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Chronic pain after lower limb total joint replacement is an increasing challenge
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All prognoses and perspectives instruct us that the number of total hip and knee replacements will increase significantly in coming decades, mainly due to the increasing percentage of senior patients, longer life expectancies and increasing demand to be active in the senior years.
Total hip replacement (THR) has been proven to be one of the most beneficial surgical interventions to increase quality of life. This is recognized by most societies and is poised to lead to an increase in the demand of having a degenerated painful hip or knee replaced with an artificial insert.
However, we must remember to inform our patients on the risk of unexpected and unsuccessful outcomes. Major complications, like deep infection, implant loosening and periprosthetic fractures, are known by patients and rarely make a patient decide not to have the replacement. In contrast, residual pain, unchanged pain or even new unexplained pain — frequently considered to be chronic — is difficult for a patient to perceive. As it is clear for the patient — as told by the physician — that the reason for the pain is the degenerated joint and when we replace it, the pain will disappear.
Recent reports from the Swedish Hip Arthroplasty Register note that 5 years after THR, 14% of the patients are disappointed with their outcomes, mainly due pain in the replaced hip. We all have cases in our outpatient clinic where pain in the replaced hip is a major problem. If deep infection or implant loosening is ruled out, as this is frequently the reason for the pain, a clear treatment plan can be given. However, if hip aspiration, MRI/MARS MRI, CT scans, PET scans, leukocyte and technetium scintigraphy are ruled out and shown to be negative, then we are faced with a patient considered to have unexplained pain. In the past, we simply stopped at this point, asked the patient to accept the pain and live with it, as no reason could be diagnosed. However, with the increased number of joint replacements in the coming years and an expectedly higher demand of the patients with pain to find an explanation, we need to meet such challenges at a new level.
In my institution that undertakes 1,700 total hip and knee replacements annually, we have set up a multidisciplinary team including physiotherapists, radiologists, spine surgeons and microbiologists to look into these patients. Initially, we ask our teams of physiotherapists to look for any soft tissue or gait imbalance. Next, the radiologists are given “free hands” to examine the patient, frequently diagnosing new aspects using ultrasound. Finally, the spine surgeons are asked to look for spine-related reasons for pain in the hip area.
From this strategy, we frequently have diagnosed iliopsoas tendinitis, gluteal medius tendinitis or degeneration, nerve entrapment, spinal stenosis and sacroiliac arthritis as reasons for the “unexplained pain.” We get a diagnosis for the pain, but as we all know, we cannot always cure the pain from these diseases. However, the patient now has an explanation and is often happy with this.
My recommendation is to create a multidisciplinary team around your total hip and knee replacement patients with unexplained chronic pain. This will take the burden off your shoulders and will create more satisfied patients. However, it will not make unexplained pain after lower limb joint replacement disappear.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: orthopedics@healio.com.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.