Pain after knee replacement


A June 2022 study (1) Up to 20% of people who undergo total knee replacement surgery have ongoing pain and discomfort. The aim of this study was to understand what role the concepts of embodiment (of both having a body and experiencing the world through one’s body) and incorporation (integrating something into one’s body) might have in understanding experiences of pain and discomfort after total knee replacement.

  • Two main themes were identified: 1) when describing chronic postsurgical pain, some participants also described sensations of discomfort, including heaviness, numbness, pressure, and tightness associated with the prosthesis; 2) participants reported a lack of felt connection with and agency over their replaced knee, often describing it as alien or other, and lacked confidence in the knee.

Conclusion: Participants’ experiences indicate that some people do not achieve full incorporation of the prosthesis. . . Our findings suggest that to optimize postoperative outcomes, rehabilitation must focus not only on strengthening the joint and promoting full recovery to tasks but on modifying a person’s relationship to the new joint and managing sensations of otherness to achieve full incorporation of the joint or re-embodiment.

An April 2022 study (2) “Reducing postoperative pain immediately after surgery is crucial because severe postoperative pain reduces 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 differently from one patient to the next. Different postoperative courses could be explained by factors related to the treatment context and the patients. 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. Therefore, innovative treatment strategies to reduce postoperative pain should focus on eliminating negative treatment expectation through establishing a differentiated preoperative expectation management program that also focuses on emotional states.”

A May 2022 paper (9) examined previously published research on patient reported outcomes following less than hoped for knee replacement success. What the researchers found were recurring themes among patients. These themes stressed that the recovery following knee replacement was not as easy as the patents thought it would be. Many patients were on painkillers and this gave them concerns including the “perceived stigma.” In the need to take them. The fact that many patients described the recovery as a “need to endure” and that their concerns were dismissed and practical support was missing from their doctors.

Anterior femoral notching and fractures after total knee replacement.

During total knee replacement surgery, the thigh bone can get cut in the front inadvertently. This is called Anterior femoral notching. A July 2022 paper (6) noted that anterior femoral notching (AFN) is a severe complication of total knee replacement, which in a percentage of patients may lead to fractures after surgery. What the researchers noticed in patients with Anterior femoral notching is that during their gait cycle, if there is an anterior femoral cortical notch more than 3 mm, the stress will be significantly increased and that maximum equivalent stress exceeded the femoral yield strength and may increase the risk of periprosthetic fractures.

A June 2022 study (4) 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. Pain catastrophizing  is a modifiable characteristic. Several interventions show modest benefit, however more research is needed to aid in clinical decision-making for this population. Interventions are most likely to produce benefits when they are targeted to people with high levels of Pain catastrophizing.

An April 2022 study (5) comprehensive study exploring long-term pain after surgery investigated how pain and function, health-related quality of life (HRQL), and healthcare resource use evolved over 5 years after total knee replacement  for those with and without chronic pain 1 year after their primary surgery.  Chronic pain was reported in 70/552 operated knees (12.7%) 1 year after surgery. The chronic pain group had worse pain, function and HRQL presurgery and postsurgery than the non-chronic pain group. Those without chronic pain markedly improved right after surgery, then plateaued. Those with chronic pain improved slowly but steadily.

Participants with chronic pain reported greater healthcare resource use and costs than those without, especially 1 year after surgery, and mostly from hospital readmissions.

  • 64.7% of those in chronic pain recovered during the following 4 years, while 30.9% fluctuated in and out of chronic pain.

A November 2022 study (1) examined whether patients who had a previous knee arthroscopic surgery  will have a higher complication rate if they move onto to total knee replacement. The study authors speculated that “Our hypothesis was that a prior knee arthroscopy may be detrimental to the outcomes of knee arthroplasty in the future.” In this study the data of seven previous retrospective studies was examined the conclusion reached was:  “Total knee arthroplasty, when preceded by knee arthroscopy for osteoarthritis may lead to an increase in complication rates like prosthetic joint infections, revision, and re-operations.”

Why some patients need to continue opioids six months after knee or hip replacement

A December 2022 (7) paper examined factors that could predict which patients would need continued opioid use 6 months after total joint replacement. What they found was patients who had these histories were at higher risk:

  • Patients who took preoperative opioids use, increased pain, elevated preoperative Pain Catastrophizing Scale scores, lower Physical Function scores, and participants undergoing total knee replacement, compared to total hip replacement, were found to be significantly associated with continued postoperative opioid use up to 6 months.

In a retrospective analysis of 10,140 consecutive patients (8) undergoing primary total hip replacement postponed total joint replacement revealed a higher 90-day revision rate, surgical complications, internal complications and transfusion rate than on-time total joint replacement. Delay in elective primary total joint replacement correlates with higher revision and complication rates.

1 Moore A, Eccleston C, Gooberman‐Hill R. “It’s Not My Knee”: Understanding Ongoing Pain and Discomfort After Total Knee Replacement Through Re‐Embodiment. Arthritis care & research. 2022 Jun;74(6):975-81.
2 Suhlreyer J, Klinger R. The Influence of Preoperative Mood and Treatment Expectations on Early Postsurgical Acute Pain After a Total Knee Replacement. Frontiers in Psychiatry. 2022;13.
4 Patel RM, Anderson BL, Bartholomew JB. Interventions to Manage Pain Catastrophizing Following Total Knee Replacement: A Systematic Review. Journal of Pain Research. 2022;15:1679.
5 Cole S, Kolovos S, Soni A, Delmestri A, Sanchez-Santos MT, Judge A, Arden NK, Beswick AD, Wylde V, Gooberman-Hill R, Pinedo-Villanueva R. Progression of chronic pain and associated health-related quality of life and healthcare resource use over 5 years after total knee replacement: evidence from a cohort study. BMJ open. 2022 Apr 1;12(4):e058044.
6 Zhang JC, Zhang LS, Zhou H, Chen W, Hu ZH, Chen XY, Feng S. Stress distribution patterns during the gait cycle in patients with anterior femoral notching following total knee replacement. BMC Musculoskelet Disord. 2022 Jul 28;23(1):718. doi: 10.1186/s12891-022-05643-9. PMID: 35902856; PMCID: PMC9330681.
7 Giordano NA, Highland KB, Nghiem V, Scott-Richardson M, Kent M. Predictors of continued opioid use 6 months after total joint arthroplasty: a multi-site study. Archives of Orthopaedic and Trauma Surgery. 2022 Dec;142(12):4033-9.
8 Holzapfel DE, Meyer M, Thieme M, Pagano S, von Kunow F, Weber M. Delay of total joint replacement is associated with a higher 90-day revision rate and increased postoperative complications. Archives of Orthopaedic and Trauma Surgery. 2022 Nov 4:1-8.
9 Taylor CE, Murray CM, Stanton TR. Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies. Pain reports. 2022 May;7(3).



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