Causes of Aseptic Persistent Pain after Total Knee Arthroplasty

Abstract

BackgroundPersistent pain after total knee arthroplasty (TKA) is dissatisfying to the patient and frustrating to the surgeon. The purpose of this study is to evaluate the aseptic causes and clinical course of intractable pain following TKA.MethodsOf the total 2,534 cases of primary TKA reviewed, 178 cases were classified as having aseptic persistent pain that was not resolved within 1 year after surgery. Except for the cases with periprosthetic fracture (56 knees), 122 cases of aseptic painful TKA were divided into two groups: intra-articular group (83 knees) and extra-articular group (39 knees).ResultsIn the intra-articular group, the main reasons for pain were aseptic loosening (n = 40), polyethylene wear (n = 16), instability (n = 10), recurrent hemarthrosis (n = 5), patellar maltracking (n = 4), tendon ruptures (n = 4), and stiffness (n = 2). In the extraarticular group, 10 knees (25.6%) were found to have nerve entrapment in the spine, 6 knees (15.4%) were found to have hip osteoarthritis or femoral head avascular necrosis. The reasons for persistent knee pain in the remaining 23 knees (59.0%) still remain elusive.ConclusionsPersistent pain after TKA originated from pathology of extra-articular origin in a considerable number of cases in this study. Therefore, it is important to perform thorough preoperative evaluations to reduce pain resulting from extra-articular causes. Furthermore, meticulous surgical procedures and optimal alignment are required to reduce pain of intra-articular origin related to implant wear, instability, and patellar maltracking.

Localized cytokine responses to total knee arthroplasty and total knee revision complications

“…In conclusion, this exploratory pilot study identified several cytokines that exhibited higher concentrations in response to implant-related and infection-specific post-operative inflammation. Some of these cytokines have been previously implicated in chronic inflammation and infection following TKA/TKR on a systemic level [ 11 , 12 , 30 – 33 ], and this study confirmed this trend on a localized tissue level. Literature has already illustrated that local inflammation is much more important for early post-operative recovery for a few markers [ 6 ], and this study expanded on that knowledge to provide an extended view of inflammatory cytokines involved in tissue health.…”

“…Properly addressing these issues is of high priority to the field of orthopaedics, especially considering the increasing demand for joint replacement [10]. Many studies have noted the pain, inflammation, and dissatisfaction that can occur following these procedures, affecting approximately 20% of patients undergoing TKA [11,12], but it is not entirely known what role cytokines play in this chronic inflammatory response. Infections, such as prosthetic joint infection (PJI), are another serious complication and are a leading cause of total joint failure [13].…”

Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

“…Metal-cement interface failure in cemented total knee arthroplasty with pseudotumor formation in the knee is not a common mechanism of knee implant failure and has not been reported in the literature. The de-bonding between the metal component and underlying cement could be triggered by a variety of reasons, including weak quality cement, poor cement mixing techniques, inadequate immobilization of the knee joint while the cement is curing, or inadequate cementing non-low viscosity cement use [1-2]. This interface failure can cause gradual loosening and dissociation of components with neighboring ALTR that could mimic PJI, inflammatory synovitis, or tumor formation occasionally, along with systemic signs of metallosis, but they rarely coexist [3].…”

Selective peripheral nerve resection for treatment of persistent pain around the knee joint after total knee arthroplasty

“…Innate factors include infection, knee joint instability, application of an inappropriately sized prosthesis, loosening of the prosthesis, an abnormal lower limb stress line, stimulation by residual bone cement, and bone fracture or osteolysis around the prosthesis. 8 – 10…”