The well-aligned yet painful total knee arthroplasty: a timeline-based diagnostic approach to persistent postoperative pain

J. S. R. G. Saran; Sahas Nithyanand; Mohith M. P.; Natasha Varghese Isaac; Praneeth D. V. S.; Sujana Theja J. S.

doi:10.18203/issn.2455-4510.IntJResOrthop20263963

Authors

J. S. R. G. Saran Department of Orthopaedics, JSS Academy of Higher Education, Mysuru, Karnataka, India
Sahas Nithyanand Department of Orthopaedics, Nischira Clinic, Mysuru, Karnataka, India https://orcid.org/0009-0001-1158-3745
Mohith M. P. Department of Orthopaedics, Chamarajanagara Institute of Medical Sciences, Chamarajanagar, Karnataka, India https://orcid.org/0009-0003-7204-407X
Natasha Varghese Isaac Department of Orthopaedics, M S Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India https://orcid.org/0009-0001-8825-3779
Praneeth D. V. S. Department of Orthopaedics, Manipal Hospital Yelahanka, Bengaluru, Karnataka, India https://orcid.org/0009-0007-1508-5843
Sujana Theja J. S. Department of Orthopaedics, JSS Academy of Higher Education, Mysuru, Karnataka, India https://orcid.org/0000-0002-7235-7717

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263963

Keywords:

Total knee arthroplasty, Persistent postoperative pain, Painful total knee replacement, Diagnostic algorithm, Central sensitization, Revision arthroplasty

Abstract

Persistent pain following technically successful total knee arthroplasty (TKA) affects 10–20% of patients despite satisfactory implant alignment and stability. Conventional diagnostic algorithms predominantly emphasize structural pathology while often under-recognizing extra-articular and centralized pain mechanisms, contributing to delayed diagnosis and unnecessary revision surgery. This narrative review was conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA). PubMed, Embase and the Cochrane Library were searched from database inception to June 2026 for studies addressing persistent pain after primary TKA. Evidence was synthesized across four domains: intra-articular pathology, extra-articular/referred causes, centralized and psychosocial pain mechanisms, and existing diagnostic algorithms. Based on the available literature, a timeline-stratified diagnostic framework was developed. Persistent pain after well-aligned TKA arises from three principal mechanistic categories: intra-articular, extra-articular/referred, and centralized pain. The differential diagnosis evolves with postoperative timing, with structural complications predominating early, instability and patellofemoral disorders emerging during intermediate follow-up, and aseptic loosening alongside centralized pain becoming increasingly relevant later. The proposed algorithm prioritizes systematic exclusion of infection, targeted assessment of mechanical pathology, evaluation of hip, spine and hindfoot disorders, and mandatory screening for central sensitization and neuropathic pain before considering revision surgery. Persistent pain following well-aligned TKA is multifactorial and requires a structured, timeline-based diagnostic strategy that integrates structural, extra-articular and centralized pain mechanisms. This comprehensive approach may facilitate earlier diagnosis, reduce unnecessary investigations and revision procedures, and support more individualized management while providing a practical framework for future prospective validation.

References

Park CN, White PB, Meftah M, Ranawat AS, Ranawat CS. Diagnostic algorithm for residual pain after total knee arthroplasty. Orthopedics. 2016;39(2):e246–52.

Hofmann S, Seitlinger G, Djahani O, Pietsch M. The painful knee after TKA: a diagnostic algorithm for failure analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19(9):1442–52.

Kim MS, Kim JJ, Kang KH, Kim MJ, In Y. Diagnosis of central sensitization and its effects on postoperative outcomes following total knee arthroplasty: a systematic review and meta-analysis. Diagnostics (Basel). 2022;12(5):1248.

Djahani O, Rainer S, Pietsch M, Hofmann S. Systematic analysis of painful total knee prosthesis, a diagnostic algorithm. Arch Bone Jt Surg. 2013;1(2):48–52.

Brown EC, Clarke HD, Scuderi GR. The painful total knee arthroplasty: diagnosis and management. Orthopedics. 2006;29(2):129-36.

Alves WM Jr, Migon EZ, Zabeu JLA. Pain following total knee arthroplasty: a systematic approach. Rev Bras Ortop. 2010;45(5):384–91.

Olsen U, Lindberg MF, Rose C, Denison E, Gay C, Aamodt A, et al. Factors correlated with pain after total knee arthroplasty: a systematic review and meta-analysis. PLoS One. 2023;18(3).

Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW. Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature. J Arthroplasty. 2017;32(12):3854–60.

Bell SW, Young P, Drury C, Smith J, Anthony I, Jones B, et al. Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee. 2014;21(1):272–7.

Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res. 1998;(356):144–53.

Panni AS, Ascione F, Rossini M, Braile A, Corona K, Vasso M, et al. Tibial internal rotation negatively affects clinical outcomes in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2018;26(6):1636–44.

Hofmann S, Romero J, Roth-Schiffl E, Albrecht T. Rotational malalignment of the components may cause chronic pain or early failure in total knee arthroplasty. Orthopade. 2003;32(6):469–76.

Stambough JB, Edwards PK, Mannen EM, Barnes CL, Mears SC. Flexion instability after total knee arthroplasty. J Am Acad Orthop Surg. 2019;27(17):642–51.

Vajapey SP, Pettit RJ, Li M, Chen AF, Spitzer AI, Glassman AH. Risk factors for mid-flexion instability after total knee arthroplasty: a systematic review. J Arthroplasty. 2020;35(10):3046–54.

Potty AGR, Tzeng TH, Sams JD, Lovell ME, Mihalko WM, Thompson KM, et al. Diagnosis and management of intra-articular causes of pain after total knee arthroplasty. Instr Course Lect. 2015;64:389–401.

Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, et al. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018;33(5):1309–14.e2.

Lim HA, Song EK, Seon JK, Park KS, Shin YJ, Yang HY. Causes of aseptic persistent pain after total knee arthroplasty. Clin Orthop Surg. 2017;9(1):50–6.

Erivan R, Jacquet C, Villatte G, Ollivier M, Paprosky W. Epidemiology of painful knee after total knee arthroplasty in a tertiary care center: assessment by decision tree. Knee. 2020;27(3):1049–56.

Manning BT, Lewis N, Tzeng TH, Saleh JK, Potty AGR, Dennis DA, et al. Diagnosis and management of extra-articular causes of pain after total knee arthroplasty. Instr Course Lect. 2015;64:381–8.

Diao N, Yu F, Yang B, Ma L, Yin H, Guo A. Association between changes in hip-knee-ankle angle and hindfoot alignment after total knee arthroplasty for varus knee osteoarthritis. BMC Musculoskelet Disord. 2021;22(1):610.

Kim MS, Kim JJ, Kang KH, Lee JH, In Y. Central sensitization and neuropathic pain cumulatively affect patients reporting inferior outcomes following total knee arthroplasty. J Bone Joint Surg Am. 2024;106(2):102–9.

Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015;8:21–32.

Momoli A, Giarretta S, Modena M, Micheloni GM. The painful knee after total knee arthroplasty: evaluation and management. Acta Biomed. 2017;88(2 Suppl 2):60–7.

McDowell M, Park A, Gerlinger TL. The painful total knee arthroplasty. Orthop Clin North Am. 2016;47(2):317–26.

Mathis DT, Hauser A, Iordache E, Amsler F, Hirschmann MT. Typical pain patterns in unhappy patients after total knee arthroplasty. J Arthroplasty. 2021;36(6):1947–57.

Mathis DT, Tschudi S, Amsler F, Hauser A, Rasch H, Hirschmann MT. Correlations of typical pain patterns with SPECT/CT findings in unhappy patients after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2022;30(9):3007–23.