Diagnosis and Management of Extra-Articular Causes of Pain After Total Knee Arthroplasty

Diagnosis and Management of Extra-articular Causes of Pain After Total Knee Arthroplasty

Blaine T. Manning, BS Natasha Lewis, MD Tony H. Tzeng, BS Jamal K. Saleh, BS Anish G.R. Potty, MD Douglas A. Dennis, MD William M. Mihalko, MD, PhD Stuart B. Goodman, MD, PhD Khaled J. Saleh, MD, MSc, FRCSC, MHCM

Abstract Postoperative pain, which has been attributed to poor outcomes after total knee arthroplasty (TKA), remains problematic for many patients. Although the source of TKA pain can often be delineated, establishing a precise diagnosis can be challenging. It is often classi- ﬁ ed as intra-articular or extra-articular pain, depending on etiolog y. After intra-articular causes, such as instability, aseptic loosening, infection, or osteolysis, have been ruled out, extra-articular sources of pain should be considered. Physical examination of the other joints may reveal sources of localized knee pain, including diseases of the spine, hip, foot, and ankle. Additional extra-articular pathologies that have potential to instigate pain after TKA include vascular pathologies, tendinitis, bursitis, and iliotibial band friction syndrome. Patients with medical comorbidities, such as metabolic bone disease and psychological illness, may also experience prolonged postoperative pain. By better understanding the diagnosis and treatment options for extra-articular causes of pain after TKA, orthopaedic surgeons may better treat patients with this potentially debilitating complication. Instr Course Lect 2015;64:381–388.

By 2030, the demand for total knee ar- suggest that 11% to 25% of patients There is a lack of consensus regard- throplasty (TKA) in the United States treated with TKA are dissatisfi ed with ing the effect of age and sex on pain is expected to quadruple from current their postoperative outcomes, largely after TKA. Although certain studies levels to nearly 3.5 million procedures because of pain.3 A study by Puolakka have cited female sex and younger age annually.1 Although the safety and et al4 found that 36% of TKA patients as important predictors of postoper- effi cacy of TKA is well known, post- reported daily pain. Hawker et al5 re- ative pain, other research, including operative pain remains problematic ported similar fi ndings in patients the 2003 National Institutes of Health and has been attributed to most poor treated with TKA at 2 to 7 years consensus statement, reported a lack outcomes after TKA.2 Recent reports postoperatively. of correlation between age, sex, and

Table 1 to knee pathology. Additional symp- Potential Sources of Postoperative Pain After Total toms, including delayed onset of post- Knee Arthroplasty operative pain, a sharp catching pain during movement, joint instability, Intra-articular Extra-articular or an abnormal radiographic fi nding, Infection Hip disease may indicate intra-articular causes. An Crystalline disease Foot and ankle disease intra-articular injection of a local anes- Instability Neurologic/spine disease thetic also can be used to rule out an Component malalignment Tendinitis/bursitis intra-articular source of pain. Limb malalignment Iliotibial band syndrome Aseptic loosening Psychological factors Hip Disease Soft-tissue irritation Heterotopic ossifi cation Pain can be referred from the hip to Component wear Connective tissue disorders the knee via the obturator and femo- Osteolysis Material hypersensitivity ral nerves originating from L2-L4.16 Extensor mechanism pathology Unexplained pain Immunohistochemistry staining has Recurrent hemarthrosis been used to demonstrate the location of referred pain from the hip joint, and pain after TKA.6-14 Younger patients extra-articular etiologies should be infl uoroscopically guided diagnostic hip are known to have greater expectations vestigated. Ruling out infection should injections have been used to map pat- for improved performance after TKA; be the fi rst step in diagnosing the source terns of referred pain to the knee.16,17 however, the effects of these expecta- of postoperative pain after TKA, and Mechanical knee pain can result from tions and higher postoperative activity the clinical practice guidelines on this increased knee torque resulting from levels and the lower expectations of topic from the American Academy of decreased hip rotation or altered gait older patients remain unclear.2 Orthopaedic Surgeons can help direct from various diseases affecting the hip Regardless of a patient’s risk factors, the evaluation.15 Obtaining a thorough joint. Patients with severe hip osteo- the diagnosis of an aseptic, painful history may aid in distinguishing be- arthritis who are awaiting hip arthro- TKA may be confounded by a myriad tween intra- and extra-articular pain plasty may have pain that is localized of potential intra- and extra- articular sources, because a lack of pain relief to the anterior and posterior aspects of causes (Table 1). If preoperative immediately after TKA could suggest the knee. Several studies have demon- symptoms are not relieved by TKA, that the initial pain was not attributable strated the association between various

Mr. Manning or an immediate family member serves as a paid consultant to or is an employee of the Southern Illinois University School of Medicine. Mr. J. Saleh or an immediate family member has received royalties from Aesculap/B. Braun; is a member of a speakers’ bureau or has made paid presentations on behalf of Carefusion; serves as a paid consultant to or is an employee of Aesculap/B. Braun and Watermark; has received research or institutional support from Smith & Nephew and the National Institutes of Health/National Institute of Arthritis and Musculoskeletal Skin Diseases; and serves as a board member, owner, offi cer, or committee member of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, and Blue Cross Blue Shield. Dr. Dennis or an immediate family member has received royalties from DePuy and Innomed; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy; serves as a paid consultant to or is an employee of DePuy; has stock or stock options held in Joint Vue; has received research or institutional support from DePuy and Porter Adventist Hospital; and serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons, the Hip Society, Joint Vue, the International Congress for Joint Reconstruction, and Operation Walk USA. Dr. Mihalko or an immediate family member has received royalties from Aesculap/B. Braun; is a member of a speakers’ bureau or has made paid presentations on behalf of Aesculap/B. Braun; serves as a paid consultant to or is an employee of Aesculap/B. Braun and Medtronic; has received research or institutional support from Aesculap/B. Braun; and serves as a board member, owner, offi cer, or committee member of the American Orthopaedic Association and ASTM International. Dr. Goodman or an immediate family member serves as an unpaid consultant to Accelalox, Biomimedica, and Tibion; has stock or stock options held in Accelalox, Biomimedica, StemCor, and Tibion; has received research or institutional support from Baxter; and serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons Biological Implants Committee. Dr. Saleh or an immediate family member has received royalties from Aesculap/B. Braun; serves as a paid consultant to or is an employee of Southern Illinois University School of Medicine Division of Orthopaedics, Aesculap, the Memorial Medical Center Co-Management Orthopaedic Board, the Blue Cross Blue Shield Blue Ribbon Panel, Watermark, Stryker, and the Exactech Data Safety Monitoring Board; has received research or institutional support from Smith & Nephew, the Orthopaedic Research and Educational Foundation, National Institutes of Health/National Institute of Arthritis and Musculoskeletal Skin Diseases (R0-1); and serves as a board member, owner, offi cer, or committee member of the American Orthopaedic Association Finance Committee, the Orthopaedic Research and Education Foundation Industry Relations Committee, the Orthopaedic Research and Education Foundation Clinical Research Awards Committee, and the American Board of Orthopaedic Surgeons. None of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Lewis, Mr. Tzeng, and Dr. Potty.

forms of hip disease, including osteo- useful in ruling out foot and ankle-re- Nevertheless, patients with LSS who arthritis, infection, hip fracture, and lated etiologies in patients with pain undergo TKA have been shown to posterior hip dislocation, with ipsilat- after TKA. have comparable outcomes to control eral knee pain.18-21 Other sources of hip patients with regard to revision rates disease, such as osteonecrosis, dysplasia, Vascular Disease and radiographic outcomes despite their and implant loosening after total hip Vascular diseases, such as lower extrem- lower preoperative functional scores.37 arthroplasty, can present as knee pain. ity peripheral artery disease (PAD) or LSS is often idiopathic and presents Stress fractures, including femoral neck, thrombosis, also have potential to con- as intermittent neurogenic claudica- pubic, and subtrochanteric stress frac- tribute to symptoms of leg pain and are tion caused by the compression of the tures, are rare complications after TKA common in older patients. Although of- cauda equina, which results from en- in patients with poor bone quality but ten useful as indicators for PAD, neither largement of the bony and soft tissues can be secondary causes of pain.22-26 the presence of known risk factors (such associated with the spinal canal. In a Generally, all patients who present with as hyperlipidemia, cardiac disease, and study of 100 patients, Amundsen et al38 knee pain should have a physical exam- diabetes) nor symptoms of claudication reported additional common symptoms ination of the ipsilateral hip to screen are defi nitive predictors of PAD.32,33 In of back pain, leg pain, weakness, and for pathology. If a painful or decreased a study of 50 consecutive patients re- voiding disturbances. Double nerve range of hip motion is noted after TKA, ferred to an orthopaedic surgeon for leg root involvement is typical, and the radiographic studies are recommended. pain, Bernstein et al34 noted that 20% L5 nerve root is the most commonly had undiagnosed PAD. Assessing for affected (prevalence of 91%), followed Foot and Ankle Disease PAD via pulse volume recording or by S1 (63%), L1-4 (28%), and S2-5 (5%). Malalignment of the hindfoot re- ankle-brachial pulse indexing (an index In patients with suspected LSS, a sulting in excess valgus alignment of of <0.9 may indicate PAD) is neither thorough physical examination should the heel secondary to posterior tib- invasive nor costly, especially given the be conducted to rule out any other ial tendon insuffi ciency or pes planus frequency of PAD in patients without a pathology that may be the source of increases stress forces on the knee.27 history of trauma or claudication who referred pain to the legs. Sensory ex- This hindfoot valgus leads to increased present with leg pain.34 amination should include vibration, lateral loading of the knee because of Indirect injury to arteries via com- proprioception, and pin-prick testing changes in ground reactive forces and pression can occur during TKA as ex- in the appropriate nerve distribution an increased valgus thrust.28 Bhave ternal forces applied to diseased vessels regions. Loss of tendon refl exes, sciatic et al29 reported that patients with pla- during tourniquet application can lead notch tenderness, and reduced lumbar novalgus malalignment had substan- to vascular damage, plaque disruption, lordosis may also be present in patients tial postoperative pain relief with shoe and subsequent thrombus formation. with suspected LSS. Motor weakness modifi cations. In addition to a physical Thrombosis is one of the most com- typically presents in the L5 nerve dis- examination, screening for malalign- mon causes of vascular insuffi ciency tribution. Amundsen et al38 reported ment of the hindfoot and ankle also after TKA and can be confi rmed with sensory changes in 51% of patients can be performed during radiographic Doppler imaging secondary to a posi- with LSS, refl ex changes in 47%, lum- measurement of the weight-bearing tive Homan sign.35 If an extra-articular bar tenderness in 40%, reduced spinal axis. Numerous studies have noted the source of pain after TKA is suspected, mobility in 36%, a positive straight- effi cacy of including the hindfoot dis- the presence of vascular diseases should leg–raising test in 24%, weakness in tal to the ankle and subtalar joint in an be investigated. 23%, and perianal numbness in 6%. If assessment of the ground mechanical a clinical diagnosis of LSS is indicated, axis deviation.27,28,30,31 A comprehensive Lumbar Spine and imaging studies should be used for con- radiographic evaluation of the rearfoot, Neurologic Disorders fi rmation. Upright plain radiographs are ankle, and leg taken in multiple planes Lumbar spinal stenosis (LSS) has an useful for excluding other spine pathol- and angles may be appropriate before incidence as high as 8% and is a com- ogies, and CT and MRI can confi rm TKA in select patients and can be mon cause of leg pain in older adults.36 nerve compression.38

Other neurologic disorders, such site. Pain relief is often a confi rmation infrapatellar, pes anserine, and semi- as complex regional pain syndrome of a cutaneous neuroma, which can be membranosus) that can become acutely (CRPS) and cutaneous neuroma, also subsequently treated with a variety of infl amed and lead to knee pain (Fig- have the potential to contribute to the nonsurgical interventions such as local ure 1). The occurrence of a popliteal incidence of pain after TKA. Previ- anesthetics or spinal cord stimulation. cyst is commonly associated with knee ously referred to as refl ex sympathetic If nonsurgical measures prove unsuc- arthritis or meniscal injury and is usu- dystrophy, CRPS symptoms include cessful, cutaneous nerve resection may ally secondary to infl ammation of the cutaneous hypersensitivity, abnormal be warranted.41,44 In a series of patients semimembranosus bursa. Rauschning47 skin color, edema, motor function im- who received a diagnosis of cutaneous showed evidence of a defect in the pairment, and abnormal sudomotor ac- neuroma after TKA, Katz and Hun- posteromedial capsule that communi- tivity.39,40 The occurrence of CRPS after gerford41 found that 87% reported cated with the semimembranosus bursa, TKA is rare; a diagnosis of CRPS was substantial improvement in visual displacing the semimembranosus and made in only 5 of 662 patients (0.8%) analog scale pain scores after sympa- gastrocnemius tendons in 46% of the in a recent series.41 As a testament to thetic blockade or sympathectomy by cadavers with no previous history of the elusiveness of a CRPS diagnosis, an anesthesiologist. knee surgery or disease. Infl ammation the mean diagnostic time in this patient of the semimembranosus bursa via an group was 5 months postoperatively. Tendinitis, Bursitis, and intra-articular communication typically Although the pathophysiologic Iliotibial Band Syndrome presents as a classic Baker cyst (Fig- mechanisms of CRPS remain unclear, Posterolateral knee pain after TKA can ure 2). Huang et al48 reported a rare the condition is thought to be initi- arise from a variety of sources. Pandher case of foreign body–mediated chronic ated by sensitization of nociceptive et al45 reported a case of biceps tendi- pes anserinus bursitis induced by poly- nerve fi bers by trauma.42,43 Regardless nitis as the etiology of an acutely pain- ethylene particles that caused pain, of etiology, the diagnosis of CRPS of- ful knee after TKA. Infl ammation of swelling, and drainage. ten consists of excluding other painful the popliteus tendon also can present Iliotibial band traction/friction conditions. A variety of tests, includ- with posterolateral knee pain secondary syndrome should be considered in pa- ing infrared thermography, quantita- to irritation from a laterally displaced tients with a painful range of motion tive sensory testing, sudomotor testing, femoral component, retained postero- (specifi cally between 20° to 80°) and and bone scintigraphy, can be used to lateral osteophyte or cementophyte, with pain localized to the lateral fem- rule out other painful conditions and or posterolateral tibial tray overhang. oral epicondylar region.49,50 Luyckx et differentiate CRPS. In TKA patients Alternatively, quadriceps and patellar al49 reported a 7.2% incidence of ilio- with suspected CRPS, orthopaedic tendinitis will present with anterior tibial band traction/friction syndrome disorders with CRPS-like symptoms knee pain and typically result from a in a cruciate-substituting TKA design. (such as rheumatic arthritis, tendon traumatic or overuse injury. The increased incidence was attribut- infection, or migratory osteoporosis) Semimembranosus tendinitis has ed to excessive lateral femoral condyle should be ruled out fi rst. Treatment of been reported as a source of pain after translation and internal rotation of the CRPS typically centers on therapeutic TKA.46 It typically presents as pain in tibia, leading to excessive tension on the interventions. Sympathetic blockade the posteromedial knee that radiates into iliotibial band. This syndrome can be by an anesthesiologist, electrotherapy, the posterior thigh or calf region and elicited using the Ober, Thomas, and occupational therapy, physical therapy, worsens in deep knee fl exion. Physical Noble tests, and it typically presents as and proper counseling are often neces- examination fi ndings typically consist of an overuse injury in conjunction with sary in managing patients with CRPS. tenderness to palpation at the semimem- increased iliotibial band tightness.51 An Cutaneous and subcutaneous neu- branosus tibial insertion and increased Ober test is conducted with the patient romas are another rare neurosensory pain during passive deep fl exion. MRI lying on his or her side. After fl exion disorder that can cause pain after TKA is useful in confi rming the diagnosis. of the knee to 90° and extension and and are often diagnosed by injecting Surrounding the knee are multi- abduction of the affected hip by the ex- lidocaine into the suspected neuroma ple periarticular bursae (prepatellar, aminer, support of the knee is released.

Figure 2 MRI demonstrating inﬂ ammation of the semimembranosus bursa and subsequent Baker cyst formation (arrow). Figure 1 Illustration of some of the prominent knee bursae.

stages of heterotopic ossifi cation be- Failure of the hip to adduct indicates a surgical release of the iliotibial band cause calcium deposition in the bone positive test. The Thomas test is con- may be necessary. matrix and developmental alkaline ducted with the patient supine. After the phosphatase elevation do not occur examiner places his or her hand under Heterotopic Ossification until several weeks after the initial on- the lumbar spine to prevent hyperlordo- Oxidative stress from hypoxic environ- set of heterotopic ossifi cation. Bone sis, the unaffected hip and knee are fully ments often induces production of mast scanning may be useful for a defi ni- fl exed. The patient holds the knee. A cells and fi broblast growth factor, which tive diagnosis and is known to detect positive sign is indicated by the affected in turn undergo metaplastic transfor- heterotopic ossifi cation earlier than leg raising off the table. Both legs can mation and leads to fi brocartilage for- radiographs or laboratory testing.56 then be fully fl exed, and the affected leg mation with subsequent endochondral Either a NSAID (such as indometh- is slowly lowered back into extension. ossifi cation and bone formation.52 Het- acin), diphosphonate (such as ethane- A lack of full extension may indicate erotopic ossifi cation can be asymptom- 1- hydroxy-1,1-diphosphate), or local iliopsoas tightness, and any external atic or associated with a loss of motion radiation therapy is recommended for rotation may suggest iliotibial band in addition to catching and snapping the treatment or prophylaxis of hetero- tightness. With the patient supine, the that is localized to the patellofemoral topic ossifi cation.57 Noble test is conducted by fl exing the joint. The incidence of heterotopic ossi- affected hip and knee to 90° and placing fi cation varies widely, with an increased Fibromyalgia and Connective pressure on the lateral femoral epicon- incidence in heavier patients, men, and Tissue Disorders dyle with the thumb. With continuing patients with larger preoperative de- Although the precise source of pain pressure, the leg is passively and slowly formities.53 Patients at elevated risk for in fi bromyalgia remains unknown, it extended. A positive test is indicated by heterotopic ossifi cation include those clearly depends on peripheral nocicep- the presence of pain at 30° of fl exion. with previous heterotropic ossifi cation, tive input as well as abnormal central Many cases of iliotibial band trac- bilateral hypertrophic osteoarthritis, pain processing.58 Some studies have tion/friction syndrome resolve with and posttraumatic osteoarthritis with suggested soft-tissue infl ammation as nonsurgical treatments, including hypertrophic osteophytosis.54,55 the source of pain in fi bromyalgia be- anti-in fl ammatory medications or lo- Radiographs and laboratory testing cause pain and weakness of the muscles cal steroid injections. If pain persists, are rarely helpful in detecting early is one of its main symptoms. Changes

indicating disturbed microcirculation, psychological predictor of poor out- warranted in a select subset of suscep- mitochondrial damage, and a reduction comes after TKA.65,66 Patients who tible patients. in high-energy phosphates all suggest catastrophize about their pain ruminate an energy-defi cient state in the rest- more often about their pain, magnify Summary ing, painful muscles of patients with its perceived threat, and experience Determining the cause of pain after fi bromyalgia.59 Although fi bromyalgia is greater feelings of helplessness when TKA can be a challenging task for an characterized by allodynia and chronic dealing with pain. Patients with higher orthopaedic surgeon. With a thorough pain, it should not be considered a con- preoperative pain and anxiety levels patient history, examination, and ap- traindication for TKA because patients typically report extended postoperative propriate diagnostic approach, most with fi bromyalgia have shown improve- TKA pain and diminished function.11 sources of pain can be identifi ed. After ment similar to that of control patients It is imperative to carefully monitor sepsis and intra-articular causes have after TKA.60,61 Nevertheless, these and, if necessary, refer for further psy- been ruled out, extra-articular sources patients have reported lower postop- chological treatment patients who may should be investigated. If the source erative satisfaction, largely because of experience diminished postoperative of pain cannot be identifi ed, revision higher levels of persistent postoperative outcomes because of anxiety, catastro- arthroplasty alone is unlikely to relieve pain.60,61 The criteria set forth by the phizing, or other psychological mala- symptoms. By establishing an accurate American College of Rheumatology are dies known to intensify pain. etiology in a timely manner, unneces- useful in diagnosing fi bromyalgia; treat- sary diagnostic testing will be avoided ment typically consists of medications Metal Hypersensitivity and the patient can be appropriately or therapy.62 There is a paucity of clinical studies treated. Rarer connective tissue disorders, correlating positive hypersensitivity such as Ehlers-Danlos syndrome, also results with clinical TKA outcomes.67,68 References have potential to cause chronic pain in Nevertheless, metal hypersensitivity has 1. Kurtz S, Ong K, Lau E, Mowat F, TKA patients. Defi ciencies of colla- been described previously as a type IV Halpern M: Projections of primary and revision hip and knee arthro- gen production in TKA patients with immunologic reaction and also may be plasty in the United States from Ehlers-Danlos syndrome has been considered as an unlikely cause for a 2005 to 2030. J Bone Joint Surg Am shown to instigate pain via degener- painful TKA if all other causes have 2007;89(4):780-785. ation and destabilization of the knee been ruled out.69 Hypersensitivity re- 2. Fehring TK, Odum S, Griffi n WL, 63 Mason JB, Nadaud M: Early failures joint. In a case series of 10 TKA pa- actions typically occur in the peripros- in total knee arthroplasty. Clin Orthop tients with Ehlers-Danlos syndrome, thetic region in the months after TKA. Relat Res 2001;392:315-318. approximately 30% reported dissatis- Although rarely used, in vitro prolifera- 3. Seil R, Pape D: Causes of failure and faction with TKA because of continued tion testing via lymphocyte transforma- etiology of painful primary total knee pain and instability.64 Although rare, a tion testing may be useful in assessing arthroplasty. Knee Surg Sports Traumatol Arthrosc 2011;19(9):1418-1432. diagnosis of Ehlers-Danlos syndrome sensitivity to metal implants. Lympho- should be confi rmed through genetic cyte transformation testing consists of 4. Puolakka PA, Rorarius MG, Roviola M, Puolakka TJ, Nordhausen K, testing and treated with a combination measuring lymphocyte proliferation Lindgren L: Persistent pain following of physical therapy and pain-relieving after activation in vitro and compar- knee arthroplasty. Eur J Anaesthesiol and anti-infl ammatory medications. ing the fi ndings with in vivo levels. 2010;27(5):455-460. Skin patch testing for nickel, cobalt, or 5. Hawker GA, Stewart L, French MR, Psychological Factors and chromium reaction may also be useful et al: Understanding the pain experience in hip and knee osteoarthritis: Pain Catastrophizing in detecting metal hypersensitivity in An OARSI/OMERACT initiative. Os- The potential for psychological factors TKA patients, although the correla- teoarthritis Cartilage 2008;16(4):415-422. to infl uence a patient’s perceptions of tion between a positive test and symp- 6. Singh JA, Gabriel S, Lewallen D: pain after TKA is well known, be- tom presentation remains unclear.3,70 The impact of gender, age, and preoperative pain severity on pain cause pain catastrophizing has been Hypoallergenic implants (specifi cally after TKA. Clin Orthop Relat Res desig nated a consistent and powerful those that do not contain nickel) are 2008;466(11):2717-2723.

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