Authors: Garbarino L1, Bub, C1, Motta F1, Gold, P1, Rasquinha VJ1, Danoff JR1
1Northwell Health Orthopaedic Institute
Abstract
Introduction
It is important to be able to identify patients who can tolerate minimal narcotic, accelerated postoperative total joint arthroplasty (TJA) recovery protocols. Conversely, surgeons must be able to identify patients likely to experience higher levels of post-arthroplasty pain. This study aims to utilize the Pain Catastrophizing Scale (PCS) and other baseline variables, to differentiate patients who are able to rapidly recover with minimal pain from those who subjectively experience more pain after TJA.
Methods
This is a prospective observational cohort study of 64 total knee arthroplasty (TKA) and 36 total hip arthroplasty (THA) patients who underwent unilateral total joint arthroplasty between January and May 2018 at four academic and community hospitals. All patients completed a preoperative PCS, which is a validated, 13-question survey that aims to identify patients that have an exaggerated perception of pain. Patients also completed the Risk Assessment and Prediction Tool (RAPT), which is a 6-question survey that assess patients preoperative functional status in order to predict discharge destination after TJA. The primary outcome was length of stay (LOS), in addition to secondary outcomes including discharge destination (home versus sub-acute rehabilitation facility), narcotic pain medication usage, readmission rate, 90-day complication rate, and baseline demographics age, gender, body mass index, Charleston Comorbidity Index, RAPT, American Society of Anesthesiologists Physical Status Classification System (ASA), home support, and diagnosis of depression.
Results
A total of 100 patients with a mean age of 65.1 + 7 years completed the Pain Catastrophizing Scale prior to total joint arthroplasty. The overall mean LOS was 2.0 days, with a daily total opioid requirement of 23.8 morphine equivalents (MEQ). Patients discharged home on postoperative day (POD) 1 or earlier showed less daily opioid use (13.9 MEQ/day) compared to a LOS > 1 day (28.5 MEQ/day, p<0.0001). PCS<15 showed less daily opioid use (19.9 MEQ) compared to PCS>15 (28.5 MEQ, p= 0.012). However, PCS was not predictive of LOS, as the mean LOS for PCS < 15 (LOS=1.9 days) was not significantly different than for PCS>15 (LOS=2.1, p=0.535). ASA of 1 or 2 also predicted less narcotic requirements (p= 0.002), but was not predictive of LOS. THA patients had a decreased LOS (1.7 days) compared to TKA (2.2 days, p = 0.004) and the direct anterior approach THA had a shorted LOS (1.3 days) compared to posterolateral (2.3, p=0.002). Following discharge, patients with a RAPT less than 10 (p< 0.0001) and those who live alone (p= 0.001) were more likely to require transfer to a sub-acute rehabilitation facility. There was one postoperative readmission for medical treatment of a pulmonary embolism.
Discussion
The PCS can help surgeons anticipate postoperative opioid requirements in TJA patients. Although in this study PCS did not predict those patients more likely to discharge home on POD1, PCS is a valuable tool to facilitate the identification of those patients that may be candidates for minimal narcotic, accelerated recovery protocols in patients with PCS<15. Although not proven by this study, further research is encouraged to intervene in those patients with PCS>15 with additional pre- and post-operative pain education, pain management consultants, and additional postoperative care. Overall, healthy patients (ASA 1 or 2) with a PCS < 15 and RAPT > 10 who have support at home tend to experience less pain and be successfully discharged home.
Significance/Clinical Relevance
The Pain Catastrophizing Scale can be used to identify patients who experience increased opioid requirements following total joint arthroplasty. The use of preoperative PCS with other factors can aid in patient selection for low narcotic protocols.