Clinical Orthopaedics and Related Research: May 2014 - Volume 472 - Issue 5 - p 1467–1474 doi: 10.1007/s11999-013-3106-4 Symposium: Perioperative Pain Management in Orthopaedic Surgery FREE

Does Limb Preconditioning Reduce Pain After Total Knee Arthroplasty? A Randomized, Double-blind Study

Memtsoudis, Stavros, G., MD, PhD1,a; Stundner, Ottokar, MD2; Yoo, Daniel, MS1; Della Valle, Alejandro, Gonzalez, MD3; Boettner, Friedrich, MD3; Bombardieri, Anna, Maria, MD, PhD1; Jules-Elysee, Kethy, MD1; Poultsides, Lazaros, MD, MS, PhD3; Ma, Yan, PhD4; Sculco, Thomas, P., MD3

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.

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