PAIN AFTER SURGERY

Pain can occur for many reasons. Being subjective, pain is difficult to interpret. The art of being a good surgeon or physio is to try and sort out if this pain is expected or if there is something that can be fixed, either non operatively or with surgery.

The perception of pain varies widely amongst individuals. One extreme is someone with terrible arthritis who says they have no pain. The other extreme is the patient who is in severe pain with no identifiable pathology.

ARTHROSCOPIES

This is a simple procedure, but do have varying results. As a surgeon we never expect to cure all our patients. The success of an arthroscopy reduces with the degree of articular cartilage damage (i.e. the more arthritis you have, the less successful surgery is). Not uncommonly, MRIs are not as accurate as we would like and you can get nasty surprises. On the flip side, a young person with a simple meniscal tear should get better.

If someone continues to have pain after an ARTHROSCOPY:

Find out who the surgeon is
Try and get hold of the operation report
If a patient has unexpected pain or is unhappy, ask them to seek a second opinion but wait at least a few months.

If someone continues to have pain after LIGAMENT SURGERY:

Pain can be due to intraarticular pathology or it can be secondary to hardware problems. Screws can be prominent under the skin. Other devices can also protrude or move over time.
This may be obvious but an x-ray or MRI is often needed.

It is amazing how helpful a simple x-ray can be. After ACLR it is very common to get anterior knee pain, more so with patella tendon grafts. This can take 6-12 months to settle down. Longstanding hamstring pain is rare but early on is quite common. Ongoing instability or failure of the graft is not really a cause for pain.

If someone continues to have pain after MCL:

Pain after MCL injuries is rare and if this does occur in the absence of instability, is difficult to treat surgically.
MCL instability is a cause of pain, both on the medial side due to the valgus thrust but also on the lateral side as more weight is placed on this side.
If this occurs a reconstruction or an osteotomy may be required.

If someone continues to have pain after a MENISCAL REPAIR:

Pain is usually due to a retear or the tear never healing.
Success of repair is dependant on numerous factors but success is probably around 70%. It is more successful in the younger patient and in those who have an ACLR at the same time.

If someone continues to have pain after a KNEE REPLACEMENT:

Unless you treat a lot of these, it is probably hard to know what to expect.
Most people are in reasonable pain for 4-6 weeks. You can do no harm to the prosthesis.
The main aim in the first 6 weeks is to get full extension and as much flexion as possible. After 6 weeks it is hard to get extra motion, particularly extension.
It can take 6-12 months to be as good as they are going to be. Certainly, a strengthening programme will help. Hydrotherapy is also of great benefit.
Some people have ongoing pain, the reason for which is often unexplained.
There are however a number of knee replacements poorly done, so if you have someone who you believe is genuine, it is reasonable to send them for a second opinion.

CAUSES OF PAIN

Causes of pain include:

Malposition of components
Ligament laxity
Patella pain due to arthritis if not replaced
Loosening of the implants
Loose bodies (e.g. cement, patella baja, under or oversising components)

Some of these conditions are easy to pick up but some are quite subtle such as mid flexion instability and really need an arthroplasty surgeon to pick up.

CONCLUSION

In summary, not everyone who has an operation is going to be happy. The first question I ask someone who has had surgery is who did it. This is the most important question. If someone has ongoing pain which you believe is genuine and not explained by their operation, then tell the patient they should think about seeking a second opinion. That being said, remember not everyone can be made happy.