Skip to main content
SpringerLink
Log in

36 Management of Patients with Painful Total Knee Replacement: A Multimodal Approach

  • Chapter
The Unhappy Total Knee Replacement

  • 2754 Accesses

Abstract

The etiology of persistent “unhappy” knee after a total knee replacement (TKR) is multifactorial, and a multidisciplinary approach is necessary for management. Adequate pain control during the index surgery is of paramount importance and forms the basis of chronic pain management. Newer techniques like preemptive and multimodal analgesia should be used to decrease the perioperative pain sensitization to minimize the incidence of chronic pain. Success of management of chronic pain lies in the accuracy of the diagnosis after an extensive evaluation. The key is pursuing a multidisciplinary approach for each individual case, including the surgeon, physiotherapists, pain management physicians, internist, rheumatologists, psychologist, and any consultant specialist on referral basis. A pain specialist should be involved early in the management of these patients specifically for the prevention of a chronic pain syndrome. Most patients with a chronic painful TKR can be managed by a multimodal conservative approach. Revision surgery should be avoided in patients with unexplained pain and without any recognized pathology since they may improve over a period of time and results of revision surgery are inferior and unpredictable. An “unhappy” TKR is a difficult problem to treat, but understanding these principles can turn this “unhappiness” into a successful outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Brown 3rd EC, Clarke HD, Scuderi GR. The painful total knee arthroplasty: diagnosis and management. Orthopedics. 2006;29(2):129–36.

    PubMed  Google Scholar 

  2. Hofmann S, Seitlinger G, Djahani O, Pietsch M. The painful knee after total knee arthroplasty: a diagnostic algorithm for failure analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19:1442–52.

    Article  CAS  PubMed  Google Scholar 

  3. Seil R, Pape D. Causes of failure and etiology of painful primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011;19:1418–32.

    Article  PubMed  Google Scholar 

  4. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press; 1994.

    Google Scholar 

  5. Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg. 2002;10(2):117–29.

    PubMed  Google Scholar 

  6. Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. Clin Orthop Relat Res. 2005;441:250–5.

    Article  PubMed  Google Scholar 

  7. Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000;284:428–9.

    Article  CAS  PubMed  Google Scholar 

  8. Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty: a prospective, randomized, blinded study. J Bone Joint Surg Am. 2007;89(6):1153–60.

    Article  PubMed  Google Scholar 

  9. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med. 2010;83(1):11–25.

    PubMed Central  CAS  PubMed  Google Scholar 

  10. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–15.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central hypersensitivity in chronic pain: mechanisms and clinical implications. Phys Med Rehabil Clin N Am. 2006;17(2):287–302.

    Article  PubMed  Google Scholar 

  12. Ji R, Kohno T, Moore K, Woolf C. Central sensitization and LTP: do pain and memory share similar mechanisms? Trends Neurosci. 2003;26(12):696–705.

    Article  CAS  PubMed  Google Scholar 

  13. Woolf C, Salter M. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765–9.

    Article  CAS  PubMed  Google Scholar 

  14. DeLeo JA. Basic science of pain. J Bone Joint Surg Am. 2006;88 Suppl 2:58–62.

    Article  PubMed  Google Scholar 

  15. Kissin I. Preemptive analgesia. Anesthesiology. 2000;93(4):1138–43.

    Article  CAS  PubMed  Google Scholar 

  16. Maheshwari AV, Blum YC, Sherkhart L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467(6):1418–23.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Reuben SS, Buvenandran A, Katz B, Kroin JS. A prospective randomized trial on the role of perioperative celecoxib administration for total knee arthroplasty: improving clinical outcomes. Anesth Analg. 2008;106(4):1258–64.

    Article  CAS  PubMed  Google Scholar 

  18. Lunn TH, Kristensen BB, Andersen L, Husted H, Otte KS, Gaarn-Larsen L, Kehlet H. Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth. 2011;106(2):230–8.

    Article  CAS  PubMed  Google Scholar 

  19. Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113(5):1144–62.

    Article  PubMed  Google Scholar 

  20. Williams-Russo P, Sharrock NE, Haas SB, Insall J, Windsor RE, Laskin RS, Ranawat CS, Go G, Ganz SB. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res. 1996;331:199–208.

    Article  PubMed  Google Scholar 

  21. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22(6 Suppl 2):33–8.

    Article  PubMed  Google Scholar 

  22. Brander VA, Stulberg SD, Adams AD, Harden RN, Bruehl S, Stanos SP, Houle T. Predicting total knee replacement pain: a prospective, observational study. Clin Orthop Relat Res. 2003;416:27–36.

    Article  PubMed  Google Scholar 

  23. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;(3):CD003071.

    Google Scholar 

  24. Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg. 1998;87(1):93–7.

    CAS  PubMed  Google Scholar 

  25. Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R, Criswell A. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 2001;16(4):436–45.

    Article  CAS  PubMed  Google Scholar 

  26. Sinha SK, Abrams JH, Arumugam S, D’Alessio J, Freitas DG, Barnett JT, Weller RS. Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study. Anesth Analg. 2012;115(1):202–6.

    Article  CAS  PubMed  Google Scholar 

  27. Lieberman JR, Huo MM, Hanway J, Salvati EA, Sculco TP, Sharrock NE. The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia. J Bone Joint Surg Am. 1994;76(3):341–8.

    CAS  PubMed  Google Scholar 

  28. Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. 2011;7(1):9–15.

    Article  PubMed Central  PubMed  Google Scholar 

  29. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg. 2002;94(3):577–85.

    Article  PubMed  Google Scholar 

  30. Liu SS, Bae JJ, Bieltz M, Ma Y, Memtsoudis S. Association of perioperative use of nonsteroidal anti-inflammatory drugs with postoperative myocardial infarction after total joint replacement. Reg Anesth Pain Med. 2012;37(1):45–50.

    Article  PubMed  Google Scholar 

  31. Joshi GP. Multimodal analgesia techniques for ambulatory surgery. Int Anesthesiol Clin. 2005;43(3):197–204.

    Article  PubMed  Google Scholar 

  32. Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg. 2010;110(1):199–207.

    Article  CAS  PubMed  Google Scholar 

  33. Clarke H, Pereira S, Kennedy D, Gilron I, Katz J, Gollish J, Kay J. Gabapentin decreases morphine consumption and improves functional recovery following total knee arthroplasty. Pain Res Manag. 2009;14(3):217–22.

    PubMed Central  PubMed  Google Scholar 

  34. Jacobs MA, Hungerford DS, Krackow KA, Lennox DW. Revision total knee arthroplasty for aseptic failure. Clin Orthop Relat Res. 1988;226:78–85.

    PubMed  Google Scholar 

  35. Mont MA, Serna FK, Krackow KA, Hungerford DS. Exploration of radiographically normal total knee replacements for unexplained pain. Clin Orthop Relat Res. 1996;331:216–20.

    Article  PubMed  Google Scholar 

  36. Elson DW, Brenkel IJ. A conservative approach is feasible in unexplained pain after knee replacement: a selected cohort study. J Bone Joint Surg Br. 2007;89(8):1042–5.

    Article  CAS  PubMed  Google Scholar 

  37. Singh JA, Mahowald ML, Noorbaloochi S.Intraarticular botulinum toxin A for refractory painful total knee arthroplasty: a randomized controlled trial. J Rheumatol. 2010;37(11):2377–86.

    Article  PubMed Central  PubMed  Google Scholar 

  38. O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(10 Suppl):S22–32.

    Article  PubMed  Google Scholar 

  39. Zorn KE, Fudin J. Treatment of neuropathic pain: the role of unique opioid agents. Pract Pain Manag. 2011;11(4):26–33.

    Google Scholar 

  40. Dellon AL, Mont MA, Mullick T, Hungerford DS. Partial denervation for persistent neuroma pain around the knee. Clin Orthop Relat Res. 1996;329:216–22.

    Article  PubMed  Google Scholar 

  41. Nahabedian MY, Johnson CA. Operative management of neuromatous knee pain: patient selection and outcome. Ann Plast Surg. 2001;46(1):15–22.

    Article  CAS  PubMed  Google Scholar 

  42. Dowd GS, Hussein R, Khanduja V, Ordman AJ. Complex regional pain syndrome with special emphasis on the knee. J Bone Joint Surg Br. 2007;89(3):285–90.

    Article  CAS  PubMed  Google Scholar 

  43. Harden RN, Bruehl S, Stanos S, Brander V, Chung OY, Saltz S, Adams A, Stulberg SD. Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study. Pain. 2003;106(3):393–400.

    Article  PubMed  Google Scholar 

  44. Janig W, Baron R. Experimental approach to CRPS. Pain. 2004;108(1–2):3–7.

    Article  CAS  PubMed  Google Scholar 

  45. McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome. Rheumatology. 2003;42(1):97–101.

    Article  CAS  PubMed  Google Scholar 

  46. Burns AW, Parker DA, Coolican MR, Rajartnam K. Complex regional pain syndrome complicating total knee arthroplasty. J Orthop Surg (Hong Kong). 2006;14(3):280–3.

    CAS  Google Scholar 

  47. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999;80(3):539–44.

    Article  CAS  PubMed  Google Scholar 

  48. Schutzer SF, Gossling HR. The treatment of reflex sympathetic dystrophy syndrome. J Bone Joint Surg Am. 1984;66(4):625–9.

    CAS  PubMed  Google Scholar 

  49. Chan CS, Chow SP. Electroacupuncture in the treatment of post-traumatic sympathetic dystrophy (Sudeck’s atrophy). Br J Anaesth. 1981;53(8):899–902.

    Article  CAS  PubMed  Google Scholar 

  50. Lindenfeld TN, Bach BR, Wojtys EM. Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. J Bone Joint Surg Am. 1996;78:1936–44.

    Google Scholar 

  51. Hogan CJ, Hurwitz SR. Treatment of complex regional pain syndrome of the lower extremity. J Am Acad Orthop Surg. 2002;10(4):281–9.

    PubMed  Google Scholar 

  52. Cooper DE, DeLee JC, Ramamurthy S. Reflex sympathetic dystrophy of the knee: treatment using continuous epidural anesthesia. J Bone Joint Surg Am. 1989;71(3):365–9.

    CAS  PubMed  Google Scholar 

  53. Katz MM, Hungerford DS, Krackow KA, Lennox DW. Reflex sympathetic dystrophy as a cause of poor results after total knee arthroplasty. J Arthroplasty. 1986;1(2):117–24.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedics and Rehabilitation, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, 30, Brooklyn, NY, 11203, USA

    Rami Joseph Elkhechen MD, Vijay J. Rasquinha MD & Aditya V. Maheshwari MD

  2. Department of Anesthesiology, Hospital for Special Surgery, New York, NY, 10021, USA

    Stephen C. Haskins MD

  3. Regional Anesthesiology Department, Kings County Hospital, Clarkson Avenue 451, Brooklyn, NY, 11213, USA

    Benjamin George MD

Authors
  1. Rami Joseph Elkhechen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stephen C. Haskins MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vijay J. Rasquinha MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Benjamin George MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Aditya V. Maheshwari MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rami Joseph Elkhechen MD .

Editor information

Editors and Affiliations

  1. Dept. Orthopaedic Surgery & Traumatology, Knee Surgery Unit, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland

    Michael T. Hirschmann

  2. Dept. Orthopaedics & Traumatology, Hospital Brandenburg, Brandenburg/Havel, Germany

    Roland Becker

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Elkhechen, R.J., Haskins, S.C., Rasquinha, V.J., George, B., Maheshwari, A.V. (2015). 36 Management of Patients with Painful Total Knee Replacement: A Multimodal Approach. In: Hirschmann, M., Becker, R. (eds) The Unhappy Total Knee Replacement. Springer, Cham. https://doi.org/10.1007/978-3-319-08099-4_43

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-08099-4_43

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-08098-7

  • Online ISBN: 978-3-319-08099-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation