Duloxetin Reduces Postoperative Pain and Improves Patient-Reported Outcomes after Total Knee Arthroplasty in Patient with Central Sensitivity Syndrome
ESSKA Academy. Cho H. May 12, 2018; 218110; FP41-468
Han Suk Cho
Han Suk Cho
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Objectives: Unexplained, persistent postoperative pain is one of the most dreadful complications after total knee arthroplasty (TKA). Central sensitivity syndrome (CSS) is a proposed term in which non-organic disorders that are presumed to share the etiology of central sensitization (CS), which involves an abnormal and intense enhancement of pain by mechanisms in the central nervous system. Recently, CS is suggested to be a reason for unexplained severe postoperative pain after TKA. On the other hand, duloxetin, a selective serotonin and norepinephrine reuptake inhibitor, is reported to be effective for management of hyperalgesia caused by CS, including postoperative pain after TKA. Thus, duloxetin can be an optimal solution for postoperative pain management in CSS patient. However, effectiveness of duloxetin for postoperative pain remains unclear. We determined whether duloxetine reduces postoperative pain and improves patient-reported outcomes after TKA in CSS patients.

Methods: We prospectively enrolled 420 patients undergoing unilateral TKA between December 2015 and December 2016. We used the Central Sensitization Inventory (CSI) for diagnosing CSS. CSI was measured in all patients preoperatively and patient who had more than 40 points of total CSI score were included. Finally, 80 patients were enrolled and randomized to receive duloxetin (30 mg) 1 day before surgery and maintain 6 weeks after TKA (Duloxetin group, n = 40), or not to receive duloxetin (Control group, n = 40). Pain visual analogue scale (VAS) was measures at postoperative 1,3, and 5 days and 1,2,6, and 12 weeks. Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC), Brief Pain Inventory (BPI), Intermittent and Constant Osteoarthritis Pain sore (ICOAP) and patient satisfaction (pain level and daily activity level) were assessed at postoperative 1, 2, 6 and 12 weeks. In addition, total opioid consumption during the hospital stay and incidence of adverse events were also measured during postoperative 12 weeks period.

Results: Although there were no differences in pain level and opioid consumption during the hospital stay, patients in Duloxetin group experienced lower pain level during the 2 to 12 weeks period. (POD 2, 6, 12 W VAS : p < 0.05) In addition, patients in Duloxetin group showed superior patient-reported outcomes including WOMAC(POD 2, 6, 12 W all p < 0.05), BPI(POD 2, 6, 12 W all p < 0.05), and ICOAP(POD 2, 6, 12 W all p < 0.05) during the overall study period. Moreover, more patients in Duloxetin group satisfied with pain level (p = 0.027) and daily activity level (p = 0.006). There were no between-group differences in incidence of adverse events.(All p>0.05)

Conclusions: This prospective randomized controlled study demonstrates that duloxetin reduced postoperative pain and improved patient satisfaction after TKA in patients with CSS. These results suggest that duloxetine administration should be considered when performing TKA in CSS patients to prevent postoperative unexplained pain after TKA.

Total knee arthroplasty, Duloxetin, Central sensitivity syndrome, Postoperative pain, Patient reported outcome
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