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Acta Anaesthesiol Scand 2006; 50: 495—500 Printed in Singapore. All rights reserved Chronic pain following total hip arthroplasty: anationwide questionnaire study , B. BRANDSBORG , U. LUCHT , T. S. JENSEN and H. KEHLET 1Department of Anesthesiology, 2Danish Pain Research Center and 3Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, and 4Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark Background: Chronic post-operative pain is a well-recognized post-operative pain [95% confidence interval (CI), 20.4—33.4%] problem after various types of surgery, but little is known about and pain complaints from other sites of the body (95% CI, chronic pain after orthopedic surgery. Severe pre-operative pain is 20.7—32.1%), but not to the pre-operative intensity of pain.
the primary indication for total hip arthroplasty (THA). Therefore, Conclusion: Chronic pain after THA seems to be a significant we examined the prevalence of chronic pain after THA in relation problem in at least 12.1% of patients. Our results suggest that to pre-operative pain and early post-operative pain.
genetic and psychosocial factors are important for the develop- Methods: A questionnaire was sent to 1231 consecutive patients who had undergone THA 12—18 months previously, and whoseoperations had been reported to the Danish Hip ArthroplastyRegistry.
Accepted for publication 14 November 2005 Results: The response rate was 93.6%. Two hundred and ninety-four patients (28.1%) had chronic ipsilateral hip pain at the time Key words: chronic pain; post-operative pain; risk factors; of completion of the questionnaire, and pain limited daily activ- ities to a moderate, severe or very severe degree in 12.1%. Thechronic pain state was related to the recalled intensity of early # Acta Anaesthesiologica Scandinavica 50 (2006) THE incidence of post-surgical pain is high after genetic and various psychosocial factors (1).
However, the relative importance of each of the mastectomy, thoracotomy, sternotomy, gallbladder above-mentioned risk factors for the development surgery and inguinal hernia repair (1, 2). Up to of chronic pain is not clear, and only a few data from 60—80% of amputees experience phantom pain after well-controlled prospective studies exist.
amputation (3), and breast surgery is followed by To gain more knowledge about post-surgical pain, chronic pain in 20—50% of patients (4). A similar we decided to study pain after total hip arthroplasty high percentage of patients develop chronic pain (THA) in a large-scale, register-based study for the after thoracotomy (5), sternotomy (6) and femoro- popliteal bypass surgery (7). Common operations,such as gallbladder surgery, inguinal hernia 1 Little is known about chronic pain after orthopedic repair and Cesarean section, may also lead to chronic pain in approximately 12—30% of patients 2 THA is a common surgical procedure.
3 Severe pre-operative pain is the primary indication The etiology behind the development of chronic 4 Early post-operative pain may be moderate/severe pain after surgery is not fully known, but several risk factors have been identified (1). Pre-operative 5 The risk of intra-operative nerve damage is low (18).
pain (11, 12) and acute post-operative pain (10, 13,14) have been shown to increase the risk of chronic Our aim was to identify various risk factors for the post-surgical pain. Intra-operative events, such as development of chronic pain, with specific attention intra-operative nerve damage, may play a role in being paid to the relationship between pre-operative the development of chronic pain (15, 16), as well as pain, early post-operative pain and chronic hip pain.
confidence intervals (CIs) where appropriate; 95%CIs for differences are presented. Data concerning the characteristics of chronic hip pain are presented Patients were recruited from the Danish Hip as a percentage of the total number of patients if Arthroplasty Registry (http://dhr.dk). The registry was established in 1995, and 94% of all primaryTHAs in Denmark are reported (19). Inclusioncriteria included an age between 18 and 90 years, Patient characteristics and chronic hip pain One thousand, two hundred and thirty-one patients [derived from the Harris Hip Score (HHS)] and met the inclusion criteria and received a question- operation performed in the period from 1 March to naire; 1152 (93.6%) responded (Fig. 1).
31 October 2003. Patients with previous or sub- Results from the questionnaires are shown in sequent ipsilateral or contralateral hip operations Tables 1 and 2. Hip pain was still present in 294 patients (28.1%; 95% CI, 25.3—30.7%) and, in 124patients (11.8%), pain was present daily or constantly.
Fifty-three patients (5.1%) had moderate or severe A questionnaire with a pre-stamped return envel- pain at rest; 115 patients (11%) had moderate or severe ope, and with a reminder in the case of no reply, pain when walking. The mean intensity of pain was was mailed to all patients in September/October 3.7 (SD, Æ 2.4; Numeric Rating Scale (NRS), 0—10) 2004. Thus, the time interval from operation to thecompletion of the interview varied from 12 to 18 months. Patients were asked to recall the inten- sity of early post-operative pain. If hip pain was stillpresent, patients were asked to describe the fre-quency and intensity of pain and its impact ondaily Questionnaire (MPQ) was used for the furtherdescription of pain. Patients also shaded an area ofthe location of their perceived pain on an anterior and posterior drawing. Finally, patients were asked about the consumption of analgesics, pain problemselsewhere, operations in the leg except for THA,scar sensibility, height and weight. The followingdata were derived from the registry: age, gender, pre-operative pain, anesthetic method and durationof operation.
The study was approved by the Danish Law of Data Protection and the oversight board of the Danish Hip Arthroplasty Registry. Because of the rules regulating the use of the registry, contact with patients was required to be based on the regis-tration in the Danish National AdministrativeSystem. The information from the two registries was linked by the use of unique social security Statistical analysisData from the returned questionnaires, together with data from the registry, were analyzed using STATA version 8.0 software. Data are presented asthe mean and standard deviation (SD), with 95% Chronic pain following total hip arthroplasty Demographic data, pre-operative pain, recalled intensity of post- Characteristics of chronic pain after hip arthroplasty.
operative pain, anesthetic method and duration of surgery.
Pre-operative hip pain (Harris Hip Score, HHS) Intensity of pain on Numeric Rating Scale (NRS), Impact on daily activities: pain is a problem when (Fig. 2). Pain disturbed sleep in 90 patients (8.9%) and had moderate, severe or very severe impact on daily life in 127 patients (12.1%). The words used from the MPQ to describe pain were tiring, exhaust-ing, shooting, tender, gnawing and cramping. Pain There was no difference between patients with drawings documented that the pain was located to and without chronic hip pain with regard to the the lateral aspect of the hip, including the trochan- following: previous operation in the same leg (e.g.
teric region, in almost all cases (Fig. 3). Eighty-six of operation for varicose veins) (21.8% vs. 18.8%), the 294 patients (29.3%) were taking analgesics daily regional anesthesia (80.6% vs. 80.9%) and body because of pain in the operated hip [paracetamol, mass index (BMI) > 25 at the time of the interview (NSAIDs), n ¼ 20; tramadol, n ¼ 16; slow-releasemorphine, n ¼ 9; amitriptyline/gabapentin, n ¼ 2].
Gender differencesThe prevalence (29.5% vs. 25.9%) and intensity (3.8 Relationship between chronic hip pain and various vs. 3.6; NRS, 0—10) of chronic hip pain were similar in women and men, but women were more likely to Chronic hip pain was related to the recalled inten- sity of moderate or severe acute post-operative pain À 33.6% ¼ 13.7%; 95% CI, 2.3—25.1%). Women also (Difference (DIFF) ¼ 58.2% À 31.3% ¼ 26.9%; 95% more often had daily or constant pain problems CI, 20.4—33.4%) and to pain complaints from other elsewhere (DIFF ¼ 44.8% À 28% ¼ 16.8%; 95% CI, sites of the body (DIFF ¼ 80.6% À 54.2% ¼ 26.4%; 11—22.3%). Severe or disabling pre-operative pain, 95% CI, 20.7—32.1%), but not to the pre-operative as recorded by HHS, was not more frequent in intensity of pain as recorded by HHS.
In this large-scale, register-based study, a high pro-portion (28.1%) of all patients had some degree of Chronic pain after primary THA may be attribu- ted to several pathogenetic mechanisms. A series of experimental studies have shown that noxious sti-muli may produce hyperexcitability and sensitiza-tion in second-order neurons in the central nervous % of patients 10
system [for a review, see Woolf and Salter (20)]. Theclinical manifestations of cellular hyperexcitabilityafter tissue injury are only partially known.
However, it has been suggested that persistentpain, various types of evoked pain, after-sensationsand extraterritorial spread to non-damaged tissue may be a consequence of cellular hyperexcitability whether produced by inflammation or nerve damage (21, 22). Therefore, an afferent barrage ofnoxious input before (e.g. input from a painful hip Fig. 2. Intensity of chronic hip pain (n ¼ 294). Patients recorded with degenerative arthritis), during and after sur- average pain intensity in the last week (Numeric Rating Scale gery (post-operative pain) could be important for the development of chronic post-THA pain. Wewere unable to demonstrate a relationship betweenpre-operative pain, as recorded by HHS, and chronic hip pain, but this may be due to the fact that most of the patients were classified as having more often reported dysesthesia and allodynia in either severe or disabling pre-operative pain. The the incisional area than did patients without pain recalled intensity of acute post-operative pain was (DIFF ¼ 7.5% À 3.1% ¼ 4.4%; 95% CI, 1.2—7.6%).
related to chronic hip pain. As the intensity of post-operative pain and the consumption of analgesicswere not recorded at the time of surgery, we do notknow whether these patients indeed suffered frommore post-operative pain. A prospective studywith a more detailed description of pre- and post-operative pain is necessary to clarify these issues.
Chronic pain after THA may theoretically be caused by intra-operative damage to the sciatic,femoral and obturator nerves (18). Indeed, morepatients with chronic hip pain reported dysesthesia/allodynia. From the present (patient-reported)sensory whether the reported dysesthesia/allodynia was aresult of damage to one of the nerves or of non-specific hypersensitivity referred from deep struc-tures. Mikkelsen et al. (23) examined pain and sen-sory dysfunction in 72 patients, 6—12 months afteringuinal hernia repair. Sensory dysfunction wascommon (51%), but was equally frequent in patientswith and without pain, suggesting that the specifi-city for chronic post-surgical pain is rather low.
Patients with chronic hip pain were more likely to suffer from pain problems elsewhere, as also Fig. 3. Location of chronic hip pain.
Chronic pain following total hip arthroplasty demonstrated in hernia surgery (10). Again, this to clarify the relative pathogenetic role of these feature is non-specific, but raises the question of whether genetic and psychosocial factors are impor-tant for the development of chronic pain aftersurgery.
Women reported more pain than men, confirming This study was supported by a grant from the Lundbeck other studies on gender and pain, and this is prob- Foundation. We would like to thank H. O. Andersen and ably related to a number of biological and psycho- A. Hjelm for excellent secretarial assistance.
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