Total knee replacement: Those who struggle truly struggle

Total Knee Arthroplasty (TKA), commonly referred to as Total Knee Replacement (TKR), is one procedure that, until recently, went unnoticed by the media. One of the most common disorders I’ve treated patients for in my career is TKAs. I’ve seen many of my patients recover well, and the research is typically in favour of them.

Knee Osteoarthritis - An Overview - Robert Howells

The ones that struggle, however, truly struggle. Up to 30% of patients who get TKA (1) do not see a meaningful improvement, which is A LOT for a procedure that is often performed and is expensive for the healthcare system.

In this blog, I talk about

  • Who often has trouble with TKAs?
  • Alternatives for avoiding negative results.

Even though this article is on TKAs, I think it applies to many other surgical procedures as well as to other types of persistent musculoskeletal pain in general (2).

Before we get to the heart of the matter, it’s crucial to realize that many patients who need or need TKAs may also have additional comorbidities to consider.

⇒Who often struggles with TKAs?

The following are the main indicators of persons who are more likely to have difficulties after a TKA:

  • Obesity – Numerous studies have linked obesity to knee osteoarthritis (OA) and a worse TKA result. It is yet unclear whether this is brought on by increased joint stress, inflammation (5), general ill health, or deconditioning.
  • Smoking – Given that smoking has an impact on blood flow, causes inflammation, and impairs cardiorespiratory function, it is easy to see why smoking is a risk factor for bad outcomes (4) and may “make or break” a decision to have surgery.
  • Psychosocial variables – Unless you’ve been living under a rock or haven’t read a musculoskeletal pain study article in the previous ten years, you’ve probably heard about the connection between psychosocial factors and pain, and this holds true for TKAs (6).
  • Radiographic OA and symptoms are unrelated – The degree of arthritis and joint deterioration seen on an x-ray or MRI is referred to as radiographic OA. It’s interesting to note that a bad TKA result is predicted by detecting very little on the X-ray (7). It makes logic if you give it some thought as well. The goal of orthopaedic surgery is to correct the tissue defect that is to blame for the condition. There may be other causes of the client’s discomfort if there are significant tissue changes but just little pain in the client.

⇒Part 2: How can we avoid TKA complications?

This actually boils down to two main strategies:

  • conversing (when appropriate) with the client’s family physician and surgeon
  • Knowledge of the client’s circumstances and worries about undergoing surgery. In the past when I collaborated with several medical professionals, this may determine whether an individual had surgery or not.
  • Considering the next steps: I sometimes hear from patients that doctors tell them “surgery won’t help you and there’s nothing we can do for you.” There are nearly always methods to advance the situation and lessen pain if the patient is ready to do so, regardless of whether that is what the surgeon really says or what the patient understands.

Considering several possible predictive elements, such as:

  • Body weight: collaborating with nutritionists to assist with lowering body weight and inflammation, as well as by promoting exercise in regions that aren’t bothersome but have some signs of chronic pain (8).
  • Quitting smoking: Depending on your jurisdiction, this can fall outside of your area of expertise and need a referral to another professional.
  • Referrals for mental health to address psychosocial concerns.
  • Suitable rehabilitation programme

Although there is mixed evidence about the effectiveness of prehab after TKA (9), I do think prehab speeds up recovery. Having a better degree of fitness and mobility before to the operation, in my opinion, is more important than everything else.

A client may feel quite overwhelmed by the above while working on it all at once. In a “block periodized” form of recovery, don’t be scared to give various things priority at different periods.

Setting expectations and goals is another crucial aspect with these patients. I dislike it when patients anticipate surgery to be the “cure all” when, at most, there may only be a little to moderate improvement. The patient may feel highly discouraged and disappointed as a result of this. Orthopaedic surgeons, family doctors, and rehab specialists must be extremely open and honest with patients about the anticipated prognosis. Wouldn’t you want your loved one to know what to anticipate from surgery if they were undergoing it?


Although many procedures will still be performed, particularly as society ages, it is probable that more will be done in the future to discourage individuals from having orthopaedic surgery. As a physiotherapist cannot repair a broken ankle or a busted femur, there are still many valid grounds for various orthopaedic procedures. However, there should be more thought given to the selection and preparation of surgical patients.


  1. Kulkarni, K., Karssiens, T., Kumar, V., Pandit, H. (2016). Obesity and osteoarthritis. Maturitas, 89, 22-28. doi: 10.1016/j.maturitas.2016.04.006.
  2. Mohammad, H.R., Gooberman-Hill, R., Delmestri, A., Broomfield, J., Patel, R., Huber, J., Garriga, C., Eccleston, C., Pinedo-Villanueva, R., Malak, T.T., Arden, N., Price, A., Wylde, V., Peters, T.J., Blom, A.W., Judge, A. (2021). Risk factors associated with poor pain outcomes following primary knee replacement surgery: Analysis of data from the clinical practice research datalink, hospital episode statistics and patient reported outcomes as part of the STAR research programme. PLoS One, 16(12), e0261850. doi: 10.1371/journal.pone.0261850.
  3. Ditton, E., Johnson, S., Hodyl, N., Flynn, T., Pollack, M., Ribbons, K., Walker, F.R., Nilsson, M. (2020). Improving Patient Outcomes Following Total Knee Arthroplasty: Identifying Rehabilitation Pathways Based on Modifiable Psychological Risk and Resilience Factors. Front Psychol, 11, 1061. doi: 10.3389/fpsyg.2020.01061.
  4. Wylde, V., Sayers, A., Odutola, A., Gooberman-Hill, R., Dieppe, P., Blom, A.W. (2017). Central sensitization as a determinant of patients’ benefit from total hip and knee replacement. Eur J Pain, 21(2), 357-365. doi: 10.1002/ejp.929.
  5. Gutke, A., Sundfeldt, K., De Baets, L. (2021). Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions. J Clin Med, 10(22), 5397. doi: 10.3390/jcm10225397.
  6. Su, W., Zhou, Y., Qiu, H., Wu, H. (2022). The effects of preoperative rehabilitation on pain and functional outcome after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res, 17(1), 175. doi: 10.1186/s13018-022-03066-9.
  7. Klem, N.R., Smith, A., O’Sullivan, P., Dowsey, M.M., Schütze, R., Kent, P., Choong, P.F., Bunzli, S. (2020)/ What Influences Patient Satisfaction after TKA? A Qualitative Investigation. Clin Orthop Relat Res, 478(8), 1850-1866. doi: 10.1097/CORR.0000000000001284.
  8. Yusuf, E. (2012). Metabolic factors in osteoarthritis: obese people do not walk on their hands. Arthritis Res Ther, 14(4), 123. doi: 10.1186/ar3894.
  9. Klem, N.R., Kent, P., Smith, A, et al. (2020). Satisfaction after total knee replacement for osteoarthritis is usually high, but what are we measuring? A systematic review. Osteoarthritis and Cartilage Open, 2(1) ,100032. DOI: 10.1016/j.ocarto.2020.100032. PMID: 36474554.