Systematic Analysis of Painful Total Knee Prosthesis, a Diagnostic Algorithm



Orthopaedic Hospital Stolzalpe Department of Joint Reconstruction A-8852 Stolzalpe, Austria.


Remaining pain after total knee arthroplasty (TKA) is a common observation in about 20% of postoperative patients; where
in about 60% of these knees require early revision surgery within five years. Obvious causes of this pain could be identified
simply with clinical examinations and standard radiographs. However, unexplained painful TKA still remains a challenge for
the surgeon. The management should include a multidisciplinary approach to the patient`s pain as well as addressing the
underlying etiology. There are a number of extrinsic (tendinopathy, hip, ankle, spine, CRPS and so on) and intrinsic (infection,
instability, malalignment, wear and so on) causes of painful knee replacement. On average, diagnosis takes more than 12
months and patients become very dissatisfied and some of them even acquire psychological problems. Hence, a systematic
diagnostic algorithm might be helpful. This review article aims to act as a guide to the evaluation of patients with painful TKA
described in 10 different steps. Furthermore, the preliminary results of a series of 100 consecutive cases will be discussed.
Revision surgery was performed only in those cases with clear failure mechanism. 


  1. Ohdera T, Tokunaga M, Hiroshima S, Yoshimoto E, Masuda S. Recurrent hemarthrosis after knee joint arthroplasty: etiology and treatment. J Arthroplasty. 2004; 19:157-61.

  2. Barnes CL, Scott RD. Popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty. 1995;10:543-5.

  3. Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty. 1997;12:353-5.

  4. Bilgen O, Atici T, Durak K, Karaeminogullari O, Bilgen MS. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001;29:7-12.

  5. Greidanus NV, Masri BA, Garbuz DS, Wilson SD, McAlinden MG, Xu M, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose before revision total knee arthroplasty: a prospective evaluation. J Bone Joint Surg Am. 2007;89:1409-16.

  6. Bottner F, Wegner A, Winkelmann W, Becker K, Erren M, Götze C. Interleukin-6, procalcitonin and TNF alpha: markers of periprosthetic infection following total joint replacement. J Bone Joint Surg Br. 2007;89:94-9.

  7. Rau C, Thomas P, Thomsen M. Metal sensitivity in patients with joint replacement arthroplasties before and after surgery. Der Orthopäde. 2008; 37: 102-10.

  8. Barrack RL, Jennings RW, Wolfe MW, Bertot AJ. The Coventry Award: the value of preoperative aspiration before total knee revision. Clin Orthop and Relat Res. 1997;345:8-16.

  9. Chimento GF, Finger S, Barrack RL. Gram stain detection of infection during revision arthroplasty. J Bone Joint Surg Br. 1996;78:838-9.

  10. Mason JB, Fehring TK, Odum SM, Griffin WL, Nussmann DS. The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty. 2003;18:1038-43.

  11. Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R. Synovial fluid leucocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004;117:556-62.

  12. Della Valle C, Parvizi J, Bauer TW, Dicesare PE, Evans RP, Segreti J, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18:760-70.

  13. Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J. 2013;95:1450-2.

  14. Stähelin T, Kessler O, Pfirrmann C, Jacob HA, Romero J. Fluoroscopically assisted stress radiography for varus-valgus stability assesment in flexion after total knee arthroplasty. J Arthroplasty. 2003;18:513-5.

  15. Palaestro CJ, Swyer AJ, Kim CK, Goldsmith SJ. Infected knee prosthesis: diagnosis with In-111 leucocyte, Tc-99m sulfur colloid, and c-99m MDP imaging. Radiology. 1991;179:645-8.

  16. Love C, Marwin SE, Palestro CJ. Nuclear medicine and the infected joint replacement. Semin Nucl Med. 2009;39:66-78.

  17. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determing the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res. 1993;286:40-7.

  18. Vince KG. Why knees fail. J Arthroplasty. 2003; 18: 39-44.

  19. Brander VA, Stulberg SD, Adams AD, Harden RN, Bruehl S, Stanos SP, et al. Predicting total knee replacement pain: a prospective, observational study. Clin Orthop Relat Res. 2003;416:27-36.

  20. Brander V, Gondek S, Martin E, Stuhlberg SD. Pain and depression influence outcome 5 years after knee replacement surgery. Clin Orthop Relat Res. 2007;331:216-20.