Finding help for post knee replacement pain and complications

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Can we help you with your continued knee pain after knee replacement surgery? In this article, we will explore the problems identifying the source of knee pain after knee replacement and how identifying and treating soft tissue damage may be the answer to why you have pain after knee replacement.

Many patients we see with post-knee replacement pain have pain on the outer sides of the knee. This is where the surviving knee ligaments and tendons are. The knee ligaments help hold the thigh and shin bone in place while the knee tendons attach the muscles to the bone. These soft tissues act to help stabilize and move the knee and leg. Most often these connective tissues are damaged either by the surgery itself or, by new stress placed on them by the implant. This can be the cause of why a knee wobbles, is unstable and has become hypermobile. This unsteadiness and hypermobility will also pull and tug at the ligaments and tendons which will cause the patient a lot of pain. Some patients have nerve irritations. This nerve irritation can be below or above the knee or along with the kneecap. In some people, they become hypersensitive to pain. They have more pain than they should.

This explanation is one possible cause of post-knee replacement pain. Below we will discuss others but our focus will be on damage to the natural remaining tissue and what solutions can be offered to address this problem.

Many people have excellent results with their knee replacement surgery. These are typically not the people we see in our office.

Before we get into the various reasons people still have pain and problem knees after knee replacement, we want to remind the reader that knee replacement surgery can be a life changer for many people and return them to a high quality of life. We see the people who still have pain, knee instability, and also suffer from pain in the other knee from over-compensation among other challenges. Some of these people were told that their surgery was a complete success. “The surgery was good.” But as we hear in these patient stories. The surgery came up short of expectations.

Article outline:

Part 1: Looking for causes of post-surgical knee replacement pain

  • Research: Doctors are looking for the causes of pain after knee replacement and it is hard to find.
  • Research: “Patients with persistent pain after knee replacement are dissatisfied.”
  • Patients who underwent revision knee replacement had lower rates of improvement and higher rates of worsening problems.
  • Painful knee after total knee replacement – what can be done? First, find a diagnosis.
  • Establishing a precise diagnosis of where knee pain is coming from after knee replacement can be challenging.
  • Is pre-surgery patient evaluation outdated for predicting replacement failure?
  • Lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement.

Part 2: A large number of people are affected by chronic pain after total knee replacement. 

  • Doctors report knee replacement surgery as a success. Their patients say not so fast. What is a successful knee replacement surgery? To a patient that would be long-term relief from pain and increased function and mobility. This is NOT a realistic expectation for patients to have according to researchers.
  • The problem is clearly the patients think they can do more after knee replacement and they are not forewarned to reduce their expectations.
  • Patient expectations of greater independence immediately following the surgery were not met. Patients are upset that they cannot walk as well as they thought they could.
  • A loose knee replacement – Everything is normal I guess, except for my pain, knee instability, and the explained noises my knee is making.
  • Doctors say we are rushing too many patients to knee surgery, this can be why expectations are not met.
  • Patients did not have good knee replacement outcomes because their knee was not that bad to begin with.
  • Adverse knee pain occurs in 10-34% of all total knee replacements, and 20% of total knee replacement patients experience more pain post-operatively than pre-operatively.
  • Men and women have different ideas about what makes a knee replacement successful or not.
  • Everything was great with my knee replacement, then I plateaued, then I started going backward.

Part 3: Many knee replacements should not have been done

  • One-third of knee replacements should not have been done.
  • Patients did not have good knee replacement outcomes because their knee was not that bad to begin with.
  • Patients had knee pain after a knee replacement because, after the fact, it was determined that knee replacement was the wrong surgery. The knee was not the problem and the patient was inappropriately rushed to surgery.
  • Patients may still be undergoing knee replacement for degenerative lumbar spine and hip osteoarthritis.

Part 4: Knee replacement complications

  • Twenty-two complication risks associated with a total knee replacement.
  • Pes anserinus pain syndrome
  • Did extended delays to knee replacement surgery cause you post-surgery problems?
  • Another word on COVID-19 and knee replacement complications.
  • Is it the opioids causing pain after knee replacement?
  • Studies have demonstrated that poor management of acute pain after total knee replacement is strongly associated with the development of chronic pain.
  • After the surgery, the researchers found patients had to alter their recovery and post-surgery strategy to account for new health problems and problems with mobility.
  • Did your knee get larger after knee replacement? “Patient-perceived enlargement of the knee.”
  • When knee replacement fails you need a team of specialists.
  • Pain catastrophizing.
  • The problems of obesity.
  • The more joints that hurt, the less successful the knee replacement.
  • Knee replacement complications in former athletes
  • Peripheral nerve injury.
  • Problem: Difficulty and Pain in Kneeling.
  • When knee replacement fails you need a team of specialists.
  • Problem: Post-surgical stress following knee replacement.
  • Pain catastrophizing.
  • Catastrophizing thoughts and central sensitization = catastrophic results and opioid dependence after knee replacement.
  • The problems of obesity.
  • The problem of pre-replacement urinary incontinence.
  • The more joints that hurt, the less successful the knee replacement.
  • Problem: Post-surgical stress following knee replacement.

Part 5: Mystery or neurologic pain

  • Surgeons say one in four patients with pain after knee replacement had no clear reason for their pain. It wasn’t the hardware, it wasn’t anything obvious that they could see.
  • It looked like neuropathy but it wasn’t neuropathy. Mystery pain, unclear pain, difficult to treat pain after knee replacement. Post-knee replacement health problems are a bigger problem than anticipated.
  • Problem: Neuropathic knee pain after surgery – nerve damage caused by the surgery.

Part 6: The spouse and support groups

  • When the medical system is non-supportive, patients reach out to support groups.
  • The pressure to help the knee replacement patient recover fails mainly on the spouse and this may be a job that the spouse will need a lot of help doing.

Part 7: Surgery for post-knee replacement pain

  • Research: Surgeons warn surgeons that knee pain after knee replacement does not automatically mean REVISION KNEE SURGERY
  • “Patients may need subsequent surgeries to maximize the benefits of joint replacement.”
  • Total knee replacement in the middle-aged patient population.
  • Revision surgery with a high risk of failure.
  • Problem: Fixing Pain After Total Knee Replacement may include Amputation.
  • Will your bones even allow for a revision knee replacement?
  • The problems of osteoporosis.
  • A complication of a second knee replacement in obese patients.

Part 8: Non-surgical treatment of post-knee replacement pain

  • Physical therapy after failed knee replacement.
  • Can physical therapy help post-total knee replacement pain?
  • Radiofrequency ablation of genicular nerves.
  • Neuromuscular electrical stimulation.

Part 9: Is the problem of post-surgical chronic knee pain weakness and stretching of the surviving knee ligaments?

  • The kneecap was floating because the MCL was released. Patellar maltracking after total knee replacement. The concern of “catastrophic laxity”
  • How can we help these problems? The often overlooked and ignored cause of pain after knee replacement is knee Ligaments.
  • Post-surgical pain and knee instability may be from the surviving ligaments.
  • Ligament instability was the primary reason for repair surgery.
  • The kneecap was floating because the MCL was released. Patellar maltracking after total knee replacement. The concern of “catastrophic laxity.”
  • Previous ligament reconstruction surgery – higher risk for complications after knee replacement.
  • The ligament problem is a clue that for some patients, post-knee replacement pain may be a problem of overdoing it, even while in the hospital or nursing home.
  • Prolotherapy and Platelet Rich Plasma Therapy for post-knee replacement pain.
  • The patient problems after knee replacement surgery are many. At Caring Medical, we can address many of these problems. We cannot address all, especially when the problem of knee replacement is caused by hardware failure and hardware placement failure.
  • A realistic assessment of what we can do to help with your pain after knee replacement.

Part 1: Looking for causes of post-surgical knee replacement pain

post-knee replacement pain

Research: Doctors are looking for the causes of pain after knee replacement and it is hard to find

Let’s start this article with research into the confusion as to what may be the cause of chronic knee pain after knee replacement. This confusion and the problems of patients with continued pain after knee surgery is a cause of great concern not only among doctors but obviously among patients. We often find patients to be unsure of what is considered normal and what is not normal after knee replacement. They also become confused when they have problems after knee replacement but are assured that the surgery was a successful one.

Below we will help answer these questions:

  • Is some pain normal?
  • Are the clunking sounds normal?
  • Is the knee instability normal?

Research: “Patients with persistent pain after knee replacement are dissatisfied.”

That is an obvious statement, but what are the patients dissatisfied with and how can we help them? Here is the study that statement came from, research in the journal Osteoarthritis Cartilage(1)

In the most dissatisfied knee replacement patients:

  • The pain was associated with instability in the coronal plane (the centerline from head to foot that marks the front of the body from the back of the body):
    • In other words, this caused difficulty in:
      • Maintaining balance.
      • Leg and knee stiffness,
      • and negative social support. (A sense of abandonment or not being helped).

In patients who were dissatisfied on a lesser level:

Patients who underwent revision knee replacement had lower rates of improvement and higher rates of worsening problems.

When patients are dissatisfied, one solution would be to carefully consider, the revision surgery to see if the knee replacement can be made to work better. A February 2024 study published in The Journal of Arthroplasty (2) comes from doctors at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School. In this study, patient outcomes were assessed in patients having to undergo revision surgery to fix or adjust a problem that remained after the primary knee replacement surgery. The researchers here compared 2,448 patient outcomes, of which 2,239 were primary knee replacements against 209 total knee replacement revision surgeries. The end result was that people who needed a second or revised knee replacement did not have as good of outcomes as the people who had only the primary knee replacement. Here are the findings:

  • Patients who underwent revision knee replacement had lower rates of improvement and higher rates of worsening problems. Specifically, the patient outcomes reported a worsening of physical function. As a side note the researchers also wrote: “Although primary knee replacement surgery patients did better overall, the improvement rates may be considered relatively low and should prompt discussions on improving outcomes following primary knee replacement surgery and revision knee replacement. Painful knee after total knee arthroplasty – what can be done? First, find a diagnosis.

Establishing a precise diagnosis of where knee pain is coming from after knee replacement can be challenging.

Diagnosis of what is causing knee pain after a knee replacement is hard to find. The first thing most doctors and radiologists look for is some type of hardware failure or pain caused by the surgery itself. If you have pain after knee replacement you have probably had these discussions with your surgeon.

In December 2020, doctors in Germany offered the suggestion that if you have pain or a failed knee replacement surgery, you may be better served seeking a surgical specialist to fix a bad knee replacement. One who understands the factors in why the knee replacement failed. (3)

  • “About one-third of all patients after total knee arthroplasty experience persistent or recurring pain and/or dissatisfaction. Clinically, the symptoms are very complex and vary greatly from individual to individual. Diagnostic clarification is difficult and should be carried out by an orthopedic surgeon specializing in knee arthroplasty revisions. Only if the cause(s) of the complaints are identified is there a chance of improvement, regardless of whether conservative or surgical treatment is used.”

Researchers at the Department of Surgery, Southern Illinois University School of Medicine offered this assessment in the medical information publication Instructional Course Lectures (4to guide doctors trying to help patients with pain after knee replacement.

According to the research: This is what doctors need to look for in trying to find the source of knee pain after knee replacement:

  • Pain after knee replacement can be classified as intra-articular (from within the knee) or extra-articular pain (from sources outside the knee).
  • After intra-articular causes (described below), such as knee instability, aseptic loosening (a loose knee replacement), infection, or osteolysis (loss of bone), have been ruled out, extra-articular sources of pain should be considered.
  • Extra-articular sources of pain can be found after a physical examination of the other joints which may reveal sources of localized knee pain, including diseases of the spine, hip, foot, and ankle.
    • Let’s stop for a moment to comment. After the knee replacement, you still have knee pain. The doctors in this study are saying to examine the spine, the hips, the ankles, and the feet, these joints may be causing the knee pain problem. An August 2016 study (5) suggests that “In cases undergoing knee replacement, the effect of the acute change in the alignment of the knee on the ankle should be taken into consideration and the amount of correction should be calculated carefully in order not to damage the alignment of the ankle.” The knee replacement can cause ankle pain and send pain back up the body towards the knees and hips.
    • What if these joints were the cause of knee pain in the first place? See below, was knee replacement the wrong surgery? 
    • MORE: Additional extra-articular pathologies (pain from degenerative disorders from outside the knee) that have the potential to instigate pain after total knee replacement include cardiovascular problems, tendinitis, bursitis, and iliotibial band friction syndrome.
    • Patients with medical comorbidities, such as metabolic bone disease and psychological illness, may also experience prolonged postoperative pain.

Is pre-surgery patient evaluation outdated for predicting replacement failure?

In September 2020, a multi-national research team including orthopedic surgeons suggested that 20% of patients do not have favorable outcomes following knee replacement surgery and that the mechanism for screening outpatients who are at high risk for surgical failure is outdated. Here is exactly what they said in the prestigious medical journal BMJ Open (6):

“One in five patients undergoing total knee arthroplasty (replacement) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavorable outcomes is necessary to develop tailored interventions to minimize risk. There is a need to review more current literature with an updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses.”

Lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement.

Doctors also wrote in the British Medical Journal (7) that the problem of post-surgical pain in knee replacement patients had reached a point of significance and that researchers should prioritize their studies to help people with pain. They wrote:

  • “Our (study) highlights a lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement. As a large number of people are affected by chronic pain after total knee replacement, development of an evidence base about care for these patients should be a research priority.” We are going to return to this study below.

There is a significant problem. The main part of this problem is identifying what is causing people to have pain after knee replacement.


Part 2: A large number of people are affected by chronic pain after total knee replacement. 


A large number of people are affected by chronic pain after total knee replacement

Doctors report knee replacement surgery as a success. Their patients say not so fast.

What is a successful knee replacement surgery? To a patient that would be long-term relief from pain and increased function and mobility. This is NOT a realistic expectation for patients to have according to researchers.

What is a successful knee replacement? Doctors in Spain examined what factors influenced a patient to have a successful knee replacement surgery, and what influences prevent patients from having successful knee replacement surgery. (8) In their study appearing in the Journal of Evaluation in Clinical Practice, they write: “There is conflicting evidence about what factors influence outcomes after total knee replacement. The objective of this study is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference and a patient-acceptable symptom state in pain and function, measured by WOMAC (Pain scoring system), after total knee replacement from those who do not attain scores above the cutoff for improvement.”

What were the two most important factors the Spanish team looked at one year after surgery?

  • Expectations -patients did not have realistic expectations of what they could and could not do after the knee replacement.
  • The mental anguish and health of the patient while they were waiting for the knee replacement.

The recommendation from this research?

  • While they wait for surgery, doctors and caregivers should manage the patient’s expectations so they have a realistic opinion of what happens after the surgery. Manage their mental health before the surgery to help with a more positive outlook afterward.

The problem is clearly the patients think they can do more after knee replacement and they are not forewarned to reduce their expectations.

Doctors at Australia’s leading medical universities combined to produce this opinion published in the Australian and New Zealand Journal of Surgery.

“Walking ability and speed are important to the total knee replacement patient and are representative of their pain and function.”(9 Important functions to the patients such as how fast they can walk are typically not measured in determining patient outcome scores, compromising true patient outcome surveys.

Patient expectations of greater independence immediately following the surgery were not met. Patients are upset that they cannot walk as well as they thought they could.

  • Important functions to the patients such as how fast they can walk are typically not measured in determining patient outcome scores, compromising true patient outcome surveys.
  • For many patients, simple expectations turned out to be unrealistic expectations as witnessed by research that suggested that people who receive knee replacements expect to have greater independence immediately following the surgery.

In May 2022 doctors at the University of South Australia wrote in the journal Pain Reports (10) looked at patient outcomes, in people who “experience suboptimal pain relief and functional improvement” following knee replacement. Among these patients, they found these four main themes:

  • “Theme 1 addressed experiences of recovery after surgery, which often differed from expectations.”
  • “Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in the context of personal beliefs and perceived stigma.”
  • “Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to “endure.”
  • “Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing.”

What the patients faced simply was the recovery was more difficult than they thought it would be. They were on medications that concerned them. They needed to “endure” the recovery. They felt that they were not helped.

What made the patients dissatisfied? Greater pain, reduced functionality and unmet expectation one month postoperatively.

A May 2024 study (78) from the University Medical Center Hamburg-Eppendorf published in the journal Knee surgery, sports traumatology, arthroscopy, looked to predict which patients would suffer from the most dissatisfaction after their knee replacement surgery. The authors write: “Dissatisfaction after total knee replacement is a prevalent and (a) clinically relevant problem that affects approximately 10%-20% of patients. ”

  • This study included 236 patients enrolled after total knee replacement.
  • One year after the surgery, 16% of the patients were dissatisfied.
    • Dissatisfied patients were typically younger and had a higher body mass index (BMI). Although patients over 63 years old had greater risk for dissatisfaction after surgery.
    • What made the patients dissatisfied? Greater pain, reduced functionality and unmet expectation one month postoperatively.

A May 2024 study from doctors at the Department of Orthopaedic Surgery, Northwestern University (79) found that patients had a different idea as well when it came to what they considered a successful knee replacement and what they considered “unmet expectations” leading to dissatisfaction with the surgery.

In this paper the researchers refer to “minimal clinically important difference (MCID)” in patient-reported outcomes. Minimal clinically important difference (MCID) signifies enough post-surgical improvement to consider the surgery a success.  However, the doctors write: “Achieving a minimal clinically important difference (MCID) in patient-reported outcomes (PROs) following total knee arthroplasty (replacement) is common, yet up to 20% patient dissatisfaction persists. Unmet expectations may explain post-total knee arthroplasty dissatisfaction. “

  • In this study, 93 patients were asked what type of pain reduction and physical function return would they realistically like to see? What are their expectations from their knee replacement? This question was asked 12 months after the replacement.

In this study, it was seen that patients expected more from their knee replacement.

  • When patients answered surveys about their knee pain and function, 12 months after surgery, the patients achieved scores that would signify minimal clinically important difference (MCID) in physical function. However, patients had twice the expectation of functionality improvement.
  • The patients also expected significantly more pain relief.

Because of these outcomes, the researchers concluded: “This discrepancy challenges currently accepted standards of success after total knee arthroplasty and indicates a need for improved expectation setting prior to surgery.”

A loose knee replacement – Everything is normal I guess, except for my pain, knee instability, and the explained noises my knee is making.

This is something we typically hear in a post-knee replacement patient who is having some challenges with pain and function.

I started to become concerned when I noticed a clunking and clicking sound coming from my knee.

I put off the knee replacement as long as I could. This was not a decision I wanted to take lightly but my knee was in constant pain, and my doctor told me I really had no other choice. So I had surgery on one knee. My doctor was very pleased with the surgery. Said everything went well, the rest was up to me. I needed to do physical therapy, I needed people at home to help me, and I was going to be very dependent. Luckily for me, I had everything I needed to ensure a good recovery.

I started to become concerned when I noticed a clunking and clicking sound coming from my knee. Like metal on metal. My doctor told me that this was no concern, some people who get knee replacements have these “old car,” sounds coming from their knee. I should not worry. My doctor did advise me that the sounds if they continued could be caused by weakened muscles and tendons in my knees and I should consider an exercise program to tighten them up.

I did ask if the knee implant was coming loose. My doctor said, if it were, I would not be able to walk up and down stairs or even put weight on that foot. I would have a lot of swelling and I would feel like my knee may give out. I looked at the doctor and said, BUT I DO HAVE THOSE SYMPTOMS, “Yes you do,” the doctor said, but it is not from implant loosening. You probably just need to strengthen that knee up.

A June 2022 paper in The Journal of Arthroplasty (11) examined the impact of a loose or migrating knee replacement on patient satisfaction following total knee replacement. The researchers looked at patients who were satisfied with their knee replacement and those patients who were dissatisfied with their knee replacement. The thinking, prior to the study was that a loose or migrating implant would create problems with knee movement leading to the patient’s unhappiness. What they found was functionally dissatisfied patients had more anteriorly positioned contact on the lateral condyle (o the thigh bone) in early flexion (as they ben their knee) and reported more pain and unmet expectations. The researchers noted: “These findings suggest that improving the functional satisfaction of (a total knee replacement) requires restoration of kinematics (proper movement) in early flexion (bending) and management of patient’s pain and expectations.”

It’s not my knee – patients report the knee replacement feels alien

A June 2022 study in the journal Arthritis Care & Research (12) described patients who reported struggles with their new knee. The researchers noted that not only did participants in this study speak of pain, but, some patients “struggled with additional discomfort relating to the prosthesis and experienced it as alien and “other” than the body, resulting in a lack of felt connection and confidence in the knee. Participants’ descriptions of otherness included pressure sensations, such as heaviness, which made moving the limb a conscious and effortful action. The researchers also noted a “previously unreported sensation of limb squeezing, different from swelling, which needs further investigation.” Patients had reported that pressure from swelling gave them the sensation that their knee was going to “burst.” However, the “squeezing” sensation some patients described “appears to be experienced as an external force, acting upon, rather than emanating from the knee.”

Men and women have different ideas about what makes a knee replacement successful or not.

Above we saw factors that may cause higher risk factors for post-knee replacement pain. This included pre-surgery opioid use, depression, anxiety, or mechanically bad other joints. Let’s explore these factors that may cause post-knee replacement pain further. Let’s start with October 2022 research (13) that suggests men and women have different complaints after knee replacement and how men and women’s perceptions of these complaints help them decide whether the surgery was a success, not as successful as hoped for, or a failure.

Here are the highlights and learning points of this research

  • This study investigated satisfaction with total knee replacement and what factors contribute differently to satisfaction in women and men during the first 2 years after surgery.
  • Assuming both pain relief and an increase in function are delivered by total knee replacement, satisfaction should increase after surgery. However, up to 28% of patients are not fully satisfied with their total knee replacement surgery, regardless of their clinical or radiographic findings.
    • Explanatory note: More many patients’ reduction of pain and increase in function were not the tell-all of what they thought a successful surgery was. Let’s have the researchers explain this further.
  • In the study group, persistent pain and mechanical symptoms (Clunking syndrome among them, the sound of a clunking metal) were among the most significant negative factors affecting satisfaction.
  • Additionally, postoperative mechanical symptoms and complications requiring reoperations decreased satisfaction with a total knee replacement. Major symptoms related directly to the surgery, such as knee instability and patella-related pain, should be resolved during early reoperation.

What patients found to be most positive:

  • “For both women and men, the most positive factors associated with satisfaction were physical activity and higher general and functional (painless and stable total knee replacement).

What men found to be most negative:

  • In men, the strongest negative factors were pain and complications, followed by (front-of-knee pain) and mechanical problems (instability, foreign body sensation, and clunk syndrome).

What women found to be most negative:

  • The negative factors strongly influencing satisfaction in women were pain, followed by front-of-knee pain and knee instability, other mechanical problems, complications, and low sports activity.

Everything was great with my knee replacement, then I plateaued, then I started going backward.

The above research says that the expectation that reduced pain and better function would be considered a successful surgery, but it’s not. Some explanations are given, let’s explore more. Let’s start with the problems of “plateauing.” Often people will tell us that initially, in the first few weeks or months after their knee replacement they were doing great. Then they plateaued, then they started going backward.

An April 2022 paper (14) from researchers at Oxford University and the University of Bristol in the United Kingdom found that chronic pain was reported in 70/552 operated knees (12.7%) one year after knee replacement surgery. Those patients within the chronic pain group had worse pain, function, and health-related quality of life pre-surgery and post-surgery than the non-chronic pain group. Those without chronic pain markedly improved right after surgery, then plateaued.

Adverse knee pain occurs in 10-34% of all total knee replacements, and 20% of total knee replacement patients experience more pain post-operatively than pre-operatively.

A September 2020 study from Newcastle University in the United Kingdom (15) explains the likelihood of pain after knee replacement and what may cause it. Here are the highlights of this research:

Adverse knee pain occurs in 10-34% of all total knee replacements, and 20% of total knee replacement patients experience more pain post-operatively than pre-operatively.

  • Arthrofibrosis (excessive scar tissue),
  • Aseptic loosening,
  • Avascular necrosis,
  • Central sensitization, (over sensitization to pain. Sometimes patients are told that they have more pain than they should).
  • Component malpositioning, (the replacement is wrong).
  • Infection,
  • Instability, (what we will discuss below is not just instability from the hardware loosening, but the instability of the knee’s natural and remaining tissue causing pain in that tissue.)
  • Nerve damage,
  • Overstuffing, (your knee joint is bigger after the knee replacement and this is causing a sensation of your knee being “overstuffed,” or “too full.”
  • Patellar maltracking, (the knee cap is not in the right place or moving correctly)
  • and others.

An April 2022 study in the journal Frontiers in Psychiatry (16) tackled a problem that had not been well studied. The interaction between emotional states and preoperative treatment expectations and their effect on postoperative pain. The authors write: “Preoperative emotional states and treatment expectations (expectation of good, fair or poor outcome) are significant predictors of postoperative pain. The relationship between emotional states and postoperative pain is (influenced) by negative treatment expectations.” One way to manage expectations is to try to eliminate or reduce negative treatment expectations by addressing the patient’s emotional states

Doctors say we are rushing too many patients to knee surgery, this can be why expectations are not met.

The rising number of unmet patient expectations is why some doctors believe we are rushing too many people to surgery.

In a 2012 study appearing in the Clinical Journal of Sports Medicine, (17) researchers assessed the screening process for surgical candidates with knee osteoarthritis.

They looked at 327 patients.

More than half – 172 of them – were referred to a surgeon and 76% of them went on to have a total knee replacement. Rush to judgment? These researchers thought so and concluded

“Few conservative management options were tried before referral, indicating the need to enhance pre-surgical care for patients with knee osteoarthritis.”

Before you say, that was 2012, what about something more recent? In December 2019, (18) a study published in the journal Health and Quality of Life Outcomes noted that patients who valued quality-of-life improvements before knee replacement surgery and expected such after the surgery were among the highest unsatisfied with their knee replacement groups. One reason? Inappropriateness and over-expectation of how the knee replacement would change their quality of life.

Building on this research is a July 2021 paper in The Archives of Bone and Joint Surgery (19) which suggested that “The most important postoperative factors negatively contributing to patient satisfaction included poor postoperative knee stability and soft-tissue balance, functional limitation, surgical complication and reoperation, staff or quality of care issues, and increased stiffness.

A January 2024 study in the journal BMC Musculoskeletal Disorders (20) led by the University of Oslo looked at 136 patients, with an average age of about 68, and just about 2/3rds or 68% of the patients were women. What the researchers were looking for was improvement in pain and function or lack of improvement in pain and function up to five years after the knee replacement. In patients still suffering from moderate to severe pain, the researchers found that people who had:

  • More severe preoperative pain, more painful sites, and more severe anxiety symptoms were associated with an increased likelihood of moderate to severe pain five years after total knee replacement surgery, while more severe osteoarthritis was associated with a reduced likelihood of moderate to severe pain five years after total knee replacement.
  • More severe anxiety symptoms were also associated with an increased likelihood of moderate to severe pain-related functional impairment five years after surgery, while men were less likely to have a likelihood of pain-related functional impairment five years after surgery.

Part 3: Many knee replacements should not have been done


pain after knee replacement

One-Third of Knee Replacements Should Not Have Been Done

Over the years we have seen many patients who, following knee replacement surgery still had knee pain. After an examination, we could clearly see that some of the patients did not need the surgery and that their doctors may have had an overzealousness to get them onto the operating table.

That has been our opinion for years and many times we would get a casual email saying that we were off base to offer such an opinion.

On June 30, 2014, a statement was issued by the medical journal Arthritis & Rheumatology. In it, doctors said that their research suggested more than one-third of total knee replacements in the United States were the “inappropriate” treatment. (21)

This research strongly suggested to doctors the need for a consensus on patient selection criteria. In other words, making sure those who needed a knee replacement got one, and those who did not were offered other treatments.

The Agency for Healthcare Research and Quality reports:
• more than 600,000 knee replacements are performed in the U.S. each year.
• In the past 15 years, the use of total knee arthroplasty has grown significantly
• Some experts believe the growth is due to the use of an effective procedure, while others contend there is an over-use of the surgery that relies on subjective criteria.

In the related editorial, Dr. Jeffery Katz from the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass., writes, “We should be concerned about offering total knee replacements to subjects who (have) “none” or “mild” on all items of the pain and function scales.”

Ethically, this should be a problem for many. People are forced to live in pain until they are of the appropriate age to get a knee replacement.

In October 2015, an editorial appeared in the New England Journal of Medicine. (22) In that editorial Jeffrey N. Katz, M.D., the same mentioned above, cites the arguments that randomized trials (any further research) of total joint replacement are senseless if they all confirm a rationale to use them. After all, joint replacements are among the most significant advances of the 20th century; don’t we already know they are successful? Yes, but maybe not as successful as we think they are.

In this editorial, the readers of one of the most prestigious medical journals in the world learned that total knee replacement poses the following risks:

  • About 0.5 to 1% of patients die during the 90-day postoperative period.
  • The procedure is not universally successful; approximately 20% of patients who undergo total knee replacement have residual pain 6 or more months after the procedure.
  • Third, there are alternatives. Clinical trials have shown that physical therapy (including exercises and manual therapies) can diminish pain and improve functional status in patients with advanced knee osteoarthritis.
  • Finally, an ideal treatment for one patient may not be right for the next. Patients with knee osteoarthritis differ in the importance they attach to pain relief, functional improvement, and risk of complications. Therefore, treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes.

In a randomized, controlled trial, involving 100 patients with symptomatic knee osteoarthritis, patients were assigned to undergo total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (total-knee-replacement group) or to receive only the nonsurgical treatment (nonsurgical-treatment group), which consisted of supervised:

  • exercise,
  • education, patient information
  • dietary advice,
  • use of insoles,
  • and pain medication.

Total knee replacement proved markedly superior to nonsurgical treatment alone in terms of pain relief and functional improvement. However, it is noteworthy that more than two-thirds of the patients in the nonsurgical treatment group had clinically meaningful improvements in the pain score and that this group had a lower risk of complications.

Patients did not have good knee replacement outcomes because their knee was not that bad to begin with.

Following this line of research and the “rush to surgery” Is this study suggesting knees that were replaced were not so bad that they needed to be replaced? This is a May 2020 study. Doctors at Massachusetts General Hospital, Copenhagen University Hospital, Harvard Medical School, Aalborg University Hospital in Denmark, and Stanford University Medical Center combined to publish data in the journal Clinical Orthopedics and Related Research. (23) The researchers found that “patients with less severe osteoarthritis were much less likely to attain the patient-acceptable symptom state (PASS) in pain and function at one year after total knee replacement, and that men were much less likely to achieve the patient-acceptable symptom state in pain at 1 year after total knee replacement. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement.

Patients had knee pain after a knee replacement because, after the fact, it was determined that knee replacement was the wrong surgery. The knee was not the problem and the patient was inappropriately rushed to surgery.

Are you getting a knee replacement because of undiagnosed back and hip pain? Above we spoke about doctors looking for knee pain that was actually coming from the spine, hip, ankle, and feet. The knee was perhaps not the problem and the patient was inappropriately rushed to surgery

Doctors warn that in the case of chronic knee pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the truth is that the source of pain is often missed and treatment then will present a significant challenge with less than desired results.

One study sought to understand why up to 20 percent of patients who undergo total knee replacement still have persistent pain and why secondary surgery rates are on the rise. (24) Forty-five patients were studied. What the researchers found was somewhat shocking. The pain was not originating in the knee – here is what they said: The wrong joint was operated on – you did not need a knee replacement.

Patients may still be undergoing knee replacement for degenerative lumbar spine and hip osteoarthritis.

“Patients may still be undergoing knee (replacement) arthroplasty for degenerative lumbar spine and hip osteoarthritis. . . We suggest heightened awareness at pre-and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

In other words, patients received a knee replacement when the cause of pain came from the hip and spine.

In the journal Modern Rheumatology, Japanese doctors wrote: “We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain.” (25)

In the case of chronic joint pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the sad truth is that the source of pain is often missed because of misinterpretation of MRI and other imaging scans. Please see our article on MRI accuracy.

In this video, our patient Jeannette had issues with spinal stenosis and problems post-knee replacement.

  • Jeannette starts discussing the knee replacement complications at 2:30 in the video. Jeannette is 81 years old.

Jeannette describes a foot-tingling problem. She cannot sit down and relax at the end of the day, it is uncomfortable for her to put her feet up or down because it is tingling. She had a nerve conduction study that showed an injury to her peroneal nerve.

The peroneal nerve branches out from the sciatic nerve. As it provides sensation to the front and sides of the legs and to the top of the feet, damage to this nerve would result in burning and tingling or numbness sensation in these areas. Further damage to this nerve would also cause loss of control in the muscles in the leg that help you point your toes upward. This can lead to walking problems and possibly foot drop, the inability to lift the front of the foot or ankle. Knee and hip replacement are leading culprits in the cause of peroneal nerve injury.

In Jeannette’s case, she had two knee replacement surgeries in that knee. After the first knee replacement surgery, the implant started to protrude away from the limb. The knee replacement became loose. The second surgery to fix the first one occurred in 2015.

  • It was determined after examination that Jeannette’s knee ligaments were loose. Her knee was hypermobile and unstable. This was causing pressure on her peroneal nerve. Knee ligament damage and weakness are also a complication of knee replacement surgery and are discussed further below.

All medical procedures have success stories and failure stories. Patient case history and descriptions of their treatments may not be typical or indicative of all outcomes. 


Part 4: Knee replacement complications


Twenty-two complication risks associated with total knee replacement

Researchers writing in the journal Clinical Orthopaedics and Related Research say you may be at high risk for these 22 different risks associated with a total knee replacement. The 22 complications and adverse events include: (26)

1. Bleeding. This is post-operative bleeding requiring surgical treatment.
2. Wound complication. This is a failure of the wound to heal enough that reoperation may be required.
3. Thromboembolic disease or symptomatic thromboembolic event, a blood clot requiring more intensive, nonprophylactic anticoagulant or antithrombotic treatment. Doctors at Harvard Medical School released their study in October 2015 that showed the risk of heart attack was significantly higher during the first postoperative month in those who had knee replacement surgery and that venous thromboembolism was a significant risk during the first month and overtime for those having total knee or total hip arthroplasty as well. (27)
4. Neural deficit. Surgery causes or results in loss of function through nerve damage.
5. Vascular injury. Acute ischemia (loss of blood flow), thrombosis (swelling and heart attack/stroke risk caused by a blood clot), hemorrhage, fistula (the leakage of synovial fluid), and aneurysm formation.
6. Medial collateral ligament injury, (surgery caused knee instability by damaging ligaments)
7. Instability.
8. Malalignment.
9. Stiffness.
10. Deep periprosthetic joint infection.
11. Periprosthetic fracture.
12. Extensor mechanism disruption. “Knee extensor mechanism injuries are a group of morbidities that involve the quadriceps muscles, quadriceps tendon, patella, and patellar ligament.” (x)
13. Patellofemoral dislocation, (knee cap is not sitting properly)
14. Tibiofemoral dislocation.
15. Bearing surface wear.
16. Osteolysis (destruction of bone).
17. Implant loosening.
18. Implant fracture or tibial insert dissociation.
19. Reoperation.
20. Revision of one or more of the TKA implants (femur, tibia, tibial insert, patella).
21. Hospital Readmission.
22. Death.

Pes anserinus pain syndrome

A June 2020 paper in the journal International orthopaedics (x) looked to examine the incidence of pes anserinus pain syndrome after total knee replacement.

Looking at 389 primary total knee replacements performed for degenerative varus knee problems, the researchers found  5.6% (22/389 patients had pes anserinus pain syndrome). Higher risk factors were:

  • female
  • overweight / obese
  • and absence of pes anserinus release

The patients with pes anserinus pain syndrome were treated non-operatively; 81.8% responded to nonsteroidal anti-inflammatory drug-physical therapy program and 18.2% required an additional local steroid injection.

Did extended delays to knee replacement surgery cause you post-surgery problems?

Let’s briefly touch on the delays caused by the pandemic as many suggest delays in knee replacement may cause significant post-replacement pain. In our over three decades of proving alternatives to surgery and over 25 years of being an online presence, we have constantly updated our articles to provide our readers with the latest in research and clinical observations. In 2020 we added a new list of impacts including COVID-19 delay to surgery. Many people have had their ability to get a knee replacement greatly impacted. You may have been told to wait as elective surgeries were stopped, delayed, and backlogged. While waiting for your knee replacement day you may have been sent back to the very treatments and medications that were not helping you and in fact, may have accelerated your need for knee replacement.
Research from 2023 had shown (28) that in March 2020 there was a 31.28% reduction in the number of knee replacements being performed compared to 2019 and by April a 96.61% reduction in knee replacements being performed. By June 2020 elective surgery numbers reached similar numbers to 2019 but the backlogged and logjammed had started.

Here are some observations on patient reaction to this delay from Emory University School of Medicine researchers publishing in the HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery, November 2020 (29)

  • In this study, 111 patients who experienced COVID-19-driven delays to scheduled total hip or knee replacements were asked a series of questions regarding this delay in getting a surgery
    • 90% said that the surgical delay was in their best interest;
    • 68% reported emotional distress from the delay, but 45% reported a desire to wait longer for the pandemic to subside.
      • Lower joint-function scores,
      • higher pain levels,
      • higher pain catastrophizing scores,
      • and longer latency (delay) from personally deciding to pursue surgery were associated with the reported need for immediate surgery. (The longer the wait, the greater the patient felt a need to get the surgery as soon as they could.)

Conclusion: “Overall, patients reported that they understood the need for elective surgical delays during the COVID-19 pandemic. However, the psychological implications they reported were not negligible (should not be ignored). Patient preference for immediate re-engagement with the healthcare system was dichotomous (divided, wait for surgery, need surgery now), with many patients favoring precautionarily furthering the delay.

You probably do not need to be told what these researchers have confirmed:

  • Patients who are waiting months until their doctor can be available for the surgery suffer from severe and accelerated knee instability, difficulty walking, and pain. Perhaps like yourself, most of these patients rely on painkillers and cortisone to get them through their surgery. Perhaps like yourself, these people as they become more disabled, take excessive medication possibly including anti-depressants to help deal with the depression and isolation that comes with battling chronic knee pain.

However, this does not have to be the fate of all patients who were told they needed to wait to get a knee/joint replacement. In many cases, the ideal intervention is actually not surgery but regenerative options that can repair the joint non-surgically. Let’s talk about the problems now of post-knee replacement pain.

One more word on Covid-19

An April 2024 paper in The Journal of Arthroplasty (30) examined complications in postoperative COVID-19-positive total knee replacement patients. What the researchers found was that contracting COVID-19 within thirty days of total knee replacement put patients at an increased risk of 30-day mortality, superficial infection, pneumonia, unplanned intubation (breathing tube), ventilator use for more than 48 hours, pulmonary embolism, urinary tract infection, myocardial infarction, deep vein thrombosis, non-home discharge, reoperation, readmission, and longer length of hospital stay.

Is it the opioids causing pain after knee replacement?

A 2019 paper from Brigham and Women’s Hospital, Harvard Medical School, Boston (31) describes the problems of opioid use before knee replacement.

“Prescription opioid use is common among patients with moderate to severe knee osteoarthritis before undergoing total knee replacement. Preoperative opioid use may be associated with worse clinical and safety outcomes after total knee replacement.”

In this study, the researchers targeted preoperative opioid use among patients 65 years and older with mortality and other complications at 30 days post-total knee replacement.

Study learning points:

  • 316,593 patients (average age about 74 – 67.8% women) who underwent total knee replacement:
    • 22,895 (7.2%) were continuous opioid users before surgery.
    • 161,511 (51.0%) were intermittent opioid users before surgery.
    • 132,187 (41.7%) did not use opioids before surgery.
  • At 30 days post-total knee replacement:
    • 828 patients (0.26%) died,
    • 16,786 patients (5.30%) had hospital readmission, and
    • 921 patients (0.29%) had a revision operation.
  • All primary and secondary outcomes occurred more frequently among continuous opioid users compared with opioid-naive patients.
    • Compared with opioid-free patients the number of different prescription medications, and frailty, continuous opioid users had a greater risk of revision operations, vertebral fractures,  and opioid overdose at 30 days post-total knee replacement.

These results highlight the need for a better understanding of patient characteristics associated with chronic opioid use to optimize preoperative assessment of overall risk after total knee replacement.

In a December 2022 paper (32) published in the Archives of Orthopedic and Trauma Surgery, military researchers combined with Emory University and Duke University researchers to understand the factors contributing to continued opioid use after joint replacement. In looking at patients who underwent either a total hip replacement or total knee replacement surgery, the researchers found that previous to surgery the following factors were significantly associated with continued postoperative opioid use for up to 6 months.

  • 15% of participants reported taking opioid medication before surgery. While 68% reported opioid use at the 2-week follow-up after surgery, this number reduced to  7% by 6 months.
  • Increased pain after surgery.
  • Elevated preoperative Pain Catastrophizing Scale score.
  • Lower Physical Function scores.

Studies have demonstrated that poor management of acute pain after total knee replacement is strongly associated with the development of chronic pain.

In March 2017, researchers went further, writing in the medical journal Clinic in Orthopedic Surgery (33):

  • Study: “Postoperative pain is a major cause of dissatisfaction among patients after total knee replacement. Studies have demonstrated that poor management of acute pain after total knee replacement is strongly associated with the development of chronic pain, emphasizing the importance of appropriate control of acute pain after total knee replacement”
    • Our Comment:
      • The patient has a knee replacement
      • The patient suffers from acute pain after surgery
      • Painkillers and other medications are prescribed to control a patient’s pain. Acute pain turns into chronic pain as the joint continues to degenerate. Pain is an indication of tissue damage that needs repair.

After the surgery, the researchers found patients had to alter their recovery and post-surgery strategy to account for new health problems and problems with mobility

In the November 2017 edition of the journal Medical Care, (34a combined research team from the University of Illinois at Chicago, China Medical University Hospital, and National Taiwan University Hospital published their findings on what concerned patients before knee replacement and the type of pre-existing conditions these patients had.

Before the surgery concerns about successful surgery circled around these factors:

  1. Anxiety/depression
  2. The ability to take care of themselves immediately after the surgery.
  3. The ability to move and have mobility after the surgery.
  4. The ability  to be able to perform their own usual activities,
  5. The amount of pain and discomfort during recovery and post-op.

Research continued:

  1. The amount of pain and discomfort in recovery and post-op became the greatest impact of post-surgical patient non-satisfaction.
  2. Compared with preoperative health problems, postsurgical health problems were associated were a bigger problem than anticipated.
  3. Significant differences in thinking before surgery and surgical outcomes were observed including
    1. Greater problems than anticipated in:
      1. Mobility,
      2. Not being able to perform usual activities,
      3. anxiety/depression.

It is important to know that the purpose of this research was to assign a set of values to these patient problems in order to be able to come up with a formula that would better help the patient with their expectations before and after the surgery. The researchers had to conclude in the end that:

“Our systematic review highlights a lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement.”

In the end, there is no way currently to predict who will benefit and who will get worse from knee replacement surgery and patients should be counseled that there is no guarantee that knee replacement will work for them.

Did your knee get larger after knee replacement? “Patient-perceived enlargement of the knee.”

In the research above the term “overstuffing” or that your knee got bigger. A June 2022 paper was published in the journal International Orthopedics (35). The researchers of this paper acknowledged that doctors are seeing patients following a total knee replacement, with the complaint that their knee seems larger.  Yet, according to the researchers,  no studies have described this phenomenon.

To identify this problem, the researchers have a name and diagnosis: “patient-perceived enlargement of the knee.” In this study, the researchers reviewed unilateral primary total knee arthroplasty patients’ cases. The patients had their knees replaced between May 2018 and April 2019. A total of 389 patients were enrolled with 101 of the patients, more than one in four, describing that their knee felt larger after the surgery. The researchers did note that patients with patient-perceived enlargement of the knee were significantly shorter and carried a lower weight, however, the knee replacement hardware or component size distribution showed no statistical difference. Ultimately, patients with patient-perceived enlargement of the knee had significantly lower functional scores and satisfaction.

Knee replacement complications in former athletes

In a recent paper, doctors from NYU Langone Medical Center, Hospital for Joint Diseases (36) suggest that total knee arthroplasty (replacement) is often the best answer for end-stage, post-traumatic osteoarthritis after intra-articular (inside) and periarticular (around) osteoarthritic fractures the knee.

However, total knee replacement in the setting of post-traumatic osteoarthritis is often considered a more technically demanding surgery and the surgical outcomes are typically worse for these patients. The goal of the NYU paper was to create a new classification label for post-traumatic osteoarthritis patients, improve medical documentation, and improve patient care.

  • The researchers looked at post-traumatic osteoarthritis patients who suffered from osteoarthritis as a result of high demand or athletic activity.  These were on average younger and healthier than the primary total knee replacement population (older patients with degenerative arthritis from wear and tear).
  • The healthier post-traumatic total knee replacement group had the following complications:
    • higher rates of superficial surgical site infections,
    • bleeding requiring transfusion,
    • prolonged operative time,
    • increased length of hospital stay,
    • and 30-day hospital readmission.

In a similar study, (37) doctors at Duke University also recognized Total Knee Arthroplasty as an important treatment for post-traumatic arthritis. However, these researchers also found complications that should not be expected in a mostly healthy patient population.

This included:

  • a higher rate of infection around the knee implant
  • cellulitis (skin infection)
  • seroma (fluid build)
  • knee wound complications (problems at the surgical incisions)
  • need for revision surgery.

Peripheral nerve injury

An April 2024 paper in The Journal of Arthroplasty (38) led by doctors at the Mayo Clinic, the Keck School of Medicine of the University of Southern California, and the University of South Carolina School of Medicine, examined the risk factors for peripheral nerve injury following revision total knee replacement.

The authors note that peripheral nerve injury “is a potentially devastating injury for patients.” In this study of 132,000 revision total knee replacement patients, doctors found about 1 in 170 patients had post-surgery peripheral nerve injury. Most at risk were patients with previously diagnosed spine conditions and postoperative anemia.

Problem: Difficulty and Pain in Kneeling

Most people had difficulty kneeling because of pain or discomfort in the replaced knee. Many patients described how this limitation affected their daily lives, including housework, gardening, religious practices, leisure activities, and getting up after a fall. Patients often adapted to these limitations by finding alternatives to kneeling, assistance from others, or home adaptations. Many patients had accepted that they could not kneel, however, some still expressed frustration. Few patients had consulted with healthcare professionals about kneeling difficulties, and unmet needs included the provision of information about kneeling and post-operative physiotherapy. (39)

Please see our expanded article Who can and who can’t kneel after knee replacement

When knee replacement fails you need a team of specialists

Above we mentioned research that suggested if you need a revision knee replacement, find a specialist who specializes in revision knee replacement because it is a tricky operation. In August 2017, doctors at the University Hospital Leipzig in Germany opened their published research in the medical journal Patient Safety in Surgery (40with this statement:

  • In spite of the improvement of many aspects around Total knee arthroplasty (total knee replacement), there is still a group of 10% to 34% of patients who are not satisfied with the outcome.
  • The therapy of chronic pain after total knee replacement remains a medical challenge that requires an interdisciplinary therapy concept. (In other words, more doctors, more providers, more treatments).

What this paper deals with is an ever-growing population of people for whom knee replacement did not work and who need a team of specialists

In their paper the Leipzig researchers were looking at effective means to help the patient with pain after knee replacement, a brief summary of their findings is presented here:

“The treatment of patients with chronic complaints after total knee replacement is a challenging task. Therefore, adequate therapy is only possible due to an interdisciplinary team of experienced orthopedic surgeons with great knowledge in the field of endoprosthetics (knowledge of hardware failure and misfit), qualified physiotherapists (patients with problems after knee replacement often suffer from the various stages of depression) and pain therapists.” (The patients are in pain, sometimes more so than before the surgery.)

Multidisciplinary and individualized interventions

In the medical journal EFORT Open Reviews, (41) published by the British Editorial Society of Bone & Joint Surgery, doctors wrote in August 2018: “Treatment of chronic pain after total knee replacement is challenging, and evaluation of combined treatments and individually targeted treatments matched to patient characteristics is advocated. To ensure that optimal care is provided to patients, the clinical- and cost-effectiveness of multidisciplinary and individualized interventions should be evaluated.

Pain catastrophizing

A June 2022 study (42) from the University of Texas at Austin also explored pain catastrophizing problems, writing that “Pain catastrophizing is a maladaptive cognitive strategy that is associated with increased emotional responses and poor pain outcomes. Total knee replacement procedures are on the rise and 20% of those who have the procedure go on to have ongoing pain. Pain catastrophizing complicates this pain and management of this is important for recovery from surgery and prevention of chronic pain.”

An April 2022 study (43) published in the journal Frontiers in Psychiatry comes from German researchers. This study stresses the importance of not allowing post-surgical pain to become long-term chronic pain with an eye to treatments from psychiatry. “Reducing postoperative pain immediately after surgery is crucial because severe postoperative pain reduces the quality of life and increases the likelihood that patients develop chronic pain. Even though postoperative pain has been widely studied and there are national guidelines for pain management, the postoperative course is different from one patient to the next. . . Preoperative emotional states and treatment expectations are significant predictors of postoperative pain. The relationship between emotional states and postoperative pain is mediated by negative treatment expectations.”

Catastrophizing thoughts and central sensitization = catastrophic results and opioid dependence after knee replacement

Researchers in Canada writing in the Journal of Pain Research found pain catastrophizing reflects a patient’s anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain, and a sense of helplessness regarding pain. (44)

Catastrophizing thoughts are unrealistic beliefs that only the worst can happen. A person who goes into any medical treatment believing it will not work is at a significant disadvantage. A patient should relay these thoughts to his/her doctor so that appropriate action can be taken. For some patients, counseling will be effective, for some therapy, for some prayer. The patients must be made aware of options that will help them move from hopelessness to cautious optimism.

A significant problem with catastrophizing thoughts that needs to be addressed is a greater risk for opioid dependence.

Doctors in Belgium write in the Bone and Joint Journal that pre-operative pain in the knee predisposes to central sensitization (catastrophizing thoughts). Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitization called ‘opioid-induced hyperalgesia’ painkillers increase chronic pain. (45)

The problems of obesity

Let’s start with a March 2019 study (46) published in The Journal of Arthroplasty. Here doctors and researchers examined the existing medical controversies surrounding joint replacement in obese and morbidly obese patients and whether or not a bariatric surgery before a joint replacement would help. Over 38,000 patient case histories were reviewed. The researchers of this paper found medical comorbidities and complications were higher in the bariatric surgery group than in the control morbid obesity group before total joint replacement. 

There were short-term benefits to bariatric surgery. The researchers observed that bariatric surgery prior to total joint replacement was associated with reduced short-term medical complications, length of stay, and operative time. However, “bariatric surgery did not reduce the short-term risks for superficial wound infection or venous thromboembolism, and the long-term risks for dislocation, periprosthetic infection, periprosthetic fracture, and revision.”

A December 2023 study from the University of Missouri, published in The Journal of arthroplasty (81) assessed the pre-surgical characteristics and post-surgical outcomes of 229 patients who had Class II or III obesity) and compared outcomes with 287 patients who had normal weight, overweight, or Class I obesity. The researchers noted the more obese patients were younger and had more severe preoperative back and knee pain in the other knee as well. They also had more frequent preoperative opioid medication use. In comparison, the more obese patients were less likely to be highly satisfied and were more likely to be highly dissatisfied.

The problem of pre-replacement urinary incontinence

Doctors at Tulane University School of Medicine published a March 2024 study in the journal Arthroplasty Today (47) addressing urinary incontinence as an increased postoperative medical and joint complications following primary total hip replacement and total knee replacement. What they found was that “patients who underwent primary total hip replacement with incontinence had statistically higher rates of dislocation, periprosthetic fracture, aseptic revisions, and overall joint complications compared to controls. Patients who underwent primary total knee replacement with incontinence had higher rates of mechanical failure, aseptic revision, and all-cause revision compared to controls. . . As such, perioperative management of urinary incontinence may help mitigate the risk of postoperative complications.”

The more joints that hurt, the less successful the knee replacement.

In a study from Toronto Western Hospital and the University of Toronto (48), researchers were looking to determine whether symptomatic (painful/problematic) joints pre-total knee replacement surgery influenced the outcomes of knee replacements, and they did

  • Pre- and post-surgery, worse outcome scores were observed with an increasing joint count. (The more joints that hurt, the less successful the knee replacement is). Why?
  • Patients had worse pre-surgery fatigue and anxiety.
  • Patients had worse fatigue, depression, pain, and function in non-operated joints post-surgery.

Surgeons should consider a spine evaluation in patients who have severe back pain prior to total knee replacement.

A June 2023 study in The Journal of arthroplasty (82) looked at the connection between back pain prior to knee replacement and patient dissatisfaction with the knee replacement after knee surgery. In this study, 9,057 patients had a total knee replacement. A total of 4,765 patients (52.6%) reported back pain at the time of surgery. The severity of their back pain was  mild back pain in 2,264 patients (24.9%), moderate back pain in 1,844 patients (20.3%), and severe back pain in 657 patients (7.2%).

  • At one year, 1657 of the 9,057 total knee replacement patients were dissatisfied, reflecting 18.3% of the patients.
  • Severe back pain was significantly associated with patient dissatisfaction at 1 year after total knee replacement. Patients who had severe back pain were 1.6 times more likely to be dissatisfied with their knee surgery.
  • The authors recommended surgeons consider a spine evaluation in patients who have severe back pain prior to total knee replacement.

Problem: Post-surgical stress following knee replacement.

Post-surgical stress: the demands of recovery and possible out-of-pocket expenses cause a great deal of stress in patients. In research published in the Journal of Psychosomatic Research that followed total knee replacement patients who reported pain and other difficulties, doctors found that “A significant percentage (20%) of patients undergoing total knee replacement reported noteworthy levels of postsurgical stress1 and 3 months following surgery.”

Further, this distress was associated with a more difficult recovery following (the knee replacement), characterized by more severe pain and greater functional limitations. There was a significant impact of psychological processes on postoperative recovery. (49)


Part 5: Research: Many studies search for answers to “Mystery Pain” after Knee Replacement


Surgeons say one in four patients with pain after knee replacement had no clear reason for their pain. It wasn’t the hardware, it wasn’t anything obvious that they could see.

In the research above (7), surgeons have a road map of where to look for pain after knee replacement. Returning to the findings released in the British Pain Journal, the doctors suggest looking for pain in other places that are usually not explored:

  • Our main findings are that some patients have severe pain that interferes significantly with their lives and that a large number of them have pain sensitization problems (heightened sense of pain), many of which can be classified as neuropathic pain (nerve damage or pain), rather than any local, nociceptive cause (pain caused by the surgical procedure).
    • A heightened sense of pain following knee replacement will be discussed throughout this article.
  • However, it was not possible to categorize all patients as having either a local cause for their pain (the site of the surgery and surrounding affected tissues) or a pain sensitization problem, as many had complex unclassifiable causes for the pain, including psychosocial problems.

What is the research saying?

  • Only a small percentage of patients at 2 years post-knee replacement have neuropathic (neuropathy) pain. It is
  • Excluded patients who had clear mechanical or other orthopedic problems, the doctors STILL found that 25% of the remainder had neuropathic-like pain, and many more had pain sensitization, contributing to the pain problem. It looked like neuropathy but it wasn’t neuropathy.
  • This is important, first, as many orthopedic surgeons are not familiar with how to detect these patients, and second, because there are simple therapies available to treat them.
  • Surgeons dealing with patients with significant and persistent knee pain following knee replacement should assess levels of neuropathic pain, pain at other sites, and depression.

In November 2018 a study was published in the Journal of Knee Surgery. (50) The doctors also were looking at nerve pain after surgery.

  • The study had 154 patients with 222 knee replacements (66 patients had both knees replaced)
  • The goal of the study was to define the prevalence of pain persisting after total knee replacement and determine the impact of neuropathic pain.
  • The ratio of patients with”
    • moderate-to-severe pain was 28% (62 knees).
    • Thirteen patients (21 knees; 9%) experienced unclear pain.
    • A significant number of patients experienced moderate-to-severe and unclear pain after total knee replacement.

It looked like neuropathy but it wasn’t neuropathy.

It looked like neuropathy but it wasn’t neuropathy. Mystery pain, unclear pain, difficult to treat pain after knee replacement. Post-knee replacement health problems are a bigger problem than anticipated.

One of the problems we see in patients who are having problems post-knee replacement surgery is the thinking that knee replacement works for everyone, how come it didn’t work for them?

When these patients are presented with research compiled from patient outcomes, they are somewhat surprised to see that they are not so unique after all, many patients have reported problems with expectations and complications of their knee replacement(s).

Knee replacement is considered one of the great innovations in musculoskeletal care. It is said to be the only known cure for knee osteoarthritis. Orthopedist surgeons routinely tell patients of the great success of the procedure. Yet, it was not until doctors started to perform outcome questionnaire studies that the medical community started to realize what patients had already known – knee surgery was not as successful as the surgeons thought.

Problem: Neuropathic knee pain after surgery – nerve damage caused by the surgery.

Above we discussed neuropathy, nerve damage, as occurring in a small portion of knee replacement patients. A study from doctors in the United Kingdom published in the Bone and Joint Journal (51) suggests that while a small percentage of patients suffer from neuropathic pain caused by knee replacement, it is still an underestimated problem in patients with pain after total knee replacement.


Part 6: The spouse and support groups. Helping depression and anxiety

husband helping wife walk after knee replacement

A May 2024 paper published in The Journal of arthroplasty (80)  investigated if patient-reported anxiety or depression increased the risk of dissatisfaction one year after total knee replacement in patients who improved in pain or function.  There were 8,745 patients who participated in this research, 11% were defined as dissatisfied. The proportion of patients who reported anxiety or depression was 35% preoperatively and 17% postoperatively. The researchers of this study found anxiety or depression did in fact increase the risk of dissatisfaction preoperatively and postoperatively. The researchers concluded: “Patient-reported anxiety or depression preoperatively and postoperatively are important and potentially treatable factors to consider, as they were found to increase the risk of dissatisfaction after total knee replacement despite improvements in pain or function.”

When the medical system is non-supportive, patients reach out to support groups.

In December 2016, research from the University of Bristol in the United Kingdom (52) examined the need for post-knee replacement support from the medical community and what happens when that support is not there. Here is what they wrote:

“Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type, and level of support people receive from others, and can also change the assistance that they themselves are able to offer.” In this study, the authors followed ten patients post-knee replacement. What they found was when medical support was lacking, patients reached out to support groups to “fill the gap.”

A main consequence of lack of support was: “Missing or ill-timed support from health professionals can have negative psychosocial consequences for patients going through joint replacement.”

In November 2019, a paper from the University of Bristol (53) continued this line of research by suggesting: “There is evidence that social support is a prognostic factor for some outcomes after joint replacement. Development and evaluation of complex interventions to improve social support and social integration are warranted.” In other words, support groups and other outreach programs would benefit the knee replacement patient.

In September 2022, a digital online program for supporting post-knee replacement patients showed “promising levels of engagement and acceptability among those who recently underwent total knee arthroplasty. The surgical care program may also help with improving postsurgical complications and clinical outcomes and lowering health care use.”

In this study of the post-Covid telemedicine age, the researchers, writing in the Journal of Medical Internet Research (54) wrote of  22 post-surgery patients who participated in a digital support program provided by medical professionals,  intervention group members reported fewer postoperative complications (27%) than the comparison group (48%), and they experienced better outcomes with regard to function, anxiety, less health care use, better adherence to their physical therapy exercises, and higher surgery satisfaction.

The pressure to help the knee replacement patient recover fails mainly on the spouse and this may be a job that the spouse will need a lot of help doing.

One of the main reasons we hear from patients as to why they did not get knee replacement surgery was that they themselves had to care for a spouse or aged parents. The pressure to help the knee replacement patient recover fails mainly on the spouse and this may be a job that the spouse will need a lot of help doing. Here is the research from a team of leading Swedish and Finnish researchers in the International Journal of Orthopaedic and Trauma Nursing: (55)

“(The spouse is) considered to be the primary caregivers. . . the spouses’ emotional state played an important role in the patients’ quality of recovery, with uncertainty and the depressive state as the main predictors (of not meeting the patient’s or spouse’s expectations of a successful knee replacement).

A June 2020 paper from doctors at the Dartmouth-Hitchcock Medical Center published in The Journal of Arthroplasty (56) suggested spouses and significant others not only suffered from the same mental (anxiety, mood, etc) as their spouse who had the joint replacement but also suffered from some of the physical burdens of disease and recovery.

To help the spouse or significant others cope with the knee replacement loved one, many studies and doctors have offered post-surgical guidelines to help with the post-operative care of the patient.

Generally, many people have successful knee surgeries. The problem is when complications and setbacks occur.


Part 7: Surgery for post-knee replacement pain


Knee replacement post surgery pain golf

Research: Surgeons warn surgeons that knee pain after knee replacement does not automatically mean REVISION KNEE SURGERY

One of the reasons that people are in our office with continued pain after knee replacement is that they are being told that eventually, or sooner, rather than later if the pain persists, they will have to have revision surgery to clean out tissue that may be causing pain, and to examine the components of the artificial knee.

A recent study from orthopedic surgeons in Italy was published in the Current Reviews in Musculoskeletal Medicine. (67) Simply stated the surgeons warned:

“Pain (after knee replacement) can be related to a lot of different clinical findings, and the surgeon has to be aware of the various etiologies that can lead to failure. Pain does not always mean revision, and the patient has to be fully evaluated to have a correct diagnosis; if surgery is performed for the wrong reason, this will surely lead to a failure.”

“Patients may need subsequent surgeries to maximize the benefits of joint replacement”

“Many patients with hip and knee arthritis have the condition in more than one of their hip or knee joints,” said the study’s lead author Dr. Gillian Hawker. “So it’s not surprising that replacing a single joint doesn’t alleviate all their pain and disability — patients may need subsequent surgeries to maximize the benefits of joint replacement.”

The study, published in the journal Arthritis & Rheumatism (68), followed a group of patients with osteoarthritis and inflammatory arthritis. Only half reported a meaningful improvement in their overall hip and knee pain and disability one to two years after surgery. What’s more, researchers found that patients who had worse knee or hip pain to begin with but fewer general health problems and no arthritis outside of the replaced joint were more likely to report benefits.

According to the study authors, nearly 83 percent of study participants had at least two troublesome hips and or knees.

  • In general, an estimated 25 percent of patients who undergo a single joint replacement will have another joint replacement — usually the other hip or knee — within two years.

“While demand for joint replacement surgery has increased as our population ages, physicians lack a set of established criteria to help determine what patients will benefit from surgery and at what point during the course of the disease,” said Dr. Hawker, physician-in-chief at Women’s College Hospital and a senior scientist at ICES. “As physicians, we need to do a better job of targeting treatments to the right patient at the right time by the right provider.”

German researchers (69) published a March 2024 study in which they assessed the functional outcome as well as the time to return to daily activities, work, and sports after the revision of unilateral knee replacement to a total knee replacement. The researchers found the functional results of revised unilateral knee replacement were significantly worse than those of primary unilateral knee replacement based on a 3-year follow-up. Return to work, sports, and activities of daily living tended to take longer after revision than after primary implantation of either a unilateral knee replacement or a total knee replacement

Total knee replacement in the middle-aged patient population

The main finding of this September 2023 paper in the journal Cartilage (70) is that total knee replacement in the middle-aged patient population up to 65 years old increased significantly over time, and that these patients present a double risk of failure with respect to older patients. total knee replacement is increasingly performed not only in elderly patients with end-stage osteoarthritis but also in younger and more active adults. While citing previously published research suggesting an overall 82% knee implant survival at 25 years, the authors note that: “This result may be satisfactory for older patients undergoing total knee replacement for end-stage osteoarthritis, making them unlikely to face revision surgery during their lifetime.” However, there is a lack of perspective on how likely are they going to risk a revision in their lifetime. In essence with a 60-year-old having knee replacement risk another surgery at 80?

The authors do note that “an increased risk of failure in patients younger than 50 years undergoing total knee replacement is already known. In reviewing the data, the authors created three groups of patients.

    • Patients under 50 years old.
      • The estimated survival rate of the knee replacement implant was about 79% at 15 years. A younger patient is more likely to wear out the knee replacement sooner. This would indicate knee replacement hardware replacement at age 65 for about 20% of patients.
    • Patients 50-65 years old.
      • The estimated survival rate of the knee replacement implant was about 89% at 15 years. This would indicate knee replacement hardware replacement for patients approaching age 80 for over 10% of patients.
    • Patients 66-79 years old.
      • The estimated survival rate of the knee replacement implant was 94.8% at 15 years.

A revision surgery with a high risk of failure

In 2017, doctors writing in the journal Clinics in Orthopedic Surgery (71) wrote: “Early diagnosis is very important for the treatment of intractable pain following total knee replacement. A reoperation conducted without identification of a specific reason carries a high risk of failure.”

    • Comment:
      • The patient has a knee replacement.
      • The patient suffers from acute pain after surgery.
      • Painkillers and other medications are prescribed to control a patient’s pain. Acute pain turns into chronic pain.
      • Doctors cannot control pain.
      • With nowhere else to go, doctors suggest another knee replacement.
      • Second knee replacement operation with a high rate of failure. (hard to control)

Problem: Fixing Pain After Total Knee Replacement may include Amputation

A 2016 paper in The Journal of Bone and Joint Surgery. American volume. (72) writes three in 1000 patients will need to have their leg amputated following knee replacement.

The causes of the amputation were:

  • infection around the implant (83%),
  • soft-tissue deficiency surrounding the implant (23%),
  • severe bone loss (18%),
  • extensor mechanism disruption, i.e., patellar and quadriceps tendon disruption (10%),
  • intractable pain (10%),
  • fracture around the implant (9%),
  • circulatory damage  (8%).

In 80% of the cases, there were more than 2 of these factors for amputation.

In research from April 2017, doctors writing in the European Journal of Orthopaedic Surgery and Traumatology (73) wrote:

Treatment for prosthetic knee replacement is becoming more common. Infection is an arthroplasty-related complication leading to prolonged hospitalization, multiple surgical procedures, permanent loss of the implant, impaired function, impaired quality of life, and even amputation of the limb.

This study aimed to identify risk factors for amputation in the periprosthetic infected knee through a case-control study, analyzing patients treated from January 2012 to November 2016 in a hospital with a high incidence of this diagnosis. We included 183 patients with periprosthetic knee infection; 23 required amputation as definitive management (cases).

They found that patients with:

  • Increased surgical time >120 min,
  • smokers,
  • obesity and
  • diabetes mellitus had an increased risk of amputation.

Will your bones even allow for a revision knee replacement?

An August 2019 study in the Journal of Orthopaedic Surgery and Research (74) offered this warning to surgeons concerning the problems of identifying whether a patient’s bones were strong and dense enough to withstand another knee replacement procedure.

“Revision total knee arthroplasty (replacement) is a demanding procedure, with a high complication and failure rate and a high rate of bone losses and poor bone quality. Different classifications for bone losses have been proposed, but they do not consider bone quality, which may affect implant fixation.

Look at the study findings:

  • Fifty-one patients (53 knees – 2 patients had both knees replaced) were included (about 3 out of 5 patients were women, an average age of 71.5 years).
  • The most frequent cause of failure was:
    • aseptic loosening of the implant (41.5%).
    • 18.9% of the cases demonstrated poor bone quality.

What the researchers of this study were seeking to point out is that if revision knee replacement is required, a plan to address and repair the possibility of bone loss, bone weakening, and a loss of bone density should be undertaken. This would significantly increase the success of the replacement.

The problems of osteoporosis

Led by researchers at the Department of Orthopaedic Surgery, The Johns Hopkins University, doctors publishing in The Journal of Arthroplasty (75) looked at the risk of revision surgery in patients who have osteoporosis after total knee replacement. A problem the paper writes is “understudied.” The goal of this research was to compare the 5-year cumulative risk of revision surgery after total knee replacement in patients who have preoperative osteoporosis.

This April 2024 study reviewed the medical data of 41,760 knee replacement patients who had osteoporosis. The 5-year incidence of revision surgery was examined for all causes, periprosthetic fracture, aseptic loosening, and periprosthetic joint infection.

Results: The 5-year rate of all-cause revision surgery was higher for patients who had osteoporosis, however, the highest risk of revision surgery was seen for periprosthetic fracture. Patients who had osteoporosis also had an elevated risk of revision surgery for periprosthetic joint infection and aseptic loosening. Osteoporosis was independently associated with periprosthetic joint infection and aseptic loosening at a higher rate in obese patients. . . Future studies should determine the extent to which treatment of osteoporosis modifies these postoperative outcomes.”

Complications of a second knee replacement in obese patients

A February 2022 study of 605,603 revision total knee arthroplasty surgeries was published in the Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews (76) examined the postoperative outcomes of obesity and morbid obesity patients after the revision of total knee arthroplasty. The researchers here found obese and morbidly obese patients were at significantly higher risk for complications than non-obese patients. “Morbidly obese patients had a significantly longer length of stay than both obese and not obese patients, while no significant difference in length of stay was observed between obese and not obese patients.”


Part 8: Non-surgical treatment of post-knee replacement pain


Why physical therapy failed post-knee replacement

Physical therapy after failed knee replacement.

A February 2022 paper in the Journal of Evaluation in Clinical Practice (67) comes to us from the Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado.

In this survey of patients and physical therapists describing the patient experience and expectation of physical therapy following a total knee replacement, the therapists found that in many cases patients were not given a true indication of the amount of therapy that would be required post-knee surgery and that further, many patients were given little or no information of how to proceed in the post-recovery period from their surgical team, specifically as their treatment related to physical therapy. Many patients in fact were not part of the “shared decision-making” processes.

The information that emerged in this survey was:

  • A lack of a standardized approach for involving patients in their rehabilitation decisions. This could impact patient motivation as the study notes patient decision-making could be “a key component of rehabilitation success and a key ingredient in promoting patient engagement.” In other words, talk with your physical therapists or any health care provider about your goals of treatment.

Subtheme: generic recovery benchmarks

  • The physical therapists noted that using generic benchmarks for guiding future treatments may not lead to successful PT. The treatments should be more customized to the patient’s lifestyle. For example, the physical therapist should determine the home setting in guiding treatment. Does the patient have to go up and down stairs to do laundry or other daily chores? How does the patient navigate around their homes and work environment?
  • The main problem discussed was the dependence on the importance of regaining range of motion (ROM), especially knee flexion, to a predetermined threshold as the primary indicator of recovery. Many patients also mentioned their rehabilitation focused heavily on restoring ROM to meet expectations set by their surgeons and physical therapists. But to some patients, this did not meet their own functioning goals.

Everything was not “good as new.” The problem of unrealistic expectations of recovery by the patient

  • The physical therapists of this survey reported that many patients were not prepared for the physical demands and length of the physical therapy required to complete the rehabilitation. Further, the surgical team did not discuss this aspect of post-recovery with the patients.

Trying to help people who should have not had the knee replacement in the first place.

  • The physical therapists of this survey reported that some patients whom they were trying to help, should not have had, in their opinion, the knee replacement due to their health condition or physical limitations, as this sets the patient up for treatment failure and post-surgical complication.

The overall view was that for post-knee replacement physical therapy to succeed, patients should be offered:

  • Pre-surgery counseling on the post-knee replacement recovery process.
  • Deep involvement in how their recovery should proceed with the performance of real-life chores and activities is the main focus as opposed to basic guidelines for simply being able to bend their knee.

Can physical therapy help post-total knee replacement pain?

Research led by the Boston University School of Medicine published in October 2021 in the journal  JAMA Network Open (68) examined the problem of patients who become long-term opioid users after undergoing a total knee replacement. The goal of this research was to see if physical therapy could help prevent opioid use. To do this the medical records of over 38 thousand people who did not use opioids and almost 29 thousand patients who did use opioids after knee replacement were assessed looking for those patients who had physical therapy either before knee replacement or after knee replacement or both or neither.

The researchers found that patients receiving physical therapy before and after total knee replacement, had six or more sessions of physical therapy care after total knee replacement, and initiation of physical therapy care within 30 days after total knee replacement was associated with lower odds of long-term opioid use. These findings suggest that physical therapy may help reduce the risk of long-term opioid use after total knee replacement.

Radiofrequency ablation of genicular nerves

A November 2021 study from the University of New Mexico School of Medicine published in the medical journal Cureus (69) wrote:

“Painful total knee replacement without an obvious underlying identifiable pathology is not uncommon. Dissatisfaction after total knee replacement can be up to 20%. Different treatment modalities, including non-operative and operative procedures, have been described in (medical studies).

Radiofrequency ablation of genicular nerves is emerging as a newer treatment modality for painful total knee replacement without an obvious underlying identifiable pathology (diagnosis). Despite a modest number of publications demonstrating the usefulness of Radiofrequency ablation of genicular nerves in managing pain in knee osteoarthritis, the efficacy of Radiofrequency ablation of genicular nerves has not been completely established in the management of residual pain after total knee replacement.”

Here is a situation where people will have pain after knee replacement and the reason for their knee pain cannot be found. One answer for these people is to burn out their nerves. For some this can be successful for others as noted above, it may not be successful because the radiofrequency ablation did not find the underlying cause of the patient’s pain.

Neuromuscular electrical stimulation

Some doctors suggest that Neuromuscular electrical stimulation (NMES) is an effective method for quadriceps strengthening which could prevent muscle loss in the early total knee arthroplasty (replacement) postoperative recovery period.

A January 2022 paper in The Journal of Knee Surgery (70) considered this question and evaluated the postoperative use of Neuromuscular electrical stimulation (NMES) on knee replacement patients and the results of increased quadriceps strength and ultimately improved functional outcomes.

  • In this study were 66 patients, 44 patients had Neuromuscular electrical stimulation (NMES) and 22 control patients.
  • Patients who used the device for an average of 200 minutes/week or more (starting 1 week postoperative and continuing through week 12) were considered compliant.
  • Patients in the treatment arm (NMES use) experienced quadriceps strength gains over baseline at 3, 6, and 12 weeks following surgery, which were statistically significant compared with controls with quadriceps strength losses at 3  and 6 weeks.
  • The use of a home-based application-controlled NMES therapy system added to standard of care treatment showed statistically significant improvements in quadriceps strength and functional timed up and go following total knee arthroplasty, supporting a quicker return to function.

Part 9: Is the problem of post-surgical chronic knee pain weakness and stretching of the surviving knee ligaments?


In this video, Ross Hauser, MD explains the problems of post-knee replacement joint instability and how Prolotherapy injections can repair damaged and weakened ligaments that will tighten the knee. This treatment does not address the problems of hardware malalignment that our patient Jeannette described in the video above. 

Summary of this video:

The patient in this video came into our office for low back pain. I did a “straight leg raise test,” on this patient to help determine if his back pain was coming from a herniated disc.

  • During the test, I noticed a clicking sound coming from his knee. The patient had a knee replacement.

It is very common for us to see patients after knee replacement who have these clicking sounds coming from knee instability. This is not instability from hardware failure. The hardware may be perfectly placed in the knee. It is instability from the outer knee where the surviving ligaments are. I believe that this is why up to one-third of patients continue to have pain after knee replacement.

Dr. Hauser performs an ultrasound scan of the patient’s knee. Small, gentle stress on the knee reveals hypermobility. This is from the ligaments’ inability to hold the whole knee joint in place. Prolotherapy can be very successful in helping patients who had a knee replacement and still have knee pain. The treatment tightens the whole joint capsule.

In the image below:

The caption reads, Models of knee replacement illustrating knee stability with intact ligaments with “loose” ligaments. In the first panel (A) Anterior view of intact ligaments. In the center (B) panel, lateral view of intact ligaments. In the right (C) panel Anterior view with loose ligament. Pain after a joint replacement is almost always from laxity in surrounding ligaments. Prolotherapy ligament-strengthening injections relieve the pain and improve stability.

How can we help these problems? The often overlooked and ignored cause of pain after knee replacement is the Knee Ligaments.

When a knee replacement is performed, the joint itself has to be stretched out so the surgeons can cut out bone and put it in the prosthesis. When the joint is stretched out, the knee ligaments and tendons that survive the operation will cause pain as they heal from the surgical damage. Sometimes the ligaments and tendons heal well. Sometimes they do not heal as well.

Is it knee tendonitis?

In many patients we see, we find that the pain is coming from the outside of the knee. When the knee is replaced, the knee cartilage is now replaced with hard plastic, so lack of or loss of cartilage is not causing the pain. What can be causing the pain are the remaining tendons and ligaments that surround the outer portions of the knee. These tendons and ligaments have become weakened, they are loose and they are allowing for a wobbly knee situation. When the knee is wobbly, it is not moving correctly, it creates an unnatural and painful pull on these ligaments and tendons and this causes pain and instability. The strain on the knee tendons can cause chronic tendinopathy.

One person’s story, the email was edited for clarity.

I had a total knee replacement on my left knee. Before the actual surgery, I was having pain on the outer side and behind my knee which I had told the doctor about. He then went ahead and did the total knee replacement. After coming home after the surgery I went to put my shoe on and there was an extremely painful “pop” on the outside lateral area of my knee. It was painful instant swelling all the way down to my foot.  I told him about it and nothing was done.  My knee pops extremely loud, I have a lot of pain and no one knows why. Previously  I had surgery on my Achilles tendon and the long (patellar tendon).

Post-surgical pain and knee instability may be from the surviving ligaments

The idea that knee ligament damage from knee replacement is one of the “mystery” pains following knee replacement has been the subject of a wave of recent studies.

A  study in the journal Orthopedics (71from Rush University Medical Center researchers identified the problems of knee instability as a cause of pain in knee replacement patients. Here is a summary of their findings:

  • Instability is one of the most common causes of failure of total knee replacement.
  • Acute instability is related to intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament in extension or the posterolateral corner in flexion. The posterolateral corner includes
    • lateral collateral ligament,
    • popliteus tendon, and
    • popliteofibular ligament.
  • Chronic instability in extension is often related to varus/valgus malalignment. (Knee hardware problem)
  • Chronic instability in flexion can be related to an undersized femoral component, excessive tibial slope, or excessive elevation of the joint line affecting the isometry of the collateral ligaments in mid-flexion. (Knee hardware and anatomy problems caused by surgical mistake).

Ligament instability was the primary reason for repair surgery

Doctors writing in the German medical journal, Der Orthopäde (72) said:

  • “In 32.6 % of all cases [requiring a revision knee replacement surgery], ligament instability was the primary reason for revision.
  • In another 21.6%, ligament instability was identified as a secondary reason for revision.
  • Analysis of the different instability forms showed combined instability in extension and flexion as the most common cause, followed by isolated instability in flexion (31.8%) and isolated instability in extension (9.1%).

The summary statement of this research is extraordinary in its simplicity

“Correct anatomical positioning of the components and balanced ligaments in the different extension and flexion positions are important for good clinical results, a stable joint, good function, and longevity.”

In other words, put the ligaments back where you found them.

The kneecap was floating because the MCL was released. Patellar maltracking after total knee replacement. The concern of “catastrophic laxity.”

Let’s look at two studies surrounding the medial collateral ligament.

The first is from 2015, the second is from 2021

In June 2015 in the journal Knee Surgery, Sports Traumatology, Arthroscopy (73) researchers wrote: “Medial collateral ligament (MCL) release is one of the essential steps toward the achievement of ligament balancing during the total knee arthroplasty (TKA) in patients with varus deformity (knee replacement caused bow-leg). When the varus deformity is severe, complete release of the MCL until balanced is often required. However, it is believed that a complete MCL release may lead to catastrophic laxity. ”

In March 2021, a study published in the journal Knee Surgery and Related Research (74) continued that Medial collateral ligament release during knee replacement could lead to the surviving knee cap floating around the knee. Here are the study’s observations: “Patellar maltracking after total knee arthroplasty (TKA) can lead to significant patellofemoral complications such as anterior knee pain, increased component wear, and a higher risk of component loosening patellar fracture, and instability. . . A complete release of the MCL during surgery was associated with patellar maltracking. Surgeons should attend to patellar tracking during surgery in medially tight knees.”

Previous ligament reconstruction surgery – higher risk for complications after knee replacement.

Doctors at the Mayo Clinic have published findings in Clinical Orthopaedics and Related Research which they suggest that patients who had previous multi-ligament reconstruction surgery were at high risk for:

  • knee replacement complications,
  • constrained knee replacement designs (less movement),
  • and a higher risk of major complications, including reoperation and infection. (75)

The ligament problem is a clue that for some patients, post-knee replacement pain may be a problem of overdoing it, even while in the hospital or nursing home.

In a study from October 2018, doctors writing in the Journal of Pain Research, (76) looking at why some people had excessive pain after knee replacement surgery asked if this was a problem of  “overdoing it” in the hospital following the surgery. The research measured the results of making patients progressively walk more steps in the hospital or nursing home up to 10 days after the surgery.

These are surgeons and pain management specialists from leading hospitals and universities in Japan talking about patients soon after knee replacement during surgery recovery.

  • Poor pacing (too many steps, too much too soon) during physical activity is associated with severe pain in postoperative patients
  • Over-activity results in a number of potential injuries to muscle fibers, nerves, bones, and ligaments. These injuries, as well as the repetitive experience of pain, will prolong pain and contribute to neurobiological mechanisms of peripheral and central sensitization.
    • Comment: Here again is the problem of the pain being worse than it should be. In the typical rehab after surgery, patients are told to walk in increasing amounts in the days following the surgery. Here the doctors discuss this new activity on a knee that likely had not seen much activity leading up to the surgery. This new activity trains the nerves to be more sensitive to pain.

Prolotherapy and Platelet Rich Plasma Therapy for post-knee replacement pain

We are going to briefly address two treatment options that we offer here at Caring Medical. We will explore these treatments more deeply below. These are non-surgical, injections. They are not cortisone, they are not gel shots.

Prolotherapy is an injection technique utilizing simple sugar or dextrose which causes a small controlled inflammation at weakened tissue. This triggers the immune system to initiate the repair of the injured tendons and ligaments. Blood supply dramatically increases in the injured area. The body is alerted that healing needs to take place and reparative cells are sent to the treated area of the knee that needs healing. The body also lays down new collagen in the treated areas, thereby strengthening the weakened structures. Once the tendons and ligaments are strengthened, the joint stabilizes and the tendonitis or tendinosis condition resolves.

Platelet Rich Plasma Therapy is the use of a patient’s blood platelets and healing factors to stimulate the repair of a tendon it is considered when tendon damage is more severe. We will be discussing these treatments further below and try to provide a realistic outlook as to if these treatments may benefit you.

The patient problems after knee replacement surgery are many. At Caring Medical, we can address many of these problems. We cannot address all, especially when the problem of knee replacement is caused by hardware failure and hardware placement failure.

  • PROBLEM: The knee replacement hardware is wearing out and loosening or it was not placed in the knee correctly and stress is causing the device problems. This problem will need surgical consultation and possibly revision surgery.
  • PROBLEM: Infection. This is during the initial recovery period. On prosthetic devices, bacteria can form and colonize. This problem will need a consultation with the surgical group and possibly emergency medicine.
  • PROBLEM: The implant or the surgery caused fractures in the thigh or shin bone. This problem will need a consultation with the surgical group and possibly emergency medicine.

PROBLEM: Knee prosthesis instability and loss of range of motion (it gets stuck), can also lead to considerable pain.

A realistic assessment of what we can do to help with your pain after knee replacement.

In our clinic, we try to provide information on helping people explore other treatment options before joint replacement. One of those options is simple dextrose Prolotherapy. This regenerative injection technique helps rebuild damaged ligaments and tendons.

When the patients have already had a joint replacement, we will do a physical examination of the knee to assess how we may be able to help.

  • Prolotherapy fixes soft tissue, but it cannot fix hardware failure,
  • Prolotherapy works by stabilizing the knee by strengthening the natural muscle and bone attachments, ligaments, and tendons.

References

1 Howells N, Murray J, Wylde V, Dieppe P, Blom A. Persistent pain after knee replacement: do factors associated with pain vary with the degree of patient dissatisfaction? Osteoarthritis Cartilage. 2016 Aug 9. [Google Scholar]
2 Salimy MS, Paschalidis A, Dunahoe JA, Chen AF, Alpaugh K, Bedair HS, Melnic CM. Patients Consistently Report Worse Outcomes Following Revision Total Knee Arthroplasty Compared to Primary Total Knee Arthroplasty. The Journal of Arthroplasty. 2024 Feb 1;39(2):459-65. [Google Scholar]
3 Mathis DT, Hirschmann MT. Trotz Knietotalprothese schmerzt das Knie – was nun? [Painful knee after total knee arthroplasty – what can be done?]. Ther Umsch. 2020;77(10):491-497. German. [Google Scholar]
4 Manning BT, Lewis N, Tzeng TH, Saleh JK, Potty AG, Dennis DA, Mihalko WM, Goodman SB, Saleh KJ. Diagnosis and Management of Extra-articular Causes of Pain After Total Knee Arthroplasty. Instructional course lectures. 2015;64:381-8. [Google Scholar]
5 Gursu S, Sofu H, Verdonk P, Sahin V. Effects of total knee arthroplasty on ankle alignment in patients with varus gonarthrosis: do we sacrifice ankle to the knee?. Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Aug;24:2470-5. [Google Scholar]
6 Olsen U, Lindberg MF, Denison EM, Rose CJ, Gay CL, Aamodt A, Brox JI, Skare Ø, Furnes O, Lee KA, Lerdal A. Predictors of chronic pain and level of physical function in total knee arthroplasty: a protocol for a systematic review and meta-analysis. BMJ open. 2020 Sep 1;10(9):e037674. [Google Scholar]
7 Beswick AD, Wylde V, Gooberman-Hill R. Interventions for the prediction and management of chronic postsurgical pain after total knee replacement: a systematic review of randomized controlled trials. BMJ open. 2015 May 1;5(5):e007387. [Google Scholar]
8 Escobar A, García Pérez L, Herrera‐Espiñeira C, Aizpuru F, Sarasqueta C, Gonzalez Sáenz de Tejada M, Quintana JM, Bilbao A. Total knee replacement: Are there any baseline factors that have influence in patient-reported outcomes?. Journal of Evaluation in Clinical Practice. 2017 May 26. [Google Scholar]
9 Graff C, Hohmann E, Bryant AL, Tetsworth K. Subjective and objective outcome measures after total knee replacement: is there a correlation?. ANZ Journal of Surgery. 2016 Nov;86(11):921-5. [Google Scholar]
10 Taylor CE, Murray CM, Stanton TR. Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies. Pain reports. 2022 May;7(3). [Google Scholar]
11 Broberg JS, Naudie DD, Lanting BA, Howard JL, Vasarhelyi EM, Teeter MG. Patient and Implant Performance of Satisfied and Dissatisfied Total Knee Arthroplasty Patients. The Journal of Arthroplasty. 2022 Jun 1;37(6):S98-104. [Google Scholar]
12 Moore A, Eccleston C, Gooberman‐Hill R. “It’s Not My Knee”: Understanding Ongoing Pain and Discomfort After Total Knee Replacement Through Re‐Embodiment. Arthritis care & research. 2022 Jun;74(6):975-81. [Google Scholar]
13 Gallo J, Kriegová E, Radvansky M, Sloviak M, Kudelka M. Odds-ratio network for postoperative factors revealing differences in the 2-year longitudinal pattern of satisfaction between women and men after total knee arthroplasty. Scientific Reports. 2022 Oct 19;12(1):17470. [Google Scholar]
14 Cole S, Kolovos S, Soni A, Delmestri A, Sanchez-Santos MT, Judge A, Arden NK, Beswick AD, Wylde V, Gooberman-Hill R, Pinedo-Villanueva R. Progression of chronic pain and associated health-related quality of life and healthcare resource use over 5 years after total knee replacement: evidence from a cohort study. BMJ open. 2022 Apr 1;12(4):e058044. [Google Scholar]
15 Li CY, Ng Cheong Chung KJ, Ali OM, Chung ND, Li CH. Literature review of the causes of pain following total knee replacement surgery: prosthesis, inflammation and arthrofibrosis. EFORT Open Reviews. 2020 Sep;5(9):534-43. [Google Scholar]
16 Suhlreyer J, Klinger R. The Influence of Preoperative Mood and Treatment Expectations on Early Postsurgical Acute Pain After a Total Knee Replacement. Frontiers in Psychiatry. 2022;13. [Google Scholar]
17 Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7. [Google Scholar]
18 Felix J, Becker C, Vogl M, Buschner P, Plötz W, Leidl R. Patient characteristics and valuation changes impact quality of life and satisfaction in total knee arthroplasty – results from a German prospective cohort study. Health Qual Life Outcomes. 2019 Dec 9;17(1):180. doi: 10.1186/s12955-019-1237-3. PMID: 31815627; PMCID: PMC6902559. [Google Scholar]
19 Rodriguez-Merchan EC. Patient satisfaction following primary total knee arthroplasty: contributing factors. Archives of Bone and Joint Surgery. 2021 Jul;9(4):379. [Google Scholar]
20 Olsen U, Sellevold VB, Gay CL, Aamodt A, Lerdal A, Hagen M, Dihle A, Lindberg MF. Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study. BMC Musculoskeletal Disorders. 2024 Jan 2;25(1):22. [Google Scholar]
21 Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of total knee replacement. New England Journal of Medicine. 2015 Oct 22;373(17):1597-606. [Google Scholar]
22 Parachutes and Preferences — A Trial of Knee Replacement. Jeffrey N. Katz, M.D. N Engl J Med 2015; 373:1668-1669 October 22, 2015 [Google Scholar]
23 Connelly JW, Galea VP, Rojanasopondist P, Nielsen CS, Bragdon CR, Kappel A, Huddleston III JI, Malchau H, Troelsen A. Which preoperative factors are associated with not attaining acceptable levels of pain and function after TKA? Findings from an international multicenter study. Clinical Orthopaedics and Related Research. 2020 May;478(5):1019.  [Google Scholar]
24 Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11. [Google Scholar]
25 Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11. [Google Scholar]
26 Healy WL, Della Valle CJ, Iorio R, et al. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society. Clinical Orthopaedics and Related Research. 2013;471(1):215-220. [Google Scholar]
27 Lu N, Misra D, Neogi T, Choi HK, Zhang Y. Total Joint Arthroplasty and the Risk of Myocardial Infarction: A General Population, Propensity Score-Matched Cohort Study. Arthritis Rheumatol. 2015 Oct;67(10):2771-9. doi: 10.1002/art.39246.2. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society.  [Google Scholar]
28 Cole MW, Collins LK, Williams GH, Lee OC, Sherman WF. Keeping the Lights On: The Impact of the COVID-19 Pandemic on Elective Total Joint Arthroplasty Utilization in the United States. Arthroplasty today.:101065. [Google Scholar]
29 Wilson JM, Schwartz AM, Grissom HE, Holmes JS, Farley KX, Bradbury TL, Guild GN. Patient Perceptions of COVID-19-Related Surgical Delay: An Analysis of Patients Awaiting Total Hip and Knee Arthroplasty. HSS Journal®. 2020 Nov;16(1):45-51. [Google Scholar]
30 Wenzel AN, Marrache M, Schmerler J, Kinney J, Khanuja HS, Hegde V. Impact of Postoperative COVID-19 Infection Status on Outcomes in Elective Primary Total Joint Arthroplasty. The Journal of Arthroplasty. 2024 Apr 1;39(4):871-7. [Google Scholar]
31 Kim SC, Jin Y, Lee YC, Lii J, Franklin PD, Solomon DH, Franklin JM, Katz JN, Desai RJ. Association of preoperative opioid use with mortality and short-term safety outcomes after total knee replacement. JAMA network open. 2019 Jul 3;2(7):e198061-. [Google Scholar]
32 Giordano NA, Highland KB, Nghiem V, Scott-Richardson M, Kent M. Predictors of continued opioid use 6 months after total joint arthroplasty: a multi-site study. Archives of Orthopaedic and Trauma Surgery. 2022 Dec;142(12):4033-9. [Google Scholar].
33 Lim H-A, Song E-K, Seon J-K, Park K-S, Shin Y-J, Yang H-Y. Causes of Aseptic Persistent Pain after Total Knee Arthroplasty. Clinics in Orthopedic Surgery. 2017;9(1):50-56. [Google Scholar].
34 Pickard AS, Hung YT, Lin FJ, Lee TA. Patient Experience-based Value Sets: Are They Stable? Med Care. 2017 Nov;55(11):979-984. [Google Scholar]
35 Zheng H, Shao H, Tang Q, Guo S, Yang D, Zhou Y. Patient-perceived knee enlargement after total knee arthroplasty: prevalence, risk factors, and association with functional outcomes and radiological analysis. International Orthopaedics. 2022 Mar 29:1-8. [Google Scholar]
36  Kester BS, Minhas SV, Vigdorchik JM, Schwarzkopf R. Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification? J Arthroplasty. 2016 Aug;31(8):1649-1653.e1. [Google Scholar]
37 Bala A, Penrose CT, Seyler TM, Mather RC 3rd, Wellman SS, Bolognesi MP. Outcomes after Total Knee Arthroplasty for post-traumatic arthritis. Knee. 2015 Dec;22(6):630-9. doi: 10.1016/j.knee.2015.10.004. Epub 2015 Oct 31. [Google Scholar]
38 Chen XT, Korber SS, Gettleman BS, Liu KC, Palmer R, Shahrestani S, Heckmann ND, Christ AB. Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients. The Journal of Arthroplasty. 2024 Apr 1;39(4):1031-5. [Google Scholar]
39 Fletcher D, Moore AJ, Blom AW, Wylde V. An exploratory study of the long-term impact of difficulty kneeling after total knee replacement. Disability and rehabilitation. 2017 Dec 4:1-6. Bristol Medical School, University of Bristol [Google Scholar]
40 Zajonz D, Fakler JK, Dahse AJ, Zhao FJ, Edel M, Josten C, Roth A. Evaluation of a multimodal pain therapy concept for chronic pain after total knee arthroplasty: a pilot study in 21 patients. Patient Safety in Surgery. 2017 Aug 30;11(1):2 [Google Scholar]
41 Wylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. Chronic pain after total knee arthroplasty. EFORT open reviews. 2018 Aug;3(8):461-70.  [Google Scholar]
42 Patel RM, Anderson BL, Bartholomew JB. Interventions to Manage Pain Catastrophizing Following Total Knee Replacement: A Systematic Review. Journal of Pain Research. 2022;15:1679. [Google Scholar]
43 Stuhlreyer J, Klinger R. The Influence of Preoperative Mood and Treatment Expectations on Early Postsurgical Acute Pain After a Total Knee Replacement. Frontiers in Psychiatry. 2022;13. [Google Scholar]
44 Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer ZE, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. Journal of pain research. 2015;8:21. [Google Scholar]
45 Lavand’homme P, Thienpont E. Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain. Bone Joint J. 2015 Oct;97-B(10 Suppl A):45-8. [Google Scholar]
46 Li S, Luo X, Sun H, Wang K, Zhang K, Sun X. Does prior bariatric surgery improve outcomes following total joint arthroplasty in the morbidly obese? A meta-analysis. The Journal of arthroplasty. 2019 Mar 1;34(3):577-85. [Google Scholar]
47 Budin JS, Waters TL, Collins LK, Cole MW, Winter JE, Delvadia BP, Iloanya MC, Sherman WF. Incontinence Is an Independent Risk Factor for Total Hip and Knee Arthroplasty. Arthroplasty Today. 2024 Jun 1;27:101355. [Google Scholar]
48 Perruccio A, Power J, Evans H, Mahomed S, Gandhi R, Mahomed N, Davis A. Multiple joint involvement in total knee replacement for osteoarthritis – effects on patient-reported outcomes.Arthritis Care Res (Hoboken). 2012 May 8. doi: 10.1002/acr.21629.  [Google Scholar]
49 Cremeans-Smith JK, Greene K, Delahanty DL. Symptoms of postsurgical distress following total knee replacement and their relationship to recovery outcomes. Journal of psychosomatic research. 2011 Jul 1;71(1):55-7.  [Google Scholar]
50 Hasegawa M, Tone S, Naito Y, Wakabayashi H, Sudo A. Prevalence of Persistent Pain after Total Knee Arthroplasty and the Impact of Neuropathic Pain. The journal of knee surgery. 2018 Nov 9. [Google Scholar]
51 Phillips JR, Hopwood B, Arthur C, Stroud R, Toms AD. The natural history of pain and neuropathic pain after knee replacement. Bone Joint J. 2014 Sep 1;96(9):1227-33. [Google Scholar]
52 Johnson EC, Horwood J, Gooberman-Hill R. Trajectories of need: understanding patients’ use of support during the journey through knee replacement. Disability and rehabilitation. 2016 Dec 17;38(26):2550-63. [Google Scholar]
53 Wylde V, Kunutsor SK, Lenguerrand E, Jackson J, Blom AW, Beswick AD. Association of social support with patient-reported outcomes after joint replacement: a systematic review and meta-analysis. The Lancet Rheumatology. 2019 Nov 1;1(3):e174-86. [Google Scholar]
54 Hong M, Loeb J, Yang M, Bailey JF. Postoperative Outcomes of a Digital Rehabilitation Program After Total Knee Arthroplasty: Retrospective, Observational Feasibility Study. JMIR formative research. 2022 Sep 19;6(9):e40703. [Google Scholar]
55 Stark ÅJ, Salanterä S, Sigurdardottir AK, Valkeapää K, Bachrach-Lindström M. Spouse-related factors associated with quality of recovery of patients after hip or knee replacement–a Nordic perspective. International Journal of Orthopaedic and Trauma Nursing. 2016 Nov 1;23:32-46. [Google Scholar]
56 Kunkel ST, Sabatino MJ, Torchia MT, Jevsevar DS, Moschetti WE. Does the impact of joint arthroplasty extend beyond the patient? The effect of total joint arthroplasty on patient’s significant others. The Journal of Arthroplasty. 2020 Jun 1;35(6):S129-32. [Google Scholar]
57 Cottino U, Rosso F, Pastrone A, Dettoni F, Rossi R, Bruzzone M. Painful knee arthroplasty: current practice. Current reviews in musculoskeletal medicine. 2015 Dec 1;8(4):398-406. [Google Scholar]
58 Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JE. Which patients are most likely to benefit from total joint arthroplasty?. Arthritis & Rheumatism. 2013 May;65(5):1243-52. [Google Scholar]
59 Scheele CB, Pietschmann MF, Wagner TC, Müller PE. Functional outcomes and return to sports, work, and daily activities after revision UKA compared to primary UKA and TKA. Orthopadie (Heidelberg, Germany). 2024 Feb 13;53(3):201-8. [Google Scholar]
60 Perdisa F, Bordini B, Salerno M, Traina F, Zaffagnini S, Filardo G. Total knee arthroplasty (TKA): when do the risks of TKA overcome the benefits? Double risk of failure in patients up to 65 years old. Cartilage. 2023 Sep;14(3):305-11. [Google Scholar]
61 Lim HA, Song EK, Seon JK, Park KS, Shin YJ, Yang HY. Causes of aseptic persistent pain after total knee arthroplasty. Clinics in orthopedic surgery. 2017 Mar 1;9(1):50-6. [Google Scholar]
62 Gottfriedsen TB1, Schrøder HM, Odgaard A. Transfemoral Amputation After Failure of Knee Arthroplasty: A Nationwide Register-Based Study. J Bone Joint Surg Am. 2016 Dec 7;98(23):1962-1969. [Google Scholar]
63 Polanco-Armenta AG, Miguel-Pérez A, Rivera-Villa AH, Barrera-García MI, Sánchez-Prado MG, Vázquez-Noya A, Vidal-Cervantes F, de Jesús Guerra-Jasso J, Pérez-Atanasio JM. Risk factors for amputation in periprosthetic knee infection. European Journal of Orthopaedic Surgery & Traumatology. 2017 Apr 7:1-5. [Google Scholar]
64 Rosso F, Cottino U, Dettoni F, Bruzzone M, Bonasia DE, Rossi R. Revision total knee arthroplasty (TKA): mid-term outcomes and bone loss/quality evaluation and treatment. Journal of orthopedic surgery and research. 2019 Dec 1;14(1):280. [Google Scholar]
65 Harris AB, Lantieri MA, Agarwal AR, Golladay GJ, Thakkar SC. Osteoporosis and Total Knee Arthroplasty: Higher 5-Year Implant-Related Complications. The Journal of arthroplasty. 2023 Oct 30. [Google Scholar]
66 Hussein IH, Zalikha AK, Tuluca A, Crespi Z, El-Othmani MM. Epidemiology of Obese Patients Undergoing Revision Total Knee Arthroplasty: Understanding Demographics, Comorbidities, and Propensity Weighted Analysis of Inpatient Outcomes. JAAOS Global Research & Reviews. 2022 Feb;6(2). [Google Scholar]
67 Graber J, Lockhart S, Matlock DD, Stevens‐Lapsley J, Kittelson AJ. “This is not negotiable. You need to do this…”: A directed content analysis of decision making in rehabilitation after knee arthroplasty. Journal of Evaluation in Clinical Practice. 2022 Feb;28(1):99-107. [Google Scholar]
68 Aoyagi K, Neogi T, Peloquin C, Dubreuil M, Marinko L, Camarinos J, Felson DT, Kumar D. Association of Physical Therapy Interventions With Long-term Opioid Use After Total Knee Replacement. JAMA network open. 2021 Oct 1;4(10):e2131271-. [Google Scholar]
69 Cheppalli N, Bhandarkar AW, Sambandham S, Oloyede SF. Safety and Efficacy of Genicular Nerve Radiofrequency Ablation for Management of Painful Total Knee Replacement: A Systematic Review. Cureus. 2021 Nov 11;13(11). [Google Scholar]
70 Klika AK, Yakubek G, Piuzzi N, Calabrese G, Barsoum WK, Higuera CA. Neuromuscular electrical stimulation use after total knee arthroplasty improves early return to function: a randomized trial. The Journal of Knee Surgery. 2022 Jan;35(01):104-11. [Google Scholar]
71 Del Gaizo DJ, Della Valle CJ.Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46. [Google Scholar]
72 Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. Ligament instability in total knee arthroplasty–causal analysis. Der Orthopade. 2007 Jul;36(7):650-2.  [Google Scholar]
73 Cho WS, Byun SE, Lee SJ, Yoon J. Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2015 Jun 1;23(6):1816-23. [Google Scholar]
74 Noh JH, Kim NY, Song KI. Intraoperative patellar maltracking and postoperative radiographic patellar malalignment were more frequent in cases of complete medial collateral ligament release in cruciate-retaining total knee arthroplasty. Knee Surgery & Related Research. 2021 Dec;33(1):1-8. [Google Scholar]
75 Pancio SI, Sousa PL, Krych AJ, Abdel MP, Levy BA, Dahm DL, Stuart MJ. Increased Risk of Revision, Reoperation, and Implant Constraint in TKA After Multiligament Knee Surgery. Clin Orthop Relat Res. 2017 Jun;475(6):1618-1626. [Google Scholar]
76 Hayashi K, Kako M, Suzuki K, Takagi Y, Terai C, Yasuda S, Kadono I, Seki T, Hiraiwa H, Ushida T, Nishida Y. Impact of variation in physical activity after total joint replacement. Journal of pain research. 2018;11:2399. [Google Scholar]
77 Algarni AD. Pes anserinus pain syndrome following total knee arthroplasty for degenerative varus: incidence and predictors. International Orthopaedics. 2020 Jun;44:1083-9.  [Google Scholar]
78 Strahl A, Delsmann MM, Simon A, Ries C, Rolvien T, Beil FT. A clinical risk score enables early prediction of dissatisfaction 1 year after total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. [Google Scholar] *
79 Arpey NC, Tanenbaum JE, Selph TJ, Suleiman LI, Franklin PD, Patel AA, Edelstein AI. Quantifying Patient Expectations for Total Knee Arthroplasty: Expectations for Improvement are Greater than MCID. The Journal of Arthroplasty. 2024 May 14. [Google Scholar] *
80 Heijbel S, Annette W, Josefine E, 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. The Journal of Arthroplasty. 2024 May 1. [Google Scholar] *
81 Rizzo EA, Phillips RD, Brown JT, Leary EV, Keeney JA. Obesity severity predicts patient dissatisfaction after total knee arthroplasty. The Journal of Arthroplasty. 2023 Dec 1;38(12):2492-6. [Google Scholar] *
82 Ayers DC, Zheng H, Yang W, Yousef M. How back pain affects patient satisfaction after primary total knee arthroplasty. The Journal of Arthroplasty. 2023 Jun 1;38(6):S103-8. [Google Scholar]

This article was updated March 31, 2024

 

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