Knee replacement complications

Revision surgery does not fix the knee replacement to levels of successful primary knee replacement

A February 2024 study (1) reviewed patient reported outcomes following a revision knee replacement surgery. They found that patients who underwent revision total knee replacement  (all causes) had lower rates of improvement and higher rates of worsening compared to patients who had only a primary total knee replacement. This suggests that patients who had failed primary knee replacement, the revision surgery will not make outcomes as good as a successful primary knee replacement. The patients of this study reported that physical function specifically a problem. The researchers here also noted that. “Although primary total knee replacement patients did better overall, the improvement rates may be considered relatively low and should prompt discussions on improving outcomes following primary total knee replacement and revision total knee replacement.”

Depression, anxiety and a positive attitude may impact knee replacement outcomes

In the research below, doctors discuss the problem of patients who expect a poor outcome to their knee replacement and how this pre-disposes them to pain after the knee replacement. Why would someone expect a poor outcome after knee replacement? One possible answer is that the person had a lot of pain for many years, nothing has helped them, and, they have reached a point where they do not believe anything can help them. For some, this can be called pain catastrophizing.

In this April 2022 study (2) doctors write: “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 June 2022 study (3) 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 answer may be found in a May 2022 paper (4) which 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.

A June 2022 paper (5) notes that “Prior research has suggested that self-efficacy, positive affect, vigor, and vitality may function as resilience factors in the face of chronic pain.” In this paper, the researchers examined these resilience factors in a prospective, cognitive-affective-behavioral pathway to recovery. In this study 110 patients undergoing unilateral, total knee replacement surgery completed self-report assessments of study variables.

  • Self-efficacy was assessed 2 one-half weeks prior to surgery, positive affect the day after surgery, vitality and vigor one-month following surgery, and post-operative pain at one- and three-months following surgery.
  • Analysis revealed significant coefficients from pre-operative self-efficacy to positive affect during hospitalization, as well as to vitality and vigor at one-month following surgery.

It doesn’t feel like my knee

Heaviness, numbness, pressure, and tightness associated with the prosthesis

A June 2022 study (6) suggests up to 20% of people who undergo total knee replacement surgery have ongoing pain and discomfort. The aim of this study then was to understand concepts of pain and discomfort patients felt and suffered from 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 control over their replaced knee, often describing it as alien or other, and lacked confidence in the knee.

“patient-perceived enlargement of knee.”

A June 2022 paper (7) suggests that in clinical practice, many patients complained that their knees became larger after total knee arthroplasty, yet no studies have described this phenomenon. The study authors then named this as “patient-perceived enlargement of knee.”

In this study the researchers reviewed patients that underwent unilateral primary total knee arthroplasty between May 2018 and April 2019. They investigated the prevalence of “patient-perceived enlargement of knee” and acquired functional scores and satisfaction. Patients were divided into two groups according to whether they complained of “patient-perceived enlargement of knee.”

A total of 389 patients were enrolled and 101 patients felt their knee became “larger” after total knee arthroplasty. Patients with patient-perceived enlargement of knee had significantly shorter height and lower weight, yet component size distribution showed no statistical difference. Patients with patient-perceived enlargement of knee had significantly lower functional scores and satisfaction.

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 (8) 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.

More hospital readmissions

The researchers of this study concluded that “rehabilitation (following surgery) 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 (9) comprehensive study exploring long-term pain after surgery investigated how pain and function, health-related quality of life, and healthcare resource use evolved over 5 years after total knee replacement. This study focused on 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, more hospital readmissions, and health-related quality of life issues pre-surgery and post-surgery as compared to those in the non-chronic pain group. Those without chronic pain markedly improved right after surgery, then plateaued. Those with chronic pain improved slowly but steadily.
  • 64.7% of those in chronic pain recovered during the following 4 years, while 30.9% fluctuated in and out of chronic pain.

Related articles:

Do Opioids Cause Knee Replacement Complications?

Do Women Have More Knee Replacement Complications?

Knee replacement outcomes and complications in patients in their 80s and 90s


1 Salimy MS, Paschalidis A, Dunahoe JA, Chen AF, Alpaugh K, Bedair HS, Melnic CM. Patients Consistently Report Worse Outcomes Following Revision Total Knee Arthroplasty Compared to Primary Total Knee Arthroplasty. The Journal of Arthroplasty. 2023 Aug 11.
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.
3 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.
4 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).
5 Cremeans-Smith JK, Greene K, Delahanty DL. Resilience and recovery from total knee arthroplasty (TKA): a pathway for optimizing patient outcomes. Journal of Behavioral Medicine. 2022 Feb 13:1-9.
6 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.
7 Zheng H, Shao H, Tang Q, Guo S, Yang D, Zhou Y. Patient-perceived knee enlargement after total knee arthroplasty: prevalence, risk factors, and association with functional outcomes and radiological analysis. International Orthopaedics. 2022 Mar 29:1-8.
8 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 Musculoskeletal Disorders. 2022 Dec;23(1):1-8.
9 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.

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