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Failure analysis for painful knees after TKA is critical for success
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ISTANBUL — For patients with a painful knee after total knee arthroplasty, orthopaedic surgeons must conduct a full failure analysis to know the exact cause of the pain, according to a presenter at the EFORT Congress.
"If you don’t understand what is wrong, then don’t do revision surgery because you might just do revision surgery and might not address the final mistake," Siegfried Hofmann, MD, PhD, said.
He said it is important for patients to have pain-free daily activities. While residual pain is normal, unexplained pain can present a diagnostic challenge.
Siegfried Hofmann
"Residual pain is normal after TKA. You have to tell the patient that residual pain is not something wrong. It might take 1 year to get rid of it. Otherwise, the patient is not happy with the results of their surgery. Unexplained pain when the patient comes to you and tells you ‘I hate my knee’ and you look at the X-rays and they look normal, this is [then] a challenge."
Hofmann outlined a 10-step diagnostic algorithm that orthopaedic surgeons should use in their approach to painful knees after TKA. Surgeons should get an extended history of the patient before revision surgery, including all the operating room reports and radiographs.
"You should know everything about that patient, even before surgery. Sometimes the history tells you the cause of the pain," he said.
Hofmann said orthopaedic surgeons also should conduct psychological exploration of the patient especially when the pain continues past 6 months. Psychological evaluations will exclude patients with secondary gain of disease.
"Psychological therapy might be necessary," he said.
A full clinical examination should include the knee, hip, lumbar spine, foot and ankle, peri-articular soft tissue, extensor mechanism, arteriosclerosis, neuropathy, arthrofibrosis and allergy. Surgeons should also test for intra-articular loosening, tendinitis, bursitis, neurinoma, and guanethin or sympathicus complex regional pain syndrome.
Additional laboratory tests are needed to include all nonspecific markers of inflammation such as C-reactive protein, PCR and interleukin-6. Hofmann said negative lab tests do not exclude infection.
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Standard radiographs, including full-leg weight bearing for alignment and joint space, should be performed. Additionally, special imaging tests, such as fluoro-controlled views, computed tomography for rotational positioning, stress radiographs for instability and rotation, bone scans for overloading and infection, should be done during the diagnostic algorithm. Orthopaedic surgeons should also consider conservative therapy for patients with the painful TKA, such as pain killers, bracing for instabilities and psychological therapy.
"If you follow this diagnostic algorithm, in 95% of unexplained painful knees, you might identify the problem and you might help the patient. Don’t do surgery without knowing the exact cause of the pain," he said.
Reference:
Hofmann S. The painful TKA: Causes and diagnostic algorithm for failure analysis. Presented at: EFORT Congress. 5-8 June 2013; Istanbul.
Disclosure: Hofmann has no relevant financial disclosures.