Sathappan S. Sathappan
James Ryan
Dan Ginat
Paul E. Di Cesare
Following total knee arthroplasty (TKA), there is normally a progressive decrease in pain and a reciprocal increase in function. Persistent and/or progressive pain is disconcerting to both the patient and surgeon. The causes of pain following TKA are often related to patient anatomy, implant design, and/or surgical technique.
Epidemiology
The occurrence of occasional knee pain after TKA can be as high as 47%; however, only 5% to 7% of patients experience persistent pain. The most common causes of pain are soft tissue tenosynovitis, patella-related complications, malalignment, infection, component loosening, instability, synovitis, and complex regional pain syndrome (CRPS). Less common causes include scarring and retained cement/osteophytes. Patients with preoperative functional limitations, severe pain, low mental health score, or multiple medical comorbidities are more likely to have a painful TKA and a poorer overall outcome.
Diagnosis
When evaluating knee pain in a post-TKA patient, a careful history and clinical examination are prerequisite in making the definitive diagnosis. Diabetic patients may have a higher propensity to infection and neuropathic pain. Establishing the time interval between TKA and development of pain can help with the diagnosis. For example, presence of pain persisting since surgery suggests infection, instability, prosthetic malalignment, or nonarticular causes. When prosthetic infection is suspected, one should inquire about fever, chills, and recent history of invasive procedure (e.g., dental treatment, urologic procedures).
Initial clinical evaluation requires determination of the site of pain. Localized pain is associated with specific causes (Fig. 27-1), and global tenderness is often due to either infection or prosthetic loosening. Constant pain is typically associated with infection, whereas pain associated with mechanical activity is often due to either inflammatory causes or mechanical derangement. Pain that is experienced with weight bearing, but improves with rest, often is caused by prosthetic loosening.
Clinical examination consists of localizing the tenderness and assessing for range of motion (ROM) and stability. Although effusion can be seen in synovitis, erythema and warmth are more often related to joint sepsis. Presence of crepitus is often indicative of either soft tissue impingement or severe polyethylene liner failure leading to metal-on-metal articulation. In addition to a thorough musculoskeletal evaluation, neurologic and vascular assessments are important.
Pathogenesis
The causes of a painful TKA are listed in Figure 27-2. Synopses of the most common causes follow.
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Figure 27-1 Etiology of the painful knee following total knee arthroplasty (TKA). |
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Figure 27-2 Pain pathogenesis in total knee arthroplasty (TKA). |
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Figure 27-3 Intraoperative photographs of a 60-year-old woman who fell on her knee, suffering a painful extensor mechanism disruption. A: The small avascular patella was attached to the quadriceps tendon by thin fibrotic tissue. B: The extensor mechanism disruption was addressed using a tendo-Achilles allograft. A Krackow stitch repair of the soft tissue ends was performed with the knee in extension. (Courtesy of Patrick Meere, MD.) |
Soft Tissue Disorders
Pes Anserinus Bursitis
The pes anserinus (Latin for goose's foot) is a bursa that lies deep to the tendons of the sartorius, gracilis, and semitendinosus. Pes anserinus bursitis is an underdiagnosed condition in which patients (often obese females) complain of a tender anteromedial knee mass (2 inches inferior to the medial joint line). Pain is exacerbated with stair climbing. Although nocturnal symptoms predominate, patients may complain of knee stiffness with limited flexion lasting ≤1 hour during daily activities. Most symptoms are secondary to overuse. Infrequently, symptoms can be caused by anteromedial overhang of the tibial component, varus coronal malalignment of the TKA components, or irritation of the pes anserinus bursa by polyethylene debris. First-line treatment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and injection of steroid and local anesthetics (e.g., lidocaine).
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Popliteus Tendon Dysfunction
Inflammation of the popliteus tendon (tenosynovitis) can be caused by chronic subluxation of the popliteus tendon over a retained lateral femoral condylar osteophyte or prominent overhang of the posterolateral condyle of the femoral prosthesis. This condition has been reported in about 0.2% of TKA patients. Patients present with lateral knee pain often associated with either a catching sensation or an audible snap at the posterolateral knee. Occasionally recurrent knee effusions mimic symptoms of a septic joint. Women
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are more likely to have this condition because their relatively smaller femoral geometry may lead to oversizing of the prosthetic component in the medial-lateral plane. Intraoperatively, retained osteophytes, if present, should be excised. In addition, following capsular closure of the knee, the surgeon should perform flexion-extension maneuvers; diagnosis of popliteus tendon dysfunction is suggested by an audible popping sound. If no obvious source of the entrapment is apparent, the popliteus tendon may be released from its femoral insertion.
Diagnosis is made based on history and physical examination; diagnostic arthroscopy may also be required. Conservative treatment options are usually ineffective. Patients may be treated with arthroscopic release of the popliteus tendon from its femoral insertion site, which often provides complete symptom resolution.
Semimembranosus Tendonitis
Semimembranosus tendonitis or tenosynovitis occurs in about 1% of TKA patients. Symptoms include posteromedial knee pain that develops several months following surgery. The pain intensifies with activity, especially during standing from a seated position. Patients with considerable preoperative varus deformity are at risk because restoration of the mechanical axis is associated with an increase in tension on the semimembranosus tendon. Another possible cause of semimembranosus tendonitis is frictional irritation of the reflected segment of the tendon inferior to the posteromedial joint line, particularly in conjunction with osteophytes at the semimembranosus groove.
Although transient pain relief may be achieved with steroid and local anesthetic injections, surgical detachment and excision of the reflected portion of the tendon may be considered. Some authors recommend release of the tendon at the semimembranous groove with lengthening of the tendon to preserve dynamic knee stability.
Extensor Mechanism Disruptions
Extensor mechanism disruptions (quadriceps and patellar tendon ruptures), both of which are uncommon, can be either indirect or direct. Indirect injuries are further subclassified as high-velocity injuries (e.g., motor vehicle accidents) and low-velocity injuries (e.g., slip during daily activities). Hyperflexion with excessive loading causes indirect disruptions. Direct disruptions result from extensor mechanism laceration. Patients typically present with anterior knee pain, weakness, and difficulty negotiating stairs. The patellar tendon ruptures at a force 17.5 times body weight, but detachment of a damaged tendon may occur with less force. Risk factors for these soft tissue disruptions include previous cortisone injections and medical conditions that compromise connective tissue integrity, such as rheumatoid arthritis, chronic renal failure, and diabetes mellitus. Acute disruptions are associated with inflammation and significant pain and can be managed with direct repair; however, rerupture rates are high, and hence one should consider augmentation with autogenous grafts. Neglected ruptures of the patellar or quadriceps tendon typically require direct repair with additional augmentation with either autogenous (e.g., semitendinosus or extended medial gastrocnemius–Achilles tendon) or allograft tissues (quadriceps-patella–achilias tendon–tibial tubercle or achilias tendon–calcaneal bone block) (Fig. 27-3).
Instability
Flexion Instability
Patients may present months to years following index TKA with symptoms of instability and pain with deep-flexion activities (e.g., stair descent or chair transfer). In posterior-cruciate–retaining designs, this has been classically described as flexion instability due to rupture of the posterior cruciate ligament. In posterior-stabilized knees, flexion instability may be secondary to fracture of the polyethylene
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stabilizing cam or an excessively large flexion gap created at the time of index TKA. Additional clinical features include intra-articular effusion, posterior tibial subluxation (sag), and pain. Tenderness is often present over the extensor mechanism, pes anserinus tendon complex, and/or distal iliotibial band. In highly symptomatic cases, revision arthroplasty may be considered (Chapter 28).
Flexion/Extension Gap Mismatches
Inequality between flexion/extension gaps can have consequences on knee stability and kinematics. Unsatisfactory coronal alignment can result in unequal loading of the knee and lead to collateral ligament strain. For example, excessive valgus is associated with medial collateral ligament strain and tenderness. Revision arthroplasty is often required and is discussed in the next chapter.
Mechanical Derangement
Fabella Impingement
The fabella (Latin for little bean) is a sesamoid bone located within the origin of the lateral gastrocnemius tendon and is present in 12% of adults. When the fabella is >2 cm in diameter (mean diameter, 1 cm), there is a risk of fabella impingement following TKA. Symptoms can develop days to months after TKA and are due to the fabella catching on either the posterior femoral, tibial, or polyethylene component. Patients complain of pain at the posterolateral knee (especially with flexion), effusion, palpable popliteal mass, and a sensation of catching. This sensation may be accompanied by a snapping sound. Recurrent impingement leads to articular erosion and notching of the fabella. The adjacent synovial tissue may be laden with birefringent polyethylene particles. In patients with a large fabella identified on preoperative radiographs, intraoperative assessment for possible impingement is accomplished by ranging the knee and listening for an audible snap. If present, the fabella may be excised with electrocautery. Patients presenting with symptoms occasionally get relief with local anesthetic injections. Excision of the fabella via a small posterolateral incision may be required if symptoms are refractory to conservative measures.
Pseudomeniscus or Retained Meniscus
Retained meniscal tissue or pseudomeniscus following TKA can catch and impinge in the tibiofemoral compartment. The suggested pathogenesis includes the production of fibrocartilage from metaplastic transformation of retained meniscal remnants or redundant intra-articular synovium subject to repetitive joint compressive forces. Patients with this condition present with persistent joint line tenderness (posterolateral or posteromedial) about 3 to 6 months following an initially uneventful postoperative course. Patients complain of pain aggravated with stair descent, sometimes accompanied by a catching sensation with knee flexion. Conservative treatment modalities such as physical therapy, bracing, and local anesthetic injections may provide modest relief. Arthroscopic excision of the meniscal tissue typically provides immediate and long-lasting remission of symptoms (Fig. 27-4).
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Figure 27-4 Arthroscopic views of medial pseudomeniscus in a 58-year-old man who presented with recurrent posteromedial pain and an associated snapping sensation. A: Before treatment. B: Arthroscopic shaver being used to debride the impinging pseudomeniscus. |
Retained Osteophyte
Meticulous removal of osteophytes is a routine step in all TKAs. However, if large osteophytes remain at the distal femur or proximal tibia, problems can arise. Patients usually present with persistent pain, crepitus, and a knee effusion. Routine radiographs are often negative. Surgical management consists of arthroscopy or open arthrotomy with excision of these osteophytes. Debridement of an associated synovitis may also improve symptoms.
Retained Cement Debris
Uncommonly, cement debris is retained following a primary TKA. The posterior aspect of the knee is the most common site and can lead to pain at this location. With the increasing number of surgeons using smaller incisions for TKA, limited surgical exposure may result in poor visualization of the posterior compartments with subsequent retention of fragments. Patients can present as late as several months after TKA with severe, sharp pain associated with a popping sensation, effusion, and decreased range of motion. Radiopaque cement debris usually can be seen on
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radiographs. Arthroscopic techniques can be used to remove cement fragments, resulting in symptom resolution.
Periprosthetic Osteolysis
Osteolysis surrounding the femoral, tibial, and patellar components can develop secondary to polyethylene, metal, and/or cement debris. If the debris particles are <15 µm in diameter, they can be ingested by macrophages, which then release numerous inflammatory mediators, including prostaglandin E2, tumor necrosis factor α, and interleukins-2 and -6. The resulting inflammatory response with subsequent activation of osteoclasts is responsible for osteolysis. Patients present with effusion, pain, and instability. Revision TKA is often the only solution to this significant problem.
Metal Sensitivity
Cutaneous contact dermatitis to metal, which can be confirmed on epicutaneous testing, is associated with nickel (Ni), chromium (Cr), cobalt (Co), and CrCoNi alloys and occurs in 8% to 15% of the general population. Metal sensitivity, an allergic reaction of the periprosthetic tissues to metals, has been correlated to contact dermatitis with possible symptom exacerbation following use of conventional prostheses. Clinical features may include eczematid dermatitis, generalized allergic vasculitis, aseptic loosening, and bone necrosis resulting in pain. Pathologic evaluation of tissues can reveal either a cell-mediated immune response or a preponderance of immunoglobulin E antibodies. The frequency of clinically relevant allergic responses to knee implants is unknown, but probably very low. In at-risk patients, titanium-containing or ceramic prostheses may be considered owing to their decreased immunogenic potential.
Catastrophic Material Failure
Most polyethylene wear occurs at the interface between the femoral component and the polyethylene tibial tray. High-molecular-weight polyethylene that has been sterilized by gamma irradiation in air is at the highest risk for catastrophic failure. Modular tibial inserts with suboptimal locking mechanisms can develop wear at the backside of the polyethylene tray. Polyethylene material failure is often associated with a painful chronic effusion and usually occurs many years following TKA. In cases with a metal-backed patella, the thin polyethylene segment can dissociate or wear through, leading to metal-on-metal articulation. Patients present with a grinding or squeaking noise and metallosis. Revision of the patella and sometimes the femoral component usually is required.
Tibial Component Overhang
Tibial component overhang results from malpositioning or oversizing the tibial component with respect to the underlying bony surface. This technical error can result in painful incursion and subsequent inflammation of the collateral ligaments. The medial collateral ligament is more frequently involved than the lateral collateral ligament. Patients who fail medical management, including NSAIDs and/or local anesthetic injection, may be considered for revision surgery.
Patellofemoral Disorders
Patella Resurfacing
Indications for patella resurfacing are still a subject of controversy. Approximately 10% of patients with a nonresurfaced TKA have some persistent anterior knee pain. This may develop several years following the index TKA. If all other diagnoses for anterior knee pain have been excluded, the patella may be resurfaced, especially if the clinical features are suggestive of either inflammatory arthropathy or patellofemoral arthrosis.
Patella Maltracking
Patella maltracking can occur in knees with or without patella resurfacing; it is often due to a tight lateral retinaculum, weak vastus medialis, or more commonly an internally rotated femoral and/or tibial component. If conservative treatment options are unsuccessful, either an extensor mechanism realignment procedure or revision arthroplasty may be required.
Patellar Clunk Syndrome
Patellar clunk is a complication previously described in association with first-generation posterior-stabilized knee designs and is infrequently encountered today. These first-generation implants had a sharp transition between the anterior flange and the intercondylar notch of the femoral component. The condition is characterized by chronic irritation of the quadriceps tendon at the superior aspect of the patella, where the tendon can abut the femoral housing. An inflammatory nodule may form at the junction of the quadriceps tendon and the proximal pole of the patella. When extending the knee from a fully flexed position, at approximately 30 to 40 degrees, patients experience crepitation and catching, frequently accompanied by pain. Treatment consists of arthroscopic or open debridement of the nodule, which is usually successful.
Patellar Fractures
Infrequently (in approximately 1%), TKA can be complicated by patellar fracture in the postoperative period. The incidence is increased with use of a patellar implant with a large central peg or by cutting the patella too thin. Bony resection should match the new prosthetic implant thickness. The minimum postresection thickness is approximately 11 mm. Fracture also may be associated with osteonecrosis of the patella.
Hoffa Fat Pad Impingement Syndrome
Impingement of the Hoffa fat pad has been described following use of mobile bearing TKAs. Compression of the well-innervated fat pad by the anterior border of the polyethylene insert results in anterior knee pain and can be associated with limited ROM. Imaging modalities such as ultrasound and positron emission tomography (PET) scan can aid in confirming the diagnosis. Intraoperative findings suggestive of fat pad impingement include tissue necrosis and sometimes an imprint of the components. If revision surgery is undertaken, it is recommended that the fat pad be removed.
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Lateral Facet of the Patella Syndrome
The use of a small inset patella with limited coverage of the lateral patellar facet can lead to painful irritation of the exposed arthritic patellar surface. Patients may complain of anterior knee pain and can have increased radionucleotide uptake over the patella on bone scans. Sunrise view of the patella may indicate abutment of the lateral facet of the patella against the lateral flange of the femoral component. Patella revision may be required for persistent symptoms.
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Figure 27-5 A 39-year-old woman with a history of rheumatoid arthritis who had an uneventful cementless total knee arthroplasty. AFour years following the index procedure, she presented with a red and inflamed knee joint; sepsis was confirmed by aspiration and cultures. B Anteroposterior radiograph indicating component loosening secondary to joint infection. |
Arthrofibrosis
Patients with arthrofibrosis (stiffness) following TKA typically have a flexion contracture of >15 degrees and/or cannot bend the knee >75 degrees. The incidence of painful postoperative stiffness has been reported to be as high as 10%. Factors associated with knee stiffness include limited preoperative knee ROM, multiple previous knee surgeries, biologic predisposition, history of diabetes, postoperative hemarthrosis, poor patient motivation, inadequate postoperative rehabilitation, improper/insufficient bone cuts, component malposition, tight flexion or extension gap, “overstuffing” of the tibiofemoral or patellofemoral joint, posterior femoral/tibial osteophytes, incorrect component size, a tight posterior cruciate ligament, and heterotopic ossification. Histologic analysis of arthrofibrotic tissue reveals a large population of ovoid and spindle-shaped cells in a dense collagen matrix. Macroscopic variants include simple fibrous bands, exuberant parasynovial fibrous hypertrophy (often in the intercondylar notch), and extensive panarticular scar formation. With diminished ROM, quadriceps work is increased with walking (67 degrees is required for normal gait). Patients may encounter difficulty negotiating stairs and rising from a chair, as these tasks require 85 and 95 degrees of flexion, respectively. Surgical intervention can be early or late. For patients with stiffness within 6 to 12 weeks following TKA, manipulation under anesthesia can be performed. Patients with chronic stiffness may be treated with an arthroscopic or open lysis of adhesions. Revision arthroplasty may be necessary if implant-related causes have been diagnosed.
Infection
The rate of infection following primary TKA is reported to be 1% to 2%. Susceptibility factors include a compromised immune system, obesity, smoking, peripheral vascular disease, venous insufficiency, history of skin ulcers, use of oral steroids, multiple previous surgeries, rheumatoid arthritis, history of knee infection, and recurrent urinary tract infection. Infections following TKA can be categorized as superficial or deep. The deep infections can be further subdivided into direct and hematogenous (seeding from distant infection site). The most common organisms are Staphylococcus aureus (coagulase-positive) and Staphylococcus epidermis (coagulase-negative). Patients may present with pain, swelling, febrile episodes, erythema, decreased ROM, and sometimes wound drainage (Fig. 27-5).
Treatment options depend on the time of diagnosis. If infections are identified early (<6 weeks) with well-fixed components, an attempt can be made to perform an open, radical debridement with exchange of the tibial insert. Polyethylene exchange is important because the glycocalyx “slime” layer that deposits on the polyethylene bearing can promote recurrence. In cases diagnosed beyond 6 weeks, the following options are considered: primary exchange, two-stage (delayed) exchange, resection arthroplasty, arthrodesis, or amputation. If reimplantation (primary or two-stage) is considered, organism-specific antibiotic-impregnated cement should be used. The most predictable results are achieved with the two-stage exchange
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method. Antibiotic suppression can be used in patients with stable implants who are not suitable candidates for surgical intervention and who are infected with a low-virulence organism.
Rare Syndromes/Conditions
Heterotopic Ossification
Heterotopic ossification (HO) tends to occur within the first three postoperative months. It occurs in 5% to 15% of TKA patients, although it is symptomatic in <1% of patients. Presentation is variable and may consist of vague discomfort, stiffness, and, in very rare cases, persistent pain and snapping. New bone formation is evident on radiographs within 3 months following surgery and usually does not change after the first year.
Preoperatively, or within the first 48 hours following surgery, high-risk patients may be given prophylaxis using either a course of indomethacin or radiation. In the occasional patient who experiences symptoms that fail to respond to conservative therapy, surgical excision of the HO may be necessary.
Hemarthrosis
Hemarthrosis may occur from months to several years (mean 2 years) following TKA. The incidence is approximately 5%, and the underlying cause is frequently unknown. In some cases, the pathogenesis is characterized by synovial proliferation secondary to polyethylene, metal, or cement debris, which can frequently bleed owing to entrapment or microtrauma. Tissue histology reveals focal synovial hyperplasia containing histiocytes and hemosiderin deposits. Other possible causes include clotting disorders such as hemophilia, chronic use of anticoagulants, remnant posterior cruciate ligament stump trauma, intercondylar notch fibrosis, pigmented villonodular synovitis, juxta-articular arteriovenous malformation, tumor, component loosening, and knee instability (including flexion instability).
Patients present with a tense, painful effusion with decreased range of motion. Coagulation studies are often normal. In the acute setting, knee aspiration is diagnostic and typically reveals bright red blood. In rare cases angiography may aid in identifying the source of bleeding. Initial management consists of short-term rest, application of ice, limb elevation, splinting, and discontinuation of anticoagulant medication. In patients who fail conservative treatment or who have recurrent hemarthrosis, arthroscopic synovectomy can be considered. In refractory cases, implant revision may provide a satisfactory long-term outcome.
Nonarticular Causes
Vascular Causes
Popliteal Artery Pseudoaneurysm.
Vascular injuries constitute a small portion of TKA complications (0.03% to 1.2%). Pseudoaneurysm of the popliteal artery is a rare and painful vascular complication that, if untreated, can result in loss of the operated limb. About 40% of cases are diagnosed within 1 month of disease onset. Symptoms include a painful and pulsatile mass that produces bruits and/or thrills and is usually associated with ecchymosis overlying the popliteal region. In addition, distal pulses may be weak. Magnetic resonance imaging (MRI) can be used to confirm the diagnosis of popliteal artery pseudoaneurysm.
Postthrombotic Syndrome.
Following TKA there is a risk of developing deep venous thrombosis (DVT) secondary to stasis, endothelial damage, and increased blood viscosity (the Virchow triad). DVT may precipitate chronic venous insufficiency, and patients may present with a painful, swollen lower limb, sometimes associated with ulceration. Clinical findings can be confirmed with venous Doppler studies. Patients should be treated with compression stockings and referred to a vascular specialist.
Neurogenic Causes
Cutaneous Neuromas.
Uncommonly, patients present with a painful TKA secondary to a cutaneous neuroma. A neuroma may develop when the infrapatellar branch of the saphenous nerve, medial femoral cutaneous nerve of the thigh, or medial/lateral retinacular nerves are divided at the index procedure. Conservative measures for neuropathic pain include topical steroids, iontophoresis, transcutaneous electrical stimulation, and medications. If symptoms last >6 months, nerve blocks and selective denervation procedures may be considered.
Complex Regional Pain Syndrome.
Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD) or Sudeck atrophy, is a diagnosis of exclusion and arises from autonomic dysfunction. It is a complex interplay of four factors: a local trigger (e.g., surgical trauma), psychologic factors, systemic factors associated with pain exacerbation (e.g., peripheral neuropathy), and sympathetically maintained pain. It is thought to occur in about 0.5% of TKA patients. There is a wide variation in disease presentation. Symptoms may include intense burning or prolonged pain in nonanatomic distributions, sensory abnormalities such as allodynia or hyperalgesia that are out of proportion to the physical examination findings, edema, sudomotor disruptions such as sweating, trophic changes such as smooth, shiny skin, cold intolerance, vasomotor disturbances such as hyperhidrosis and coolness to the touch, stiffness, and weakness. Patients with anxiety and severe pain preoperatively are more likely to develop CRPS. Although there may be a psychologic overlay in CRPS, it is unclear whether the psychologic factors predispose patients to this condition or are a result of this syndrome. Although diffuse pain and hypersensitivity suggest the presence of CRPS, the extensive variability of clinical symptoms warrants a thorough workup to exclude other causes (e.g., mechanical, prosthetic, or soft tissue causes).
In TKA patients with CRPS, osteopenia of the patella may be appreciated on plain radiographs. Technetium-99m bone scans may reveal increased uptake in affected regions. Sympathetic block is useful, both as a diagnostic and therapeutic modality.
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Initial treatment consists of NSAIDs, neuromodulating medications, and physical therapy. Narcotics and benzodiazepines are contraindicated in these patients. Instead, anesthetic sympathetic blockade can provide long-term pain relief. Lumbar sympathectomy can be attempted for recalcitrant symptoms.
Pain of Unknown Origin
The diagnosis “pain of unknown origin” is made when all causes are considered (e.g., all causes listed in Fig. 27-1) and none is applicable. The incidence of severe pain without identifiable cause following TKA is about 6%. Associated clinical factors may include history of multiple procedures, fibromyalgia, unreasonable patient expectations, injuries with workers' compensation issues, and patients who had minimal joint disease as determined radiographically prior to TKA.
Laboratory Tests
Management of painful knee arthroplasty begins with basic laboratory tests to rule out infection. The usual tests consist of the following:
Synovial biopsy can be performed either arthroscopically or open. The following conclusions can be made based on high-power view:
Radiologic Features
Radiographic workup depends on the suspected diagnoses. An overview is given below.
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Diagnostic Workup and Management Algorithm
A flowchart outlining clinical history, physical examination, diagnostic procedures, and possible treatment options of painful TKA is presented in Figure 27-6.
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Figure 27-6 Diagnostic evaluation and management of pain following TKA. |
Summary
Clinical evaluation and subsequent management of patients presenting with pain following TKA can be a diagnostic challenge even for the experienced surgeon. A systematic approach is essential to elucidating the cause of a painful TKA. Patients with definable causes of knee pain following TKA such as loosening, malalignment, oversized components, or heterotopic ossification improve most predictably from surgical intervention. Revision TKA performed prior to defining a specific cause for the patient symptoms can lead to inferior functional results and persistent or worsened symptoms.
Suggested Readings
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