Factors associated with the development of post-traumatic pain in patients at risk of post-traumatic osteoarthritis

The aim of the study – to identify the factors associated with the development of chronic post-traumatic pain (CPTP) in patients with knee joint (KJ) injury.

Materials and methods. The study group consisted of 136 patients (51.5% women, age 38.7±12.4 years) who suffered a KJ injury with damage to the anterior cruciate ligament and/or menisci. The inclusion criterion was the presence of pain in KJ ≥4 on a numerical rating scale (NRS 0–10) for at least 1 month after injury. Surgical intervention (plastic surgery of the anterior cruciate ligament, meniscus suture, meniscus resection, combined operations) was performed immediately after injury in 48.5% of patients. The incidence of CPTP was assessed (persistence of pain during movement ≥4 on NRS after 3 and 6 months of follow-up) and factors related to the development of CPTP. All patients were recommended to use orthoses of KJ, physical therapy and taking nonsteroidal anti-inflammatory drugs in the “on-demand” mode. Results. CPTP was detected after 3 months in 33.1%, and after 6 months in 32.4% of patients. Surgical treatment did not affect the development of CPTP: odds ratio (OR) – 1.241, 95% confidence interval (95% CI): 0.775–1.986 (p=0.474). The risk of CPTP after 6 months was statistically significantly higher in women, persons with a high body mass index (≥30 kg/m²), initially severe pain (≥7 on NRS), in the presence of initial signs of depression and anxiety (HADS (Hospital Anxiety and Depression Scale) ≥8) and highly probable central sensitization (CSI (Central Sensitization Inventory) ≥40): OR=2,152, 95% CI: 1,383–3,348 (p=0,002); OR=1,243, 95% CI: 1,054–1,465 (p=0,05); OR=3,567, 95% CI: 1,717–5,708 (p=0,001); OR=2,330, 95% CI: 1,070–5,726 (p=0.0044); OR=2,446, 95% CI: 1,220–4,905 (p=0,016); OR=2,584, 95% CI: 1,101–8,133 (p=0.043), respectively.

1. Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W, Treede RD; IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: Chronic postsurgical or posttraumatic pain. Pain. 2019;160(1):45-52. doi: 10.1097/j.pain.0000000000001413

2. Chernikova AA, Karateev AE, Makarov MA, Bialik EI, Makarov SA, Bialik VE, et al. Factors determining the development of post-traumatic pain and post-traumatic osteoarthritis. Nauchno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2023;61(3):377-384 (In Russ.)]. doi: 10.47360/1995-4484-2023-377-384

3. Karateev AE, Lila AM, Zagorodnii NV, Amirdzhanova VN, Pogozheva EL, Filatova ES, et al. Control of pain in the early post-traumatic period in the outpatient practice. Results of the multi-center observational study RAPTOR (Rational Analgesia PostTraumatic: an Observational Research). Terapevticheskii arkhiv. 2020;92(5):69-77 (In Russ.)].

4. Price AJ, Jones J, Allum R. Chronic traumatic anterior knee pain. Injury. 2000;31(5):373-378. doi: 10.1016/s0020-1383(00)00006-1

5. Ventura M, Seabra P, Oliveira J, Sousa P, Quesado M, Sousa H, et al. Meniscal injuries in patients aged 40 years or older: A comparative study between meniscal repair and partial meniscectomy. Cureus. 2023;15(1):e33270. doi: 10.7759/cureus.33270

6. Vogel R, Zdravkovic V, Badulescu M, Puskás GJ, Jost B. Comparing major joint injuries, interventions and late sequelae in elite male handball players with an age-matched control group. Sportverletz Sportschaden. 2021;35(3):136-141. doi: 10.1055/a-1143-7559

7. Whittaker JL, Kalsoum R, Bilzon J, Conaghan PG, Crossley K, Dodge GR, et al. Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop. Osteoarthr Cartil Open. 2024;6(2):100449. doi: 10.1016/j.ocarto.2024.100449

8. Dilley JE, Bello MA, Roman N, McKinley T, Sankar U. Posttraumatic osteoarthritis: A review of pathogenic mechanisms and novel targets for mitigation. Bone Rep. 2023;18:101658. doi: 10.1016/j.bonr.2023.101658

9. Malfait AM. Modelling pain in post-traumatic osteoarthritis of the knee. Pain. 2012;153(2):257-258. doi: 10.1016/j.pain.2011.10.009

10. Stiebel M, Miller LE, Block JE. Post-traumatic knee osteoarthritis in the young patient: Therapeutic dilemmas and emerging technologies. Open Access J Sports Med. 2014;5:73-79. doi: 10.2147/OAJSM.S61865

11. Lohmander LS, Roemer FW, Frobell RB, Roos EM. Treatment for acute anterior cruciate ligament tear in young active adults. NEJM Evid. 2023;2(8):EVIDoa2200287. doi: 10.1056/EVI-Doa2200287

12. van der Graaff SJA, Meuffels DE, Bierma-Zeinstra SMA, van Es EM, Verhaar JAN, Eggerding V, et al. Why, when, and in which patients nonoperative treatment of anterior cruciate ligament injury fails: An exploratory analysis of the COMPARE trial. Am J Sports Med. 2022;50(3):645-651. doi: 10.1177/03635465211068532

13. Anthony CA, Westermann RW, Bedard N, Glass N, Bollier M, Hettrich CM, et al. Opioid demand before and after anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(13):3098-3103. doi: 10.1177/0363546517719226

14. Assink N, Vaartjes TP, Kramer CJSA, Bosma E, Nijveldt RJ, Ten Brinke JG, et al. What is the patient-reported outcome and complication incidence after operative versus nonoperative treatment of minimally displaced tibial plateau fractures? Clin Orthop Relat Res. 2024 May 9. doi: 10.1097/CORR.0000000000003057

15. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial. BMJ. 2013;346:f232. doi: 10.1136/bmj.f232

16. Arkov VV, Dmitriev AA, Ershov PYu, Kuznetsov OV, Milenin ON. Use of combined injection therapy with chondroprotectors for relief of patellofemoral pain syndrome in sportsmen after enteral cross-ligament reconstruction. Lechaschi vrach. 2019;(5):78 (In Russ.)].

17. Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: A prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6):337-342. doi: 10.1007/s001670000143

18. Olariu L, Dumitriu B, Buse E, Rosoiu N. The «in vitro» effect of Alflutop product on some extracellular signaling factors involved in the ostearthicular pathology inflammation. Analele AOSR. 2015;4(2):7-18.

19. Belyaeva IB, Mazurov VI, Trofimov YeA. The use of small sea fish bioactive concentrate (Alflutop® drug): 25 years in Russia – researches and practical conclusions. Effective Pharmacotherapy. 2021;17(7):6-12 (In Russ.)]. doi: 10.33978/2307-3586-2021-17-7-6-12

20. Andreoletti H, Dereu D, Combescure C, Rehberg B. A systematic review and meta-analysis of three risk factors for chronic postsurgical pain: Age, sex and preoperative pain. Minerva Anestesiol. 2022;88(10):827-841. doi: 10.23736/S0375-9393.22.16489-8

21. Mills SEE, Nicolson KP, Smith BH. Chronic pain: A review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019;123(2):e273-e283. doi: 10.1016/j.bja.2019.03.023

22. Garcia MM, Corrales P, Huerta MÁ, Czachorowski MJ, LópezMiranda V, Medina-Gómez G, et al. Adults with excess weight or obesity, but not with overweight, report greater pain intensities than individuals with normal weight: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2024;15:1340465. doi: 10.3389/fendo.2024.1340465

23. Narouze S, Souzdalnitski D. Obesity and chronic pain: Systematic review of prevalence and implications for pain practice. Reg Anesth Pain Med. 2015;40(2):91-111. doi: 10.1097/AAP.0000000000000218

24. Alkassabi O, Voogt L, Andrews P, Alhowimel A, Nijs J, Alsobayel H. Risk factors to persistent pain following musculoskeletal injuries: A systematic literature review. Int J Environ Res Public Health. 2022;19(15):9318. doi: 10.3390/ijerph19159318

25. Wu L, Li M, Zeng Y, Si H, Liu Y, Yang P, et al. Prevalence and risk factors for prolonged opioid use after total joint arthroplasty: A systematic review, meta-analysis, and meta-regression. Arch Orthop Trauma Surg. 202;141(6):907-915. doi: 10.1007/s00402-020-03486-4

26. Kurien T, Kerslake RW, Graven-Nielsen T, Arendt-Nielsen L, Auer DP, Edwards K, et al. Chronic postoperative pain after total knee arthroplasty: The potential contributions of synovitis, pain sensitization and pain catastrophizing – An explorative study. Eur J Pain. 2022;26(9):1979-1989. doi: 10.1002/ejp.2018

27. Kim MS, Kim JJ, Kang KH, Kim MJ, In Y. Diagnosis of central sensitization and its effects on postoperative outcomes following total knee arthroplasty: A systematic review and meta-analysis. Diagnostics (Basel). 2022;12(5):1248. doi: 10.3390/diagnostics12051248

28. Ayers DC, Yousef M, Zheng H, Yang W, Franklin PD. The prevalence and predictors of patient dissatisfaction 5-years following primary total knee arthroplasty. J Arthroplasty. 2022;37(6):121-128. doi: 10.1016/j.arth.2022.02.077

29. Heijbel S, W-Dahl A, E-Naili J, Hedström M. Patient-reported anxiety or depression increased the risk of dissatisfaction despite improvement in pain or function following total knee arthroplasty: A Swedish register-based observational study of 8,745 patients. J Arthroplasty. 2024;1:0883-5403(24)00419-4. doi: 10.1016/j.arth.2024.04.071

30. Li J, Guan T, Zhai Y, Zhang Y. Risk factors of chronic postoperative pain after total knee arthroplasty: A systematic review. J Orthop Surg Res. 2024;19(1):320. doi: 10.1186/s13018-024-04778-w

31. Olsen U, Lindberg MF, Rose C, Denison E, Gay C, Aamodt A, et al. Factors correlated with pain after total knee arthroplasty: A systematic review and meta-analysis. PLoS One. 2023;18(3):e0283446. doi: 10.1371/journal.pone.0283446

32. Walters JL, Baxter K, Chapman H, Jackson T, Sethuramachandran A, Couldridge M, et al. Chronic pain and associated factors in India and Nepal: A pilot study of the Vanderbilt Global Pain Survey. Anesth Analg. 2017;125(5):1616-1626. doi: 10.1213/ANE.0000000000002360

33. Fernández-de-Las-Peñas C, Florencio LL, de-la-LlaveRincón AI, Ortega-Santiago R, Cigarán-Méndez M, FuensalidaNovo S, et al. Prognostic factors for postoperative chronic pain after knee or hip replacement in patients with knee or hip osteoarthritis: An Umbrella review. J Clin Med. 2023;12(20):6624. doi: 10.3390/jcm12206624

34. Minhas D. Pain mechanisms for the practicing rheumatologist. Best Pract Res Clin Rheumatol. 2024;22:101942. doi: 10.1016/j.berh.2024.101942