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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

  • Gonzalez MH, JAAOS 2004;12:436-446