Finding help for post knee replacement pain

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 knee pain following knee replacement 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 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.

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:

In patients who were dissatisfied on a lesser level:

Below we will explore research on why patients were disappointed with their successful knee surgery and how their expectations may have not been realistic as to what a knee replacement was really able to do for them.

Article outline:

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

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

Part 3: Many knee replacements should not have been done

Part 4: Knee replacement complications

Part 5: Mystery or neurologic pain

Part 6: The spouse and support groups

Part 7: Surgery for post-knee replacement pain

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

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

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:

Painful knee after total knee arthroplasty – what can be done? First, find a diagnosis

Diagnosis of what is causing knee pain after a knee replacement is hard to find. The first thing to 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 in fixing a bad knee replacement. One who understands the factors in why the knee replacement failed. (3)

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

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:

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:

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.

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

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. (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, (30a 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.

Knee replacement complications in former athletes

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

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 (35with this statement:

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 endoprosthetic (knowledge of hardware failure and misfit), qualified physiotherapists (patients with problems after knee replacement often suffer from the various stage 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, (36) 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 (37) 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 (38) 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. (39)

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. (40)

The problems of obesity

Let’s start with a March 2019 study (41) 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.”

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

In a study from Toronto Western Hospital and the University of Toronto (42), researchers were looking to determine whether symptomatic (painful/problematic) joints pre-total knee replacement surgery influenced the outcomes of knee replacements, and they did

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. (43)

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 reasoning 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. (44) 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 (45) 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

husband helping wife walk after knee replacement

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 (46) 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 (47) 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 tele-medicine age, the researchers, writing in the Journal of medical Internet research (48) 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: (49)

“(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 (50) 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. (51) 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 (52), 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.”

A revision surgery with a high risk of failure

In 2017, doctors writing in the journal Clinics in orthopedic surgery (53) 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. (54) 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 (55) 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 (56) 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.

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 (57) 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 (58) 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.

The benchmarks were too generic and not customized

Subtheme: generic recovery benchmarks

  • The physical therapists noted that using generic benchmarks for guiding future treatments may not lead to successful PT. That 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 who 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 (59) 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 was 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, and 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 (60) 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 for 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 (61) 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.
  • 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.

Acupuncture for post-knee replacement pain

An April 2022 study published in the journal BioMed research international found “beneficial effects” of acupuncture in helping patients with knee osteoarthritis. (62) The researchers concluded their paper by saying: “Acupuncture has a beneficial effect on pain relief and improves function activities, and this treatment can be recommended as a beneficial alternative therapy in patients with knee osteoarthritis, particularly for chronic patients and those currently undergoing long-term pain and help them increase the quality of life. But it should be further verified through more random control studies in function. Available studies suggested that acupuncture was superior to sham acupuncture in reducing pain and 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 – 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 the 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 (63from 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 (64) 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 (65) 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 (66) 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. (67)

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, (68) 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.



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This article was updated February 21, 2023


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