The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Botulinum Toxin A for Post-Arthroplasty Complications: A Systematic Review of Efficacy and Safety in TKA and THA

Document Type : SYSTEMATIC REVIEW

Authors
Amir-Mohammad Asgari 1
Mohammad Soleimani 2
Amirhossein Salmannezhad 3
Aida Orce Rodriguez 4
Andrew Shimmin 5
Seyyed Hossein Shafiei 2
Mohammadreza Golbakhsh 2
1 School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Orthopedic Smart-technologies Research Lab, Tehran University of Medical Sciences, Tehran, Iran - Department of Orthopedic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Student Research Committee, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
4 Hospital Vithas Las Palmas, Las Palmas de Gran Canaria, Las Palmas, Spain
5 Consultant Orthopaedic Surgeon Melbourne Orthopaedic Group (MOG), Melbourne, Australia - Monash University, Department of Surgery, School of Clinical Sciences, Melbourne, Australia
10.22038/abjs.2026.93251.4216
Abstract
Objectives: To systematically review and synthesize available human studies investigating the efficacy and safety of botulinum neurotoxin type A (BoNT/A) injections for managing complications following total knee arthroplasty (TKA) and total hip arthroplasty (THA).
Methods: A systematic search of Medline/PubMed, Web of Science, Scopus, and Embase was conducted up to May 2025 per PRISMA 2020 guidelines. Eligible studies enrolled adults who had undergone THA or TKA and received ≥50 units (U) of intra-articular or intramuscular BoNT/A for postoperative pain, stiffness, or musculoskeletal dysfunction. The assessed outcomes included range of motion (ROM), pain scores measured using the Visual Analog Scale (VAS) or Numeric Rating Scale (NRS), functional scores including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Knee Society Score (KSS), and adverse events.
Results: Thirteen studies met the inclusion criteria, including two RCTs and eleven case studies, with a total of 92 patients. In patients undergoing TKA, BoNT/A was primarily injected into hamstring or gastrocnemius muscles, with doses from 50 to 400 U. Improvements in ROM, KSS, and pain scores were reported in most studies, though statistical significance was inconsistent. In patients undergoing THA, BoNT/A injected into hip adductors, iliopsoas, and tensor fascia lata was associated with reduced flexion contractures and pain, and improved HHS and ODI. No major adverse events were reported; minor effects included bruising and flu-like symptoms.
Conclusion: BoNT/A injections appear to be safe and may be effective for managing chronic pain and flexion contractures following TKA and THA. However, heterogeneity in study design, small sample sizes, limited controls, and variable outcome measures limit the strength of the current evidence. Further high-quality randomized controlled trials are required to establish optimal dosing, timing, injection sites, and to confirm the clinical benefits of BoNT/A in this population.
Level of evidence: III
Keywords
Botulinum toxin type A
Chronic pain
Flexion contracture
Range of motion
Systematic review
Total hip arthroplasty
Total knee arthroplasty
Subjects
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The Archives of Bone and Joint Surgery
Volume 14, Issue 11
November 2026
Pages 699-710

  • Receive Date 09 December 2025
  • Revise Date 23 May 2026
  • Accept Date 24 May 2026