The Management of Patients with Painful Total Knee Replacement

Reviewed by Dr Emily Kong MBBS | Accredited Orthopaedic Registrar

  • The management of patients with painful total knee replacement
    • Although TKR is effective operation for OA, symptoms may persist post op
    • Management should have a multidisciplinary approach:
      • Diagnosis + Investigation
      • Pain Management
      • Support
    • Treatment and identify intrinsic and extrinsic causes of painful TKR early
    • Involve patient’s GP
    • Unrelieved acute severe pain can exacerbate pts pre-op tendency for anxiety, depression, hostility and pre-occupation with health
    • Early attempts to relieve pain may avoid development of chronic states

Management of Pain

  • Pain post TKR may increase or fail to improve:
    • Regular pre-op analgesia ceased
    • Physio input decreased
  • Encourage regular analgesia
  • Consider oral or topical options:
    • Sustained released orals
    • Transdermal patches

Management of Neuropathic Pain

  • Clinical Assessment:
    • Dysaesthesia
    • Allodynia
    • Pain assoc. with non-noxious stimuli
    • Hyperalgesia
    • Spontaneous pain
  • Treatment options
    • Capsaicin cream
    • 5% lignocaine plasters:
      • Trial for 2 weeks
    • Regular massage of scar
    • Tricyclic antidepressants:
      • Dual effect: relief from anxiety +/depression
    • Anticonvulsants:
      • Gabapentin, pregabalin

Management of Painful Neuroma

  • Trial conservative therapy 1st
  • Consider resection after 6 months
  • Positive response to local anaesthetic blocks crucial in identifying benefits from surgery
  • Selective denervation of nerve:
    • Satisfaction rate up to 86%
  • High incidence of post op hypersensitivity (40%):
    • Usually self limiting within 6wks

Management of CRPS

  • Prospective study prevalence:
    • 21% one month
    • 13% three months
    • 12.7% three months
  • Risk factors:
    • Pre-operative pain
    • Distress
  • Symptoms include:
    • Diffuse skin, joint and musc. pain
    • Sensory disturbances
    • Neuropathic pain
  • Signs and symptoms spread beyond the knee
    • Beware of pain at rest
    • Difficulty moving a mechanically sound TKR
    • Analgesics should be introduced early to allow pts to participate in rehab and desensitisation programs
    • Sympathetic blocks are generally not helpful:
      • Should be reserved for those with clinical symptoms of sympathetically-mediated pain
    • Success to Treatment is early Diagnosis and Management
    • Prognosis variable:
      • 50% develop chronic symptoms
    • When managed early, long term prognosis similar to uncomplicated TKR at 54mths

Infection

  • Goals of Treatment:
    • Eradication of infection
    • Alleviation of pain
    • Recovery of function
  • Variables:
    • Superficial or deep infection
    • Duration since surgery
    • Host factors
    • Soft tissue around knee
    • Organism
  • Treatment options:
    • ABx suppression
    • Arthroscopic or open debridement
    • One or Two-staged revision
    • Arthrodesis
    • Amputation

Instability

  • Unstable TKR causes pain due to abnormal stressors on knee and soft tissues
  • Ascertain nature of instability:
    • Quads weakness
    • Flexion contracture
    • PF maltracking
    • Pain
  • Early instability:
    • Uncorrected pre-op ligamentous imbalance
    • Improper intra-op ligamentous imbalancing
    • Flexion-extension mismatch
    • Iatrogenic collateral ligament damage
    • Pre-existing neuromuscular pathology
  • Late instability:
    • 2° to malalignment causing ligament stretching
    • Polyethylene wear
    • Loosening
    • Collapse
  • Management is difficult:
    • Weight loss
    • Correction of hip/foot/extra-articular deformities
    • Ligament reconstruction + constrained prosthesis
    • Revision to hinged prosthesis
    • Arthrodesis

Extensor Mechanism Problems

  • Common cause of pain and dissatisfaction post-op:
    • PF maltracking + instability
    • Extensor mechanism disruption
    • Patellar clunk syndrome
    • Peri-patellar adhesions
    • Polyethylene wear
    • Osteonecrosis
  • PF instability:
    • Incidence of sublux/disloc.
      • previously 10-35%
  • Rupture of patellar tendon:
    • Uncommon: incidence 0.12%
    • Partial avulsion can be reattached primarily
    • Reinforcement with autograft or synthetic graft
    • Extensor lag +/restricted ROM may persist
  • Quadriceps tendon rupture:
    • Uncommon: incidence 1.1%
    • Risk factors:
      • Quads turn down
      • Over-resection of patella +/patellar tendon damage
      • Extensive lateral release
      • Requires direct repair
  • Periprosthetic Fracture of Patella
    • Incidence 1-2%
    • Predisposing factors:
      • Lateral release
      • Excessive resection of bone
      • Single peg fInvestigationation
      • Patella maltracking
      • Malposition of implant
    • Management depends on:
      • Location
      • Pattern of Fracture
      • Extensor mechanism integrity
      • Stability of implant
      • Quality of bone
    • Conservative Management:
      • No extensor mechanism disruption
      • No loosening of component
      • No major malalignment
    • Surgical Management:
      • Disruption of extensor mechanism
      • Dislocation of patella
      • Unstable implants

Ortiguera and Berry classification of patellar fracture after TKA

TypeDescriptionTreatment
IStable implant, intact extensor mechanismNon-operative
IIExtensor mechanism disruptedExtensor mechanism repair with partial patellectomy or ORIF
IIIaLoose patellar component, good bone stockComponent revision or resection arthroplasty
IIIbLoose patellar component, poor bone stockComponent removal with patelloplasty or total patellectomy

Original publication Ortiguera CJ, Berry DJ. Patellar fracture after total knee arthroplasty. J Bone Joint Surg Am. 2002;84(4):532-40.

Stiffness

  • Incidence not well described:
    • 3% to 60%
  • Common presenting complaint
  • Can lead to pain and functional limitation
  • Difficult to define:
    • Need to clarify what pt is happy or unhappy about
  • Contributing factors:
    • Poor pre-op ROM
    • Previous knee surgery
    • Infection
    • Technical errors: over stuffing, imbalancing, malrotation, elevation of joint line
    • CRPS
    • Severe post-op pain preventing rehab
  • Treatment options:
    • Intense physio
    • MUA
    • Arthroscopic or open arthrolysis
    • Revision
  • MUA:
    • Risks: Fracture, rupture PT, wound breakdown, haemarthrosis
    • Rehab post manipulation critical to success
    • Analgesia
    • Timing:
      • 2 weeks Vs 6 weeks
      • Delaying factors: haematoma, medical Cx
  • Arthroscopic release:
    • May be beneficial at 3-6mths post op in well-balanced knee
    • Very stiff knee may break instruments
    • May be able to assess contributing factors to stiffness

Impingement

  • Popliteus Tendon:
    • Difficult to diagnose
    • Treatment arthroscopic release
  • Fabellar:
    • Consider in pts with discrete posterolateral pain and large fabella
    • Pain often activity-related
    • Impinges on femoral or tibial component
    • Treatment excision

Patellar Clunk Syndrome

  • Incidence up to 3.5%
  • Three main groups:
    • Isolated fibrous nodule located in suprapatellar region
    • Impinging hypertrophic synovitis, generalised hypertrophic synovitis with no fibrous nodule
    • Combination of the above
  • Excellent results with arthroscopic resection

Recurrent Haemarthrosis

  • In absence of bleeding disorder, is due to impingement of proliferative synovium
  • Often treated conservatively
  • Surgical Treatment successful:
    • Arthroscopic or open synovectomy
    • Surgical embolisation

Role of Arthroscopy in Painful TKR

  • Good for Treatment of:
    • Soft tissue impingement
    • Arthrofibrosis
    • Loose body
    • Acute infection
  • Recommend 24-48hrs prophylactic ABx
  • Care not to scratch implants wear debris

Unexplained Pain

  • Incidence at 1 year up to 18.2%
  • Series of 622 pts:
    • 4% unexplained pain
    • 55.5% improvement without intervention
  • Revision results in these pts unpredictable

Other Potential Causes of a Painful TKR and How to Avoid Them

  • Incision site:(1)
    • Avoid skin incisions too far medially: causes large lateral skin flaps and potential increased rate of wound complication
    • Placement of the skin incision slightly lateral to the midline can assist in eversion of the patella, especially in obese pts
    • Layered wound closure without tension to minimise risk of wound necrosis
  • Tourniquet:(3)
    • May not influence the satisfaction post operatively based on a pt questionnaire
    • Pain scores not significantly different between tourniquet Vs no tourniquet
  • Haemostasis before closure:(1)
    • Meticulous wound haemostasis is required to avoid a post operative haematoma
    • Pain may be increased from pressure caused by a large haematoma
  • Cement Vs Uncemented:(2, 4)
    • Start up pain occurs with initial wt bearing and improves after a few steps: following cemented arthroplasty – lasts 4-6wks, cementless – 3-4mths because micromotion is present until ingrowth occurs
    • Localised tenderness/pain of tibial component may occur due to incomplete cementation
    • Pain from loosening of a cemented femoral component may be due to inaccurate bony cuts, poor cement technique and deficient bone
    • Avoid cementing onto sclerotic bone
    • Defects in cement mantle can act as channels for passage of polyethylene debris into bone-cement mantle allows for osteolysis
    • Pain associated with loosening of cementless TKRs may be due to incomplete porous coating, screw holes and incomplete bony ingrowth
  • Patient-related risk factors:(1)
    • Long term steroid use can delay/impair wound healing
    • Obesity: difficulty with exposure, excessive retraction of wound, larger incision, thick layer of adipose tissue therefore skin less adherent to vascular supply increasing chances of necrosis
    • Malnutrition
    • Smoking
    • Diabetes
    • Peripheral vascular disease can cause delayed wound healing: hypovolaemia intra-op can reduce oxygen delivery to operative site

Take-home Message

  • Difficult problem – multifactorial
  • Needs multidisciplinary approach
  • Identify and treat cause promptly – delay may lead to chronicity
  • If no cause can be found despite extensive Investigation, revision surgery should be performed with caution:
    • Low success rate
    • More than 50% may improve with conservative Treatment alone

References

  1. D. Ayers, D. Dennis, N. Johanson, V. Pellegrini, Jr Instructional Course Lectures, The American Academy of Orthopaedic Surgeons – Common Complications of Total Knee Arthroplasty J Bone Joint Surg Am 1997;79:278-311
  2. M. Gonzalez, A. Mekhail The Failed Total Knee Arthroplasty: Evaluation and Etiology J Am Acad Orthop Surg 2004;12:436-446
  3. P.Baker, J. van der Meulen, J. Lewsey, P. Gregg The role of pain and function in determining patient satisfaction after total knee replacement J Bone Joint Surg Br 2007;89-B:893-900
  4. V. Mandalia, K. Eyres, P. Schranz, A. Toms Evaluation of patients with a painful total knee replacement J Bone Joint Surg Br 2008;90-B:265-71

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.