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.”

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.

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.

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