect of risk factors to be small rela - should not delay the operation, or the recovery and reha- tive to overall improvement from surgery, the heteroge- bilitation potential is diminished. neity of study design and outcome measures prohibited Zhang et al. Arthroplasty (2023) 5:19 Page 10 of 12 Consent for publication a meaningful meta-analysis to determine the magnitude Not applicable. of effect for each predictive factor. Future outcomes research will benefit from standardized design and out - Competing interests The authors declare that they have no competing interests. come measures that allow for meta-analysis and the pro- duction of stronger evidence. Persistent or severe postoperative pain is often dif- Received: 18 August 2022 Accepted: 15 February 2023 ficult to explain and remains a major detriment to overall patient satisfaction and recovery after THA. Iden- tification and management of preoperative risk factors References is crucial. Although age, sex, and certain socioeconomic 1. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related elements cannot be altered, they provide value in the quality of life in total hip and total knee arthroplasty. A qualitative and discussion of surgical benefits and patient expectations. systematic review of the literature. J Bone Joint Surg Am. 2004;86:963–74. 2. Judge A, Arden NK, Batra RN, Thomas G, Beard D, Javaid MK, et al. The Additionally, recognizing patients at higher risk of worse association of patient characteristics and surgical variables on symptoms pain outcomes allows the provider to appropriately man- of pain and function over 5 years following primary hip-replacement age their pain. Over-prescription of opioids is becoming surgery: a prospective cohort study. BMJ Open. 2013;3(3):e002453. 3. Nam D, Nunley RM, Sauber TJ, Johnson SR, Brooks PJ, Barrack RL. a dangerous epidemic, and more THA patients are rely- Incidence and location of pain in young, active patients following hip ing on them by the year [11]. Referring patients at high arthroplasty. J Arthroplasty. 2015;30:1971–5. risk of postoperative pain to specialists will provide safer 4. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What propor- tion of patients report long-term pain after total hip or knee replace- and more reliable pain regimens. Finally, these risk fac- ment for osteoarthritis? A systematic review of prospective studies in tors hold value in surgical decision-making. Modifiable unselected patients. BMJ Open. 2012;2:e000435. characteristics such as obesity, mental health, and medi- 5. Hernández C, Diaz-Heredia J, Berraquero ML, Crespo P, Loza E, Ruiz Iban MA. Pre-operative predictive factors of post-operative pain in patients cal comorbidities present the opportunity to improve with hip or knee arthroplasty: a systematic review. Reumatol Clin. pain outcomes with preoperative optimization. 2015;11:361–80. 6. DeMik DE, Bedard NA, Dowdle SB, Elkins JM, Brown TS, Gao Y, et al. Com- plications and obesity in arthroplasty-A hip is not a knee. J Arthroplasty. Conclusion 2018;33:3281–7. We have identified preoperative risk factors that were 7. Busato A, Roder C, Herren S, Eggli S. Influence of high BMI on functional outcome after total hip arthroplasty. Obes Surg. 2008;18:595–600. consistently predictive of greater postoperative pain after 8. Röder C, Staub LP, Eggli S, Dietrich D, Busato A, Muller U. Influence of THA, despite the varying quality of studies that prohibit preoperative functional status on outcome after total hip arthroplasty. J reaching concrete conclusions. Modifiable factors should Bone Joint Surg Am. 2007;89:11–7. 9. Prentice HA, Inacio MCS, Singh A, Namba RS, Paxton EW. Preoperative risk be optimized preoperatively, whereas non-modifiable factors for opioid utilization after total hip arthroplasty. J Bone Joint Surg factors may be valuable to patient education, shared deci- Am. 2019;101(18):1670–8. https:// doi. org/ 10. 2106/ JBJS. 18. 01005. PMID: sion-making, and individualized pain management. 10. Goodman SM, Mehta B, Zhang M, Szymonifka J, Nguyen JT, Lee L, et al. Acknowledgements Disparities in total hip arthroplasty outcomes: census tract data show None. interactions between race and community deprivation. J Am Acad Orthop Surg. 2018;26:e457–64. Authors’ contributions 11. Bedard NA, Pugely AJ, Dowdle SB, Duchman KR, Glass NA, Callaghan JJ. The corresponding author attests that all listed authors meet authorship cri- Opioid use following total hip arthroplasty: trends and risk factors for teria and that no others satisfying the criteria have been omitted. Substantial prolonged use. 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The effect of patient age at intervention on risk of implant revision after total replace- ment of the hip or knee: a population-based cohort study. Lancet. 2017;389(10077):1424–30. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arthroplasty Springer Journals

Risk factors for pain after total hip arthroplasty: a systematic review

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Abstract

Background Approximately 23% of patients develop hip pain after total hip arthroplasty ( THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgi- cal planning. Methods Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preopera- tive modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently. Results Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes. Conclusions Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management. Keywords Total hip arthroplasty, Systematic review, Pain, Risk factors pain include loosening of implants, infection, peripros- Introduction thetic fracture, and soft-tissue abnormalities [3]. How- Total hip arthroplasty (THA) is highly effective in allevi - ever, many cases cannot be explained by radiographic or ating pain, restoring function, and improving quality of mechanical abnormalities. life in patients with severe hip arthritis. However, approx- Hip pain following THA is often exacerbated by using imately 23% of patients develop hip pain after THA [1– stairs, walking on uneven surfaces, sitting for extended 4]. Some may even experience no improvement or worse periods of time, and standing from a seated position. pain postoperatively [2]. Known causes of postoperative Factors that may influence hip pain involve both modifi - able and non-modifiable risk factors. Modifiable risk fac - *Correspondence: tors include body mass index (BMI), certain medical and Kevin L. Mekkawy psychological comorbidities, and select socioeconomic kevin.mekkawy@gmail.com variables. Non-modifiable risk factors may cover age, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA sex, and race. Identification of these modifiable risk fac - tors of increased postoperative pain is critical in guiding © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Zhang et al. Arthroplasty (2023) 5:19 Page 2 of 12 preoperative optimization. Understanding non-modifia - assess risk factors, pain, risk factors for pain, or specific ble risk factors also has added value in determining sur- THA data were excluded from this analysis. gical expectations, individualizing pain management, and guiding the informed decision-making process. Bias assessment This systematic review aimed to determine preopera - Criteria for bias are not well described for systematic tive risk factors that are associated with post-THA pain. reviews of observational studies. We performed a bias Hernández et  al. reviewed studies prior to 2013 for pre- assessment for each article based on study design and dictive factors in total knee and total hip replacements characteristics. The bias assessment was based on (1) loss [5]. However, THA and TKA are fundamentally distinct to follow-up of <20% before 1  year or <30% after 1  year; surgeries with well-documented differences in outcomes (2) consecutive patient selection; (3) multicenter recruit- [6]. To our knowledge, there has been no systematic eval- ment; and (4) use of univariable or multivariable analysis uation of risk factors for postoperative pain specific to to adjust for confounders. Studies were rated as high risk THA. (meeting zero or one criterion), medium risk (meeting two criteria), or low risk (meeting three or more crite- ria). If it was unclear whether a study met a criterion, we Methods assumed that it did not. Search strategy We developed a comprehensive search strategy according Data to the Preferred Reporting Items for Systematic Reviews Data extracted included study design, patient charac- and Meta-Analyses guidelines with the assistance of a teristics, preoperative risk factors, study duration, out- trained librarian. A systematic search was conducted in come measurements, postoperative pain outcomes, and the PubMed (Medline), Scopus, Web of Science, Cumula- criteria for bias assessment. Results for each factor were tive Index of Nursing and Allied Health Literature Plus compared across the studies. Medical or psychological (EBSCO), Embase, and Cochrane databases by using comorbidities, BMI, preoperative pain, and certain socio- title, abstract, keywords, and medical subject headings economic elements were considered modifiable factors; (MeSH). MeSH terms included arthroplasty, replace- whereas, age, sex, and race were deemed as non-modifi - ment, total hip, THA, follow-up, risk assessment, risk able. A descriptive analysis was performed as the hetero- factors, reinforcing factors, predictors, pain, postopera- geneity of outcome measures and study characteristics tive, chronic, long-term, and pain measurement. Title, prohibited a meaningful meta-analysis. abstract, and keyword search terms were "hip arthro- plasty, THA, THR, hip replacement, OR total hip" AND Patient and public involvement "after, continue, post, recur, ongoing, chronic, persistent, No patients were involved in determining the research OR long term" AND "pain" AND "risk, predict, factor, question, outcome measures, or study design. There associated, correlate, effect, affect, OR influence". The are no plans to involve patients in the dissemination of search strategy was tailored to and optimized for each research findings. database. Results Inclusion and exclusion criteria Study characteristics Our review screened for prospective controlled tri- A total of 11,729 studies were identified, including dupli - als, prospective and retrospective observational cohort cates. The full-text review was performed for 339 pub - studies, and case–control studies. The inclusion criteria lications, and 54 studies satisfied our inclusion criteria were full-text articles published between January 1995 (Fig.  1). Most studies were observational cohort studies. and August 2020 with postoperative pain outcomes in The sample size ranged from 54 to 37,393 patients, and only adult THA cases for osteoarthritis with respect to follow-up ranged from 24  h to 12  years. Other than in preoperative risk factors. Studies of patients undergoing the studies by Busato et al. [7] and Röder et al. [8], THAs THA in combination with other large-joint replacement were performed in 1993 or later. Commonly evaluated surgeries were included if data specific to THA were risk factors for postoperative pain were preoperative provided. The literature review was performed indepen - pain and function (20 studies), medical and psychological dently by three researchers. Search results were reviewed comorbidities (18 studies), BMI (13 studies), socioeco- in order of title, abstract, then full text, and excluded if nomic status and ethnicity (12 studies), sex (11 studies), they did not meet all criteria. Additional relevant studies and radiographic severity of osteoarthritis (4 studies). were identified through a manual search of the bibliog - Functional outcomes were assessed using the West- raphies of selected studies. All other studies that did not ern Ontario and McMaster Universities Arthritis Index Zhang  et al. Arthroplasty (2023) 5:19 Page 3 of 12 Fig. 1 Flow diagram of a systematic review of articles published from January 1995 to May 2018 about adults undergoing total hip arthroplasty. The databases searched were PubMed (Medline), Scopus, Web of Science, Cumulative Index of Nursing and Allied Health Literature Plus (EBSCO), Embase, and Cochrane (WOMAC), Oxford Hip Score (OHS), Harris Hip Score Preoperative pain and hip function (HHS), and Hip Disability and Osteoarthritis Outcome We found that preoperative pain and function were sig- Score (HOOS). nificant predictors of pain or persistent opioid use after According to the bias criteria, 10 studies had a high THA in 16 of 20 studies (Table 3). Of the studies, 2 had a risk of bias, 31 had a medium risk, and 13 had a low risk low risk of bias, 14 had a medium risk, and 4 had a high (Table  1). Most studies adjusted for confounders. How- risk. ever, because of the retrospective design of many studies, selection methods and follow-up rates often could not be Age assessed. We found an association between patient age and pain or opioid use after THA in 9 of 12 studies, but these results were controversial (Table  4). Of these studies, Preoperative BMI 3 showed older age to be predictive of persistent pain, We found that high BMI was associated with worse pain whereas 5 found young age to be predictive. One study outcomes or increased opioid use after THA in 9 of 13 concluded that two opposite age ranges studied were studies, although conclusions varied regarding its clinical associated with worse pain, and three studies found no importance (Table  2). Of the studies, 5 had a low risk of association. Notably, 4 studies had a high risk of bias, 3 bias, 7 had a medium risk, and 1 had a high risk. had a medium risk, and 5 had a low risk. Zhang et al. Arthroplasty (2023) 5:19 Page 4 of 12 Table 1 Risk of bias among 53 studies of adult THA First author Year Consecutive patient Multicenter Adequate follow- Adjustment for Risk of bias selection enrollment up confounders Prentice [9] 2019 Yes Yes Yes Yes Low Goodman [10] 2018 Yes No Yes Yes Low Bedard [11] 2017 - Yes - No High Brembo [12] 2017 Yes Yes Yes Yes Low Li [13] 2017 - Yes - Yes Medium Pinto [14] 2017 Yes - - Yes Medium Dowsey [15] 2016 Yes No Yes Yes Low Goesling [16] 2016 - No Yes Yes Medium Greene [17] 2016 - Yes - Yes Medium Tilbury [18] 2016 Yes No No Yes Medium Lavernia [19] 2015 - No No Yes High Mannion [20] 2015 - - Yes Yes Medium Nam [3] 2015 No Yes No No High Rajamaki [21] 2015 No No Yes Yes Medium Dowsey [22] 2014 - No - Yes High Greene [23] 2014 - Yes No Yes Medium Judge [24] 2014 - Yes - Yes Medium Lavernia [25] 2014 Yes No - Yes Medium Motaghedi [26] 2014 No No Yes No High Petrovic [27] 2014 - Yes Yes Medium Singh [28] 2014 Yes No - Yes Medium Haverkamp [29] 2013 Yes - Yes No Medium Judge [2] 2013 Yes Yes Yes No Low Krupic [30] 2013 - Yes - Yes Medium Neuburger [31] 2013 - Yes - Yes Medium Pinto [32] 2013 Yes No No Yes Medium Singh [33] 2013 Yes No - Yes Medium Singh [34] 2013 Yes No - Yes Medium Jones [35] 2012 Yes Yes Yes Yes Low Liu [36] 2012 No Yes - Yes Medium Smith [37] 2012 Yes - No Yes Medium Allen Butler [38] 2011 Yes - Yes No Medium Clement [39] 2011 Yes No - No High Clement [40] 2011 - No - Yes High Lavernia [41] 2011 - No Yes Yes Medium Lavernia [42] 2011 - Yes Yes Yes Low Johansson [43] 2010 - - - No High Riediger [44] 2010 Yes - No No High Schafer [45] 2010 Yes No No Yes Medium Singh [46] 2010 Yes No - Yes Medium Lavernia [47] 2009 - - - Yes High Quintana [48] 2009 - Yes Yes Yes Low Rolfson [49] 2009 - Yes - Yes Medium Busato [7 ] 2008 - Yes - Yes Medium Kessler [50] 2007 Yes - Yes Yes Low Röder [8] 2007 - Yes - Yes Medium Moran [51] 2005 Yes No Yes Yes Low Fortin [52] 2002 Yes Yes Yes Yes Low Holtzman [53] 2002 - Yes No Yes Medium Zhang  et al. Arthroplasty (2023) 5:19 Page 5 of 12 Table 1 (continued) First author Year Consecutive patient Multicenter Adequate follow- Adjustment for Risk of bias selection enrollment up confounders Nilsdotter [54] 2002 Yes No Yes No Medium Jones [55] 2001 Yes Yes Yes Yes Low Nilsdotter [56] 2001 - No Yes Yes Medium Meding [57] 2000 Yes No Yes Yes Low Fortin [58] 1999 - Yes No Yes Medium “-”: unable to assess Adequate follow-up was defined as a loss to follow-up of < 20% before 1 year or < 30% after 1 year Table 2 Associations of BMI with pain/opioid use after THA First author Year Study design n Follow-up BMI groups (% of patient) Outcome measures Associations of high BMI with postoperative pain/ opioid use Prentice [9] 2019 RC 12,560 1 yr < 30 (60.8); 30–35 (24.5); Opioid usage Greater postoperative opioid > 35 (14.6) use after initial 90-day recov- ery period Li [13] 2017 RC 2040 6 mo 25–29.9 (37); 30–34.9 (22); PCS, HOOS Worse pain at baseline and 35–39.9 (10); ≥ 40 (4) 6 months, more improvement postoperatively Rajamaki [21] 2015 CC 54 1–2 yr < 30 (53); 30–35 (31); > 35 Questionnaire Higher proportion of patients (16) with pain Judge [24] 2014 RS 1431 1 yr < 25 (33); 25–30 (42); 30–35 OHS Worse pain, low clinical dif- (18); ference 35–40 (5.5); > 40 (1.7) Motaghedi [26] 2014 PC 60 1 d < 25 (33); 25–30 (33); > 30 VRS No association (33) Judge [2] 2013 PC 1431 1–5 yr < 25 (33); 25–30 (42); 30–35 OHS Worse pain (18); 35–40 (5.5); > 40 (1.7) Jones [35] 2012 PC 231 3 yr > 35 (14) WOMAC Worse pain at 6 months; no association at 3 years Liu [36] 2012 CC 428 1 d 30 VAS for pain Worse pain, low clinical significance Smith [37] 2012 PC 1318 3 yr NA HHS Worse pain Singh [46] 2010 CC 5707, 3289 2 yr, 5 yr < 25 (24); 25–29.9 (39); Questionnaire Worse pain 30–34.9 (24); 35–39.9 (8); ≥ 40 (1) Busato [7] 2008 RC 20,553 3, 6, 9, 12 yr < 25 (38); 25–30 (44); > 30 Questionnaire No association (18) Kessler [50] 2007 PC 67 10 d, 3 mo < 25 (16); 25–30 (54); > 30 WOMAC No association (30) Moran [51] 2005 PC 800 6, 18 mo 28 (range, 14–49) HHS Worse pain BMI Body mass index, CC Case control, CI Confidence interval, HHS Harris Hip Score, HOOS Hip Disability and Osteoarthritis Outcome Score, NA Not available, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PCS Pain catastrophizing scale, RC Retrospective cohort, SD Standard deviation, VAS Visual analog scale, VRS Verbal rating scale Expressed as mean BMI Sex Radiographic severity of arthritis Female gender was a predictor of worse pain or opioid Of the studies investigated, four examined the asso- use after THA in 9 of 11 studies (Table  5). There were ciation between preoperative radiographic severity of no studies with a high risk of bias, and three had low arthritis and postoperative pain. We noted that 3 of risk. these studies reported better pain outcomes in patients Zhang et al. Arthroplasty (2023) 5:19 Page 6 of 12 Table 3 Associations of preoperative pain medication or opioid use and function with pain medication or opioid use after THA First author Year Study design n Follow-up Outcome measures Associations of poor preoperative pain/function with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 yr Opioid usage Number of preoperative opioid prescriptions, preoperative NSAID use, back pain, and non-specific chronic pain associated with greater postoperative opioid use Bedard [11] 2017 RC 37,393 1 yr Opioid usage rate Greater preoperative opioid use associated with greater postop- erative opioid use Pinto [14] 2017 PC 64 2 d NRS No association Goesling [16] 2016 PC 331 6 mo WOMAC Greater preoperative opioid use associated with greater postop- erative pain and opioid use Dowsey [22] 2014 PC 835 1 yr HHS No association between preoperative pain and postoperative pain; conflicting results for association between preoperative function and postoperative pain Petrovic [27] 2014 CC 90 1 d NRS Higher odds of postoperative pain Singh [28] 2014 RC 3823 2, 5 yr VAS for pain Worse pain in patients using a walking aid Haverkamp [29] 2013 PC 1892.3 yr VAS, WOMAC Worse pain Judge [2] 2013 PC 1431 1–5 yr OHS Worse pain Pinto [32] 2013 CC 48 4–6 mo NRS Higher odds of postoperative pain Singh [33] 2013 RC 3823 2, 5 yr HHS Worse hip pain with preoperative ipsilateral knee pain Liu [36] 2012 CC 428 1 d VAS for pain Higher odds of postoperative pain Smith [37] 2012 PC 1318 3 yr HHS Worse pain Johansson [43] 2010 PC 75 2 yr WOMAC, HHS, SF-36 Worse pain Lavernia [47] 2009 PC 127 3 yr WOMAC Worse pain Röder [8] 2007 RC 13,766 ≤ 10 yr VAS for pain No association Fortin [52] 2002 PC 86 2 yr WOMAC Worse pain Holtzman [53] 2002 PC 1046 1 yr VAS for pain Higher odds of postoperative pain Nilsdotter [56] 2001 PC 162 1 yr WOMAC Worse pain Fortin [58] 1999 PC 116 6 mo WOMAC Worse pain CC Case–control, CI Confidence interval, HHS Harris Hip Score, NRS Numerical rating scale, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PCS Physical component summary, RC Retrospective cohort, RR Risk ratio, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index a † Mean follow-up. Included THA and total knee arthroplasty cases with severe arthritis, while one study found no predic- these, 2 articles had a high risk of bias, 11 had a medium tive value (Table  6). Regarding risk of bias, 2 studies risk, and 5 had a low risk. Psychological comorbidities had a low risk and 2 had a medium risk. were another frequently studied risk factor. Discussion Socioeconomic status and race/ethnicity The most consistent association were found between Associations of various socioeconomic parameters and poor pain outcomes and the female sex, high preopera- race/ethnicity with pain or opioid use after THA were tive pain or low function, and various medical or psy- assessed in 12 studies (Table 7). Three studies had a high chiatric comorbidities. Females not only had worse risk of bias, 6 had a medium risk, and 3 had a low risk. Of pain at both short- and long-term follow-ups but also these studies, 4 found worse pain in African Americans had higher odds of severe acute postoperative pain and at 2–3.5 years postoperatively [10, 19, 38, 42]. Reports on long-term opioid use. Although this should not affect the the educational level were mixed. Three studies reported patient selection, an effort should be made to optimize that low socioeconomic status was a risk factor for poor multimodal pain management in women to achieve bet- pain outcomes after THA [31, 38, 40]. ter short-term pain control, decrease chronic pain, and minimize opioid dependence [59]. Postoperatively, multi- Preoperative comorbidities disciplinary pain therapy has been shown to provide sub- Seventeen of 18 studies found a negative association stantial pain relief and may be a valuable referral [60]. between medical or psychological comorbidities and Preoperative pain and loss of function are two primary pain after THA or postoperative opioid use (Table 8). Of criteria for performing THA; therefore, they cannot be Zhang  et al. Arthroplasty (2023) 5:19 Page 7 of 12 Table 4 Associations of patient age with pain/opioid use after THA First author Year Study design n Age, yr Follow-up Outcome measures Associations of older age with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 67 (59–75) 1 yr Opioid usage Less risk of postoperative opioid use Bedard [11] 2017 RC 37,393 < 50, 2.7% 1 yr Opioid use Less risk of postoperative opioid use Brembo [12] 2017 PC 223 69 (41–91) 3 mo WOMAC Worse pain Nam [3] 2015 PC 196 50 , SD = 7.1 2.9 yr Pain scale of 0–5 Less odds of having pain Dowsey [22] 2014 PC 835 68 SD = 9.9 12 mo HHS Better pain Judge [2] 2013 RC 1431 70 1–5 yr OHS Worse pain in patients aged < 60 or > 70 Liu [36] 2012 CC 428 67 SD = 11 1 d VAS for pain Better pain Smith [37] 2012 PC 1318 68.5 SD = 9.9 3 yr HHS Worse pain Clement [39] 2011 PC 171 > 80 1 yr OHS No association 495 65–74 Quintana [48] 2009 PC 291 > 70 2 yr WOMAC Worse pain 299 ≤ 70 Nilsdotter [54] 2002 PC 124 71 1 yr WOMAC No association Jones [55] 2001 PC 197 55–79 (83%), ≥ 80 (17%) 6 mo WOMAC, SF-36 No association CC Case–control, CI Confidence interval, HHS Harris Hip Score, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, RC Retrospective cohort, SD Standard deviation, SF-36 36-Item Short-Form Health Survey, WOMAC Western Ontario and McMaster Universities Arthritis Index Data presented as mean Data presented as median (interquartile range) Table 5 Associations of female sex with pain/opioid use after THA First author Year Study design n Female sex, % Follow-up Outcome measures Associations of female sex with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 59 1 yr Opioid usage Greater opioid use Brembo [12] 2017 PC 223 71 3 mo WOMAC No association Pinto [14] 2017 PC 64 59 2 d NRS Worse pain Mannion [20] 2015 RC 261 50 1 yr OHS, WOMAC, SF-12 No association Petrovic [27] 2014 CC 90 47 1 d NRS Higher odds of pain Liu [36] 2012 CC 428 58 1 d NRS Worse pain Smith [37] 2012 PC 1318 NA 3 yr HHS Worse pain Lavernia [41] 2011 RC 658 59 2 yr HHS, SF-36, WOMAC Worse pain Singh [46] 2010 PC 5707, 3289 51 2 yr, 5 yr Pain medication use Greater pain medication use Rolfson [49] 2009 RC 6158 57 1 yr VAS Worse pain Quintana [48] 2009 PC 590 49 2 yr WOMAC, SF-36 Worse pain CC Case–control, CI Confidence interval, HHS Harris Hip Score, NA Not available, NRS Numerical rating scale, NSAID Nonsteroidal anti-inflammatory drug, OR Odds ratio, PC Prospective cohort, RC Retrospective cohort, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index treated like other modifiable factors. A difference should without. Other medical comorbidities had a similar be noted for patients using chronic pain medication, who effect. Increased odds of acute and chronic pain, as are at higher risk of postoperative opioid dependence and well as opioid dependence, were repeatedly observed in may benefit from referral to a pain specialist preopera - patients with anxiety or depression. Our data suggest that tively for intervention and a weaning protocol at the cost preoperative medical optimization may be beneficial to of delaying surgery [11, 16]. pain outcomes. Additionally, treating those with active Patients with existing comorbidities are more reluc- psychiatric conditions may also improve perceived pain tant to undergo elective surgeries [61]. In THA, they and satisfaction [63]. also experience increased complications requiring revi- Less consistent association was seen between poor pain sions [62]. Notably, patients with diabetes had eight outcomes and high BMI, low radiographic grade, and low times higher odds of having persistent pain than those socioeconomic status. The difference in pain outcomes Zhang et al. Arthroplasty (2023) 5:19 Page 8 of 12 Table 6 Associations of preoperative radiographic severity of arthritis with pain after THA First author Year Study design n Radiographic grade (% Follow-up Outcome measures Associations of higher- patients) grade osteoarthritis with postoperative pain Tilbury [18] 2016 PC 302 mK-L grade: 1 or 2 (26) mild, 3 1 yr HOOS, OHS, SF-36 Greater pain improvement or 4 (74) Dowsey [15] 2016 CC 382 mK-L grade: 2 (1.4), 3a (6.8), 3b 1 and 2 yr HHS Greater odds of pain (33), 4a (25), 4b (35) improvement Nilsdotter [56] 2001 PC 162 OARSI grade: 3 (70), 2 (29), 1 (1) 1 yr WOMAC, SF-36 No association Meding [57] 2000 PC 1163 -independent scale 32 (6–93) mo HHS Less pain CC Case–control, HHS Harris Hip Score, HOOS Hip Disability and Osteoarthritis Outcome Score, mK-L modified Kellgren and Lawrence grade, OARSI Osteoarthritis Research Society International, OHS Oxford Hip Score, PC Prospective cohort, SF-36 36-Item Short-Form Health Survey, WOMAC Western Ontario and McMaster Universities Arthritis Index Expressed as mean (range) Table 7 Associations of race/ethnicity and SES with pain/opioid use after THA First author Year Study design n Follow-up, yr Outcome measures Associations of race/ethnicity and SES with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 Opioid usage Higher opioid use in African Americans, lower opioid use in Asian (compared to white) Goodman [10] 2018 RC 4170 2 WOMAC Worse pain in African Americans Lavernia [19] 2015 RC 564 3.5 (1–9) VAS, WOMAC, SF-36 Worse pain in African Americans Dowsey [22] 2014 PC 835 1 HHS No association Greene [23] 2014 RC 11,464 1 VAS Worse pain in patients with low education Neuburger [31] 2013 RC 59,680 0.5 OHS Worse pain in low SES Krupic [30] 2013 RC 1216 1 VAS Worse pain in immigrants Allen Butler [38] 2011 PR 119 2 VAS, HHS Worse pain in African Americans, those with low education, and those with low income Lavernia [42] 2011 RC 739 2 WOMAC, SF-36 Worse pain in minority patients, especially African Americans Clement [40] 2011 PC 1359 1 OHS Worse pain in more deprived patients Schafer [45] 2010 CC 1113 0.5 WOMAC Greater odds of poor pain outcome in patients who are single, living alone, on disability Fortin [58] 1999 PC 116 0.5 WOMAC No association with education level CC Case–control, CI Confidence interval, HHS Harris Hip Score, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PR Prospective randomized, RC Retrospective cohort, SES Socioeconomic status, SF-36 36-Item Short-Form Health Survey, THA Total hip arthroplasty, VAS Visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index Data presented as mean (range) among BMI groups was often small when compared With respect to race and socioeconomic factors, most with the overall improvement. Although most data show studies found worse pain outcomes in African Ameri- worse postoperative pain scores in patients with high cans, immigrants, patients with low educational levels, BMI, this may be due to greater preoperative pain rather and patients with low socioeconomic status. Additionally, than a less surgical benefit. Nevertheless, weight loss African Americans and patients of lower socioeconomic may be beneficial in decreasing baseline pain, ultimately status had worse pain on presentation. A lack of access improving postoperative pain [64]. to resources, along with health care disparities affecting Advanced preoperative radiographic severity of osteo- these populations, likely contribute to a delayed presenta- arthritis was mostly found to be associated with worse tion with greater pain from advanced disease or improper pain outcomes. Although the data were not robust, they non-operative management [66]. Although it is encourag- support the current guidelines of attempting non-oper- ing that these patients achieved similar improvement from ative modalities for those with low-grade radiographic surgery as their counterparts, they may still benefit from arthritis [65]. attention to pain management and preoperative education. Zhang  et al. Arthroplasty (2023) 5:19 Page 9 of 12 Table 8 Associations of preoperative medical/psychological comorbidities with pain/opioid use after THA First author Year Study design n Follow-up Outcome measures Associations of preoperative comorbidities with postoperative pain/opioid use Prentice [9] 2019 RC 12,560 1 yr Opioid usage Higher postoperative opioid prescriptions with anxiety, chronic pulmonary disease, substance abuse, acquired immunodeficiency syndrome (AIDS), peripheral vascular disease, chronic blood loss anemia, congestive heart failure Bedard [11] 2017 RC 37,393 1 yr Opioid use Higher risk postoperative opioid use with preoperative anxiety, depression, drug use, alcohol use, smoking Brembo [12] 2017 PC 223 3 mo WOMAC Worse pain with increased medical comorbidities Dowsey [15] 2016 PC 382 1 and 2 yr HHS Worse pain with poor mental function Greene [17] 2016 RC 17,147 1 yr VAS for pain Worse pain if using antidepressants Rajamaki [21] 2015 PC 54 1–2 yr NRS Greater odds of pain in diabetes Lavernia [25] 2014 RC 60 11 (3–24) mo HHS Worse pain in vitamin D insufficiency Petrovic [27] 2014 CC 90 1 d NRS Higher odds of pain in type D personality, anxiety, depres- sion Dowsey [22] 2014 PC 835 1 yr HHS Worse pain with increased medical comorbidities Pinto [32] 2017 CC 48 4–6 mo NRS Worse pain with poor disease process perception and emotional representation Judge [2] 2013 PC 1431 1–5 yr OHS Worse pain in medical comorbidities Singh [34] 2013 PC 5707, 3289 2 yr, 5 yr VAS for pain No association Jones [35] 2012 PC 231 3 yr WOMAC Worse pain with cardiac disease Smith [37] 2012 PC 1318 3 yr HHS Worse pain with cardiac disease, hypertension, increase medical comorbidities, NSAID use Allen Butler [38] 2011 PR 119 2 yr VAS, HHS, SF-12 Worse pain with poor mental component score Singh [46] 2010 PC 5707, 3289 2 yr, 5 yr Pain medication use Greater odds of pain, NSAID use, and opioid use in depres- sion Riediger [44] 2010 PC 79 8 wk WOMAC, SF-36 Worse pain in depression and somatoform disorders Rolfson [49] 2009 RC 6158 1 yr VAS for pain Worse pain in anxiety and depression ASA American Society of Anesthesiologists, CAD Coronary artery disease, CC Case–control, CCI Charlson Comorbidity Index, CI Confidence interval, HHS Harris Hip Score, HTN Hypertension, NRS Numerical rating scale, NSAID Nonsteroidal anti-inflammatory drug, OHS Oxford Hip Score, OR Odds ratio, PC Prospective cohort, PR Prospective randomized, RC Retrospective cohort, SF-12 12-Item Short-Form Health Survey, SF-36 36-Item Short-Form Health Survey, VAS 10-cm visual analog scale, WOMAC Western Ontario and McMaster Universities Arthritis Index The relationship between age and pain outcomes is less This is the first systematic review, to our knowledge, clear. Studies showed that older age could be associated that assessed common preoperative risk factors for pain with better, worse, or no difference in postoperative pain. after THA. A strength of this study is that a large num- Possible explanations for worse outcomes in younger ber of studies were included, most of which had a low or patients include an increased level of activity and expec- medium risk of bias. However, there are several limita- tations [67]. Conversely, confounding comorbidities and tions to consider. The majority of outcome-based studies poor recovery may contribute to persistent pain in older are observational cohorts with varying quality and risk of patients. Notably, two studies reported worse outcomes bias. In retrospective studies, appropriate patient selec- in older patients at 3- and 6-month follow-up, whereas, tion and loss of follow-up are difficult to assess. Addi - most studies at later time points showed no effect or tionally, not all studies adjusted for confounding factors. the opposite. This may be attributed to decreased heal - Most studies reported follow-up of < 2  years, and only ing and rehabilitation potential in older patients who are two studies continued beyond 5 years. The effects, if any, less healthy and less active. Although results conflict, that these risk factors may have beyond this time frame data exist showing both ends of the age spectrum hav- are impossible to evaluate. Additionally, it is apparent ing worse pain outcomes. We may consider holding off that there is no consensus on an outcome measure for surgery in young patients due to worse pain outcomes, postoperative pain. The differences in the various ques - in addition to other complications such as early implant tionnaires may also be a source of bias. Although some failure [68]. Older patients, if they meet surgical criteria, studies reported the effect of risk factors to be small rela - should not delay the operation, or the recovery and reha- tive to overall improvement from surgery, the heteroge- bilitation potential is diminished. neity of study design and outcome measures prohibited Zhang et al. Arthroplasty (2023) 5:19 Page 10 of 12 Consent for publication a meaningful meta-analysis to determine the magnitude Not applicable. of effect for each predictive factor. Future outcomes research will benefit from standardized design and out - Competing interests The authors declare that they have no competing interests. come measures that allow for meta-analysis and the pro- duction of stronger evidence. Persistent or severe postoperative pain is often dif- Received: 18 August 2022 Accepted: 15 February 2023 ficult to explain and remains a major detriment to overall patient satisfaction and recovery after THA. 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The effect of patient age at intervention on risk of implant revision after total replace- ment of the hip or knee: a population-based cohort study. Lancet. 2017;389(10077):1424–30. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

Journal

ArthroplastySpringer Journals

Published: Apr 3, 2023

Keywords: Total hip arthroplasty; Systematic review; Pain; Risk factors

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