Finding help for post knee replacement pain

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.

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 need to do physical therapy, I needed people at home to help me, I was going to be very dependent. Lucky 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.”

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 (12) 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 backwards.

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 backwards.

An April 2022 paper (13) 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 replacements patients experience more pain post-operatively than pre-operatively.

A September 2020 study from Newcastle University in the United Kingdom (14) 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 replacements 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.

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, (15) 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, (16) 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 (17) which suggested “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.

Part 3: Many knee replacements should not have been done

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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. (18)

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.”

Further as discussed below, patients are being made to wait until they are old enough for knee replacement.

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. (19) 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 being 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. (20) 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. (21) 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.” (22)

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 shows 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 is also a complication of knee replacement surgery and is 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: (23)

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. (24)
4. Neural deficit. Surgery causing or resulting 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.

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 nearly three decades of proving alternatives to surgery and our nearly 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 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 has shown (25) 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 (26)

• 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 to get 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 until 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 need 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.

Is it the opioids causing pain after knee replacement?

A 2019 paper from Brigham and Women’s Hospital, Harvard Medical School, Boston (27) 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 (28) 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 (29):

• 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, (30) a 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 (31). 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 it 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.

In a recent paper, doctors from NYU Langone Medical Center, Hospital for Joint Diseases (32) 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 and 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, (33) 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.

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. (34)

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

References

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