You are here

TKA Painful / Failed

ICD-9 Classification / Treatment
Etiology / Natural History Associated Injuries / DDx
Anatomy Complications
Clinical Evaluation Follow-up Care
Xray / Diagnositc Tests Review References


Painful TKA ICD-9


Painful TKA Etiology / Epidemiology / Natural History

  • Meta-analysis of 9,879 TKA; average of 4.1 years’ follow-up; 89.3% good or excellent result, 10.7% fair or poor; 3.8% underwent revision TKA.  (Callahan CM, Drake BG, Heck DA, Dittus RS: Patient outcomes following tricompartmental total knee replacement: A meta-analysis. JAMA 1994;271: 1349–1357)
  • Painful TKA can be related to pain, stiffness, and or instability as well as alternative etiologies (see differential diagnosis below)

Painful TKA Anatomy


Painful TKA Clinical Evaluation

  • Evaluate for varus or valgus thrust
  • Internally rotated tibial component leads to an externally rotated foot progression. 
  • Evaluate PCL-retaining TKAs for PCL insufficiency: posterior tibial sag, a positive posterior drawer test, and a positive 90° quadriceps active test.  Treatment = arthroscopic excision. (Beight JL, . Clin Orthop 1994;299: 139)

Painful TKA Xray / Diagnositc Tests

  • Review prior records, operative report, imaging.
  • Knee AP weight bearing, lateral and sunrise views.  Beam should be parallel to tibial baseplate.  Femoral component: 4°-7° of valgus, anterior flange in contact with anterior cortex. Tibial component: perpendicular to long axis of the tibia on AP view and perpendicular or sloped < 10° on lateral view. Evaluate for periosteal reaction, scattered foci of osteolysis, bone resoprtion, implant wear, progressive radiolucencies, osteopenia,
  • Loosening: change in position noted on sequential radiographs, a radiolucent line extending under the entire prosthesis, progressive widening of the cement-bone or bone-prosthesis interface, lucencies at the metal-cement interface, cement cracking or fragmentation.  Incomplete, non-progressive radiolucencies are not considered pathologic
  • Bone Scan: sensitivity = 33%, specificity = 86%, positive predictive value = 30%, negative predictive value = 88%. (Levitsky KA, J Arthroplasty. 1991;6:237)
  • ESR (Westergen erthrocyte sedimentation rate): rises normally after total joint surgery. Returns to normal 6 weeks after surgery. Infection suggested if elevated 3 months after surgery.
  • CRP (C-reactive protein): Rises normally after total joint surgery. Returns to normal @3weeks after surgery. Infection suggested if elevated 3 months after surgery.
  • Interleukin-6 (IL-6): Rises normally after total joint surgery. Returns to normal within 48 hours after surgery. Elevated (>10 pg/mL [>10 ng/L]) in patients with periprosthetic infection.
  • Aspiration of Joint fluid: send for aerobic culture anaerobic culture, sensitivities, Gram stain, acid-fast staining, CBC with differential. Leukocyte count > 1.7x109/L indicates infection.
  • Leukocyte esterase reagent strips: Moderate or large WBC on strips indicates infection.  Sensitivity=92.9%, specificity=88.8%.  Blood or debris in synovial fluid renders the strips unreadable in 1/3 of cases.  (Parvizi, J, AAHKS annual meeting 2011).

Painful TKA Classification / Treatment

  • Instability: may be related to Quad weakness
  • Pain: common causes: loosening and component failure, patellar dysfunction, limb deformity, infection. Less common causes: neuroma, CRPS, bursitis, referred pain. 
  • Pain in full extension: overstuffed extension space.
  • Pain with full flexion: impingement between a posterior femoral osteophyte and the tibial component, or overstuffing of the flexion space.
  • Pain with stairs: dysfunction of the extensor mechanism.
  • Pain with activity: loosening  and component failure.
  • Patellar Clunk: audible popping as the knee moves from flexion to extension due to a nodule or mass just superior to the patellar tendon.  Treatment = arthroscopic excision. (Beight JL, Clin Orthop 1994;299: 139)
  • Loosening / Osteolysis:  new onset of pain or effusion, effusion, crepitus, grinding of the knee, rarely, skin staining from metal fretting and debris.  Treatment =  revision

Painful TKA Associated Injuries / Differential Diagnosis

  • CRPS
  • Disk herniation
  • Spinal stenosis
  • Vascular claudication
  • Psychosomatic illness
  • Hip osteoarthritis
  • Postphlebitic syndrome
  • Diabetic neuropathic pain
  • Superficial neuroma
  • Pes Anserine bursitis

Painful TKA Complications

Painful TKA Follow-up Care


Painful TKA Review References





The information on this website is intended for orthopaedic surgeons.  It is not intended for the general public. The information on this website may not be complete or accurate.  The eORIF website is not an authoritative reference for orthopaedic surgery or medicine and does not represent the "standard of care".  While the information on this site is about health care issues and sports medicine, it is not medical advice. People seeking specific medical advice or assistance should contact a board certified physician.  See Site Terms / Full Disclaimer