Does limb preconditioning reduce pain after total knee arthroplasty? A randomized, double-blind study

Abstract

Background: Total knee arthroplasty (TKA) can be associated with considerable postoperative pain. Ischemic preconditioning of tissue before inducing procedure-related underperfusion may reduce the postoperative inflammatory response, which further may reduce associated pain.

Questions/purposes: In this prospective, randomized study, we aimed at evaluating the impact of ischemic preconditioning on postoperative pain at rest and during exercise; use of pain medication; levels of systemic prothrombotic and local inflammatory markers; and length of stay and achievement of physical therapy milestones.

Methods: Sixty patients undergoing unilateral TKA under tourniquet were enrolled with half (N = 30) being randomized to an episode of limb preconditioning before induction of ischemia for surgery (tourniquet inflation). Pain scores, analgesic consumption, markers of inflammation (interleukin-6 [IL-6], tumor necrosis factor [TNF]-α in periarticular drainage), and periarticular circumference were measured at baseline and during 2 days postoperatively. Changes in prothrombotic markers were evaluated.

Results: Patients in the preconditioning group had significantly less pain postoperatively at rest (mean difference = -0.71, 95% confidence interval [CI] = -1.40 to -0.02, p = 0.043) and with exercise (mean difference = -1.38, 95% CI = -2.32 to -0.44, p = 0.004), but showed no differences in analgesic consumption. No differences were seen between the study and the control group in terms of muscle oxygenation and intraarticular levels of IL-6 and TNF-α as well as levels of prothrombotic markers. No differences were found between groups in regard to hospitalization length and time to various physical therapy milestones.

Conclusions: Ischemic preconditioning reduces postoperative pain after TKA, but the treatment effect size we observed with the preconditioning routine used was modest.

Clinical relevance: Given the ease of this intervention, ischemic preconditioning may be considered as part of a multimodal analgesic strategy. However, more study into the impact of different preconditioning strategies, elucidation of mechanisms, safety profiles, and cost-effectiveness of this maneuver is needed.

Fig. 1

This figure shows the CONSORT flow diagram with information about enrollment and followup. *Other reasons for exclusion are: patient was part of another study (data integrity concerns) or timing of surgery not suitable for data collection.

Fig. 2

This figure depicts the unadjusted pain scores obtained at baseline and 6, 24, and 48 hours postoperatively, respectively, at rest and with light exercise. VAS = visual analog scale.