Work Up of the Painful Total Knee Arthroplasty


- See: TKR Menu: (Function and Activity after TKR)

- Natural History of Painful TKR:
    - references:
              - Pain and Depression Influence Outcome 5 Years after Knee Replacement Surgery.
              - Impact of Psychological Distress on Pain and Function Following Knee Arthroplasty


- Potential Causes of TKR failure:

    - early failures:
          - references:
                - Early failures in total knee arthroplasty.
                - Early failures among 7,174 primary total knee replacements: a follow-up study from the Norwegian Arthroplasty Register 1994-2000.  
    - infected TKR
          - bone scans:
                - may indicate loosening after 6-12 months, but can not distinguish between septic and aseptic loosening; 
          - aspiration: for gm stain & culture:
                - most accurate method of dx, and is required prior to all revisions;
                - remember that knee aspiration can yield false positives up to 25% of the time; 
          - sed rate and CRP
                - Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation.

    - component misplacement:
          - varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement
          - rotation of the femoral component
                 - references: 
                        - Rotational malalignment of the femoral component in total knee arthroplasty.
                        - [Rotational malalignment of the components may cause chronic pain or early failure in total knee arthroplasty.
  
          - rotation of tibial component
                 - references:
                         - Internal rotational error of the tibial component is a major cause of pain after total knee replacement

    - mis-sizing of components
          - medial tibial overhang;
          - over-sizing the femoral component; 
          - references:
                 - Overhang of the femoral component in total knee arthroplasty: risk factors and clinical consequences. 
                 - Unique relationship between osteophyte and femoral-tibia component size mismatch in determining polyethylene wear in primary total knee arthroplasty: a case report. 
                 - The influence of the implant size on the outcome of unconstrained total knee arthroplasty.

    - knee arthroplasty instability: 
    - remnant medial meniscus:
          - An impinging remnant meniscus causing early polyethylene failure in total knee arthroplasty: a case report.
          - Pseudomeniscal Synovial Impingement After Unicondylar Knee Arthroplasty 

    - patellar problems:
          - patellar frx
          - patellar clunk syndrome
          - patellar subluxation
          - eccentric patellar button placement (causing patellar tilt and contact between the lateral patellar facet and the lateral femoral condyle);
          - asymmetric patellar resurfacing: tendency to underresface the medial patellar facet; 
          - ref: The John Insall Award: control-matched evaluation of painful patellar Crepitus after total knee arthroplasty.
    - painful tibial stem
          -
Tibia pain at end of stem with stemmed revision total knee arthroplasty: treatment with cortical strut graft technique.
          - Tibial stem tip pain in stemmed revision total knee arthroplasty: treatment with tension band plating.

    - malalignment of feet:
          - Persistent hindfoot valgus causes lateral deviation of weightbearing axis after total knee arthroplasty.
          - Evaluation of knee and hindfoot alignment before and after total knee arthroplasty: a prospective analysis.
    - component failure:
          - fibrous ingrowth:
                - pain resulting from fibrous ingrowth should always be considered in a patient with a press fit femoral or tibial component;
          - polyethylene failure:
                - look for asymmetrical polyethylene thickness;
                - polyethylene may wear out, especially postero-medially;
                - may be associated w/ osteolysis;
                - polyethylene wear may yield green fluid aspirate;
          - tibial component frx 
          - patellar frx
          - ref: Mechanisms of failure of the femoral and tibial components in total knee arthroplasty

    - neuropathic pain:
          - back pain:
                 - Patient-reported outcomes after total knee replacement vary on the basis of preoperative coexisting disease in the lumbar spine and other nonoperatively treated joints: the need for a musculoskeletal comorbidity index.
                 - The natural history of pain and neuropathic pain after knee replacement: a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up.
          - neuroma: (saphenous nerve)
                 - Neuroma of the infrapatellar branch of the saphenous nerve a cause of reversible knee stiffness after total knee arthroplasty.
                 - Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty
                 - Infrapatellar Saphenous Neuralgia After TKA Can Be Improved With Ultrasound-guided Local Treatments

    - gout / pseudogout as a cause of painful TKR (gout and pseudogout):
    - allergy:
          - Pain in a chromium-allergic patient with total knee arthroplasty: disappearance of symptoms after revision with a special surface-coated TKA ­— a case report



- Radiographs:
    - comparing sunrise views and lateral films to the native knee (or ipsilateral pre-op films) can help clarify patellofemoral problems
           (tracking, "stuffed" patellofemoral joint, lateral facet contact due to an undersized component, etc.)
    - component loosening:
           - loosening w/ knee replacements is most often due to subsidence, in which component actually sinks into bone;
                    - malalignment, esp. varus alignment, usually has a causal relationship to this failure mode;
           - when its unclear whether loosening or slight subsidence is present, consider obtaining radiographs under flouroscopic control;
                    - also consider need for subtraction arthrogram inorder to emphasize the space between bone and cement or between cement and prosthesis;
                    - also indicated for sublte femoral component loosening, which is difficult to diagnose on plain radiographs;
                    - in study by Vyskocil et al, (1999), authors found that flourscopically assisted xrays identified significantly more radioluncent
                             lines in femoral components than were found by conventional xrays;
                             - authors note that deviation of x-ray beam of only 2.3 deg to component interface could obscure a radiolucent line of 2 mm, but despite this,
                                      authors were unable to demonstrate a significant advantage to flouroscopically assisted radiographs to detect tibial loosening;
      - references:
             - Radioluncent lines and component stability in knee arthroplasty.  Standard versus flouroscopically assisted radiographs.
             - Fluoroscopic evaluation of the painful total knee arthroplasty.
             - Radionuclide imaging of asymptomatic versus symptomatic total knee arthroplasties
             - Early Femoral Component Loosening of Constrained Condylar Primary Total Knee Arthroplasties Inserted Without Stems 
             - ACR Appropriateness Criteria® imaging after total knee arthroplasty.
             - Assessment of radionuclide arthrography in the evaluation of loosening of knee prostheses



- Treatment Options:
        - Role of Arthroscopy following TKR 
        - Revision TKR 
        - Physical Therapy following TKR



Intraarticular botulinum toxin a for refractory painful total knee arthroplasty: a randomized controlled trial.

Recurrent hemarthrosis after knee joint arthroplasty: etiology and treatment



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, January 20, 2015 3:47 pm