36 Management of Patients with Painful Total Knee Replacement: A Multimodal Approach

Abstract

The etiology of persistent “unhappy” knee after a total knee replacement (TKR) is multifactorial, and a multidisciplinary approach is necessary for management. Adequate pain control during the index surgery is of paramount importance and forms the basis of chronic pain management. Newer techniques like preemptive and multimodal analgesia should be used to decrease the perioperative pain sensitization to minimize the incidence of chronic pain. Success of management of chronic pain lies in the accuracy of the diagnosis after an extensive evaluation. The key is pursuing a multidisciplinary approach for each individual case, including the surgeon, physiotherapists, pain management physicians, internist, rheumatologists, psychologist, and any consultant specialist on referral basis. A pain specialist should be involved early in the management of these patients specifically for the prevention of a chronic pain syndrome. Most patients with a chronic painful TKR can be managed by a multimodal conservative approach. Revision surgery should be avoided in patients with unexplained pain and without any recognized pathology since they may improve over a period of time and results of revision surgery are inferior and unpredictable. An “unhappy” TKR is a difficult problem to treat, but understanding these principles can turn this “unhappiness” into a successful outcome.