The evolution of primary hyperalgesia in orthopedic surgery: quantitative sensory testing and clinical evaluation before and after total knee arthroplasty.
BACKGROUND
Quantitative sensory testing (QST) allows precise characterization of sensory deficits and painful symptoms and may offer additional information on the pathophysiology of postoperative pain.


METHODS
We evaluated 20 patients scheduled for total knee arthroplasty clinically and with QST before surgery, at 1 and 4 days after surgery, and at 1 and 4 mo after surgery. The clinical evaluation included preoperative pain and inflammation of the operative knee, postoperative assessment of pain at rest and during movement (Visual Analog Scale score), cumulative morphine consumption, and circumference and temperature of both knees. QST included thermal and mechanical (pressure) pain threshold measurements and assessment of responses to suprathreshold stimuli. Brush-evoked allodynia was also evaluated. Measurements were taken on the operative knee, contralateral knee, and on the hand as a control site.


RESULTS
All patients had prolonged and severe pain before surgery and inflammation of the operative knee. Preoperative QST provided evidence of heat hyperalgesia in the inflammatory area on the operative knee, but absence of punctate or brush-evoked allodynia in the adjacent noninflamed area. Patients had intense postoperative pain, mostly induced by movement. Primary heat hyperalgesia was present on the operative knee on the first and fourth day after surgery, and was associated with punctate mechanical allodynia in the inflammatory area, but not in the adjacent noninflamed area. Postoperative morphine consumption was correlated with preoperative heat hyperalgesia (r = 0.63; P = 0.01). QST returned to baseline at the 4-mo evaluation. Only four patients had moderate knee pain induced by movement at that time.


CONCLUSIONS
Heat hyperalgesia was the predominant QST symptom associated with perioperative pain after total knee arthroplasty, and was predictive of postoperative morphine consumption.
Martinez
Valéria
V
Department of Anesthesia, Assistance Publique Hôpitaux de Paris, Hôpital Raymond Poincaré, Garches, France.
Fletcher
Dominique
D
Bouhassira
Didier
D
Sessler
Daniel I
DI
Chauvin
Marcel
M
D000368:Aged; D016058:Analgesia, Patient-Controlled; D000701:Analgesics, Opioid / Q000008:administration & dosage; D001168:Arthritis / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D019645:Arthroplasty, Replacement, Knee; D005260:Female; D006358:Hot Temperature; D006801:Humans; D006930:Hyperalgesia / Q000473:pathology / Q000503:physiopathology*; D007717:Knee / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D009020:Morphine / Q000008:administration & dosage; D010147:Pain Measurement; D017288:Pain Threshold; D010149:Postoperative Pain / Q000188:drug therapy / Q000503:physiopathology*; D011182:Postoperative Care; D011300:Preoperative Care; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D009020:Morphine
Pain. 2001 Jun;92(3):373-80
11376910
Anesthesiology. 2003 May;98(5):1214-22
12717144
Anesth Analg. 2003 Aug;97(2):526-33, table of contents
12873948
Pain. 2003 Dec;106(3):393-400
14659522
Anesthesiology. 2004 Jan;100(1):115-9; discussion 5A
14695732
J Neurol Neurosurg Psychiatry. 1976 Nov;39(11):1071-5
188989
Pain. 1990 Jun;41(3):303-7
1697058
Pain. 1992 Nov;51(2):207-19
1484717
Pain. 1993 Mar;52(3):259-85
7681556
Anesth Analg. 1993 Aug;77(2):362-79
8346839
Pain. 2000 May;86(1-2):19-24
10779656
Anesthesiology. 2000 Sep;93(3):601-10
10969291
Clin J Pain. 2000 Sep;16(3 Suppl):S131-8
11014457
Anesthesiology. 2000 Oct;93(4):1123-33
11020770
Curr Rev Pain. 2000;4(3):234-41
10998739
Pain. 2001 Feb 15;90(3):261-9
11207398
Anesth Analg. 1994 Feb;78(2):205-9
8311269
Br J Anaesth. 1996 Jun;76(6):816-21
8679356
Pain. 1996 Dec;68(2-3):401-11
9121830
Anesth Analg. 1997 Jul;85(1):117-23
9212133
Acta Anaesthesiol Scand. 1997 Jun;41(6):785-9
9241343
Acta Anaesthesiol Scand. 1997 Oct;41(9):1124-32
9366932
Pain. 1998 Apr;75(2-3):177-85
9583753
Anesth Analg. 1999 Jan;88(1):146-8
9895082
Behav Brain Sci. 1997 Sep;20(3):404-19; discussion 435-513
10097003
Pain. 1999 Mar;80(1-2):265-72
10204739
Anesthesiology. 2005 Jul;103(1):147-55
15983467
Anesthesiology. 2005 Sep;103(3):613-8
16129988
Reg Anesth Pain Med. 2006 Jan-Feb;31(1):1-3
16418016
Anesthesiology. 2006 Mar;104(3):601-7
16508408
Pain. 2002 Jun;97(3):189-94
12044615
Anesthesiology. 2003 Jun;98(6):1422-6
12766652