Total knee replacement (TKR) is a common surgical approach for treating degenerative and musculoskeletal disorders such as knee osteoarthritis (OA) or acute knee trauma.1,2 However, many patients who undergo TKR experience prolonged pain and limitations with mobility related to the surgery.3,4 On the basis of a systematic review of 11 studies on knee replacement, including 12,800 patients who underwent TKR, 10-34% of patients experience long-lasting pain related to TKR.3 Individuals should experience improvements in their pain and mobility within six to eight weeks postoperatively; however, some patients may not reach full capacity for daily activities until at least six months postoperatively, with 13% experiencing moderate to severe pain 12 months after TKR.5
While patients preparing to undergo TKR may experience some stress, preoperative stress can have lasting impacts on the recovery process and success of the surgery.5,6 One prospective observational study evaluated 116 patients with OA at 1, 3, 6, and 12 months post-TKR to describe the course of pain and identify factors leading to prolonged pain after TKR.5 Half of these patients who underwent knee replacement reported that their pain was resolved within three months; however, about 13% reported moderate to severe pain after one year despite normal radiographic evidence and clinical criteria that their TKR was clinically successful. Individuals reporting higher levels of depression and anxiety preoperatively were more likely to experience prolonged pain ranked moderate to severe a year after the TKR was completed compared to those with lower levels of anxiety and depression before surgery.5
A qualitative study using focus groups with 22 patients described the most common stressors patients undergoing knee replacement face in the first few weeks after TKR. Some of the most common stressors were levels of pain, adequate pain management, physical therapy, and dependency on others, highlighting the need for preoperative education around these topics.7 Transitioning to post-operative care and rehabilitation was difficult for many patients undergoing knee replacement due to unrealistic postoperative expectations. These included the amount of time and effort required for recovery, lack of independence after surgery, and expectations about the time frame for returning to work or achieving certain fitness goals that were set preoperatively .7-9 Strategies to control preoperative and postoperative stress may be effective in reducing pain and increasing mobility after knee replacement surgery.5-7
Patients with higher self-efficacy, social support, and locus of control, or feelings of being in control over the outcomes of their life, demonstrated quicker recovery times and greater improvements in pain and mobility compared to patients who did not.8,10-12 Patients undergoing knee replacement were not used to heavily depending on others for activities of daily living. This dependence on others was cited as a source of stress for knee replacement patients and is vital to their recovery from surgery. An analysis of 1,722 patients undergoing knee and hip replacement over the course of 24 months at four different hospitals measured the importance of social support in recovering from joint replacement surgery.13 The data indicated that those with stronger social support were discharged from the hospital sooner (2.7 days vs. 3.6 days, p<0.05), discharged to home more frequently (95.6% vs. 57.1%, p<0.0001), and were more confident in their ability to take control of their recovery after discharge (81.5% vs. 33.3%, p<0.0001) compared to patients with lower levels of social support.13 Self-efficacy and locus of control can be fostered in patients through relaxation and breathing techniques14 while social support can be achieved through relationships with family, friends, and professionals.5,7,8,10,13,15
Physical therapy and rehabilitation exercises are important for TKR recovery. Patients who challenge their selves to move their bodies shortly after surgery often experience better outcomes. One randomized control trial (n=44) compared a standard of care exercise program to an intense exercise and behavioral intervention program for patients after TKR. Individuals in the intervention arm experienced a greater improvement in pain level (−7.8 ± 6.1 vs. 5.4 ± 9.4, p=0.035), physical function (20.2 ± 17.7 vs. 6.8 ± 17.3, p=0.017), and single-leg stance (2.0 ± 4.2 vs. −1.9 ± 4.4, p=0.037) compared to patients in the standard of care arm.16 While rehabilitation is important for TKR recovery, it is often difficult for patients to adhere to rehabilitation exercises due to postoperative pain.5,16,17 While pain management is an important factor in joint replacement surgery, pain medications should be tapered or returned to presurgical doses in patients with chronic pain within six weeks of surgery.18-20 Patients who experience prolonged pain after TKR may adopt other pain management strategies, such as ice or heat therapy, and over-the-counter pain relievers under the guidance of their physician.18,21
- Dieppe P, Basler H, Chard J, et al. Knee replacement surgery for osteoarthritis: effectiveness, practice variations, indications and possible determinants of utilization. Rheumatology (Oxford) 1999; 38 (1): 73-83.
- Benazzo F, Rossi SM, Ghiara M, et al. Total knee replacement in acute and chronic traumatic events. Injury 2014; 45: S98-S104.
- Beswick AD, Wylde V, Gooberman-Hill R, et al. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2 (1).
- Ethgen O, Bruyere O, Richy F, et al. Health-related quality of life in total hip and total knee arthroplasty: a qualitative and systematic review of the literature. JBJS 2004; 86 (5): 963-974.
- Brander VA, Stulberg SD, Adams AD, et al. Ranawat award paper: Predicting total knee replacement pain: A prospective, observational study. Clin Orthop Relat Res 2003; 416: 27-36.
- Edwards RR, Haythornthwaite JA, Smith MT, et al. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Res Manag 2009; 14 (4): 307-311.
- Barksdale P, Backer J. Health-related stressors experienced by patients who underwent total knee replacement seven days after being discharged home. Orthop Nurs 2005; 24 (5): 336-342.
- Showalter A, Burger S, Salyer J, et al. Patients' and their spouses' needs after total joint arthroplasty: a pilot study. Orthop Nurs 2000; 19 (1): 49.
- Scott C, Howie C, MacDonald D, et al. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br 2010; 92 (9): 1253-1258.
- Kendell K, Saxby B, Farrow M, et al. Psychological factors associated with short‐term recovery from total knee replacement. Br J Health Psychol 2001; 6 (1): 41-52.
- Keefe FJ, Caldwell DS, Martinez S, et al. Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery. Pain 1991; 46 (2): 153-160.
- Wylde V, Dixon S, Blom A. The role of preoperative self‐efficacy in predicting outcome after total knee replacement. Musculoskeletal Care 2012; 10 (2): 110-118.
- Theiss MM, Ellison MW, Tea CG, et al. The connection between strong social support and joint replacement outcomes. Orthopedics 2011; 34 (5): e50-e58.
- Ayers S, Baum A, McManus C, et al. Cambridge Handbook of Psychology, Health and Medicine. Cambridge University Press; 2007.
- Lin C-WC, March L, Crosbie J, et al. Maximum recovery after knee replacement–the MARKER study rationale and protocol. BMC Musculoskelet Disord 2009; 10 (1): 1-8.
- Piva SR, Almeida GJ, Gil AB, et al. Effect of comprehensive behavioral and exercise intervention on physical function and activity participation after Total knee replacement: a pilot randomized study. Arthritis Care Res (Hoboken) 2017; 69 (12): 1855-1862.
- Rosal MC, Ayers D, Li W, et al. A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement. BMC Musculoskelet Disord 2011; 12 (1): 1-7.
- AMDG 2015 interagency guideline on prescribing opioids for pain. Washington State Agency Medical Directors’ Group. http://agencymeddirectors.wa.gov/guidelines.asp.
- Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015; 90 (6): 828-842.
- Fujii MH, Hodges AC, Russell RL, et al. Post-discharge opioid prescribing and use after common surgical procedure. J Am Coll Surg 2018; 226 (6): 1004-1012.
- Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016; 17 (2): 131-157.