The Painful Total Knee Arthroplasty

Total knee arthroplasty is one of the most successful operations performed, with 95–98% good to excellent results reported at 10–15 years (Schai et al., J Bone Joint Surg 80-B:850–858, 1998; Ritter et al., Clin Orthop 309:136–145, 1994; Ranawat et al., Clin Orthop 286:94–102, 1993). Up to 20% of patients, however, report dissatisfaction with their outcomes due to persistent pain (Baker et al., J Bone Joint Surg Br 89-B:893–900, 2007). A thoughtful and systematic approach to these patients can help elucidate the mechanism of failure and develop an appropriate treatment paradigm. The results of exploration for debilitating pain of unknown etiology in a total knee replacement remain poor, with only 59% fair or poor results reported after surgery (Mont et al., Clin Orthop 331:216–220, 1996). Thus, it is paramount to consider all potential causes of pain from a total knee arthroplasty before considering intervention. We shall consider the diagnosis and treatment of the painful total knee replacement from an anatomical perspective, stratified into intra-articular, periarticular, and extra-articular/systemic causes.