Quality of life in total knee replacement (TKR) patients – A review


  • M. RangaPriya Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Tamil Nadu
  • M. Karthika Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Tamil Nadu
  • Meril Lucy Shibu Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Tamil Nadu
  • B. Kowsalya Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Tamil Nadu
  • Lini Jacob Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Tamil Nadu




Pain, TKR, Quality of Life, WOMAC, Multimodal Analgesia


Worldwide, severe pain and disability are caused to patients by Osteoarthritis, which is a common condition of the joints. A need for knee replacement had become a great option for patients when conventional treatment fails in granting appropriate relief in them, especially in elderly patients. Like all joint replacement surgeries, a total knee replacement procedure is also a quite painful and risky procedure that requires sufficient postoperative rehabilitation and therapies to prevent further complications. Post-surgical pain had a great influence on the patients' quality of life and a need to measure pain intensity had become a basic requirement. Measuring pain intensity can be done using traditional pain scales like a visual analogue scale (VAS), and a numerical rating scale (NRS). A risk assessment and predictor tool (RAPT) determines the discharge accuracy in patients. The WOMAC scale which is the abbreviated form of the questionnaire for checking the health status of the patients known as the Western Ontario and McMaster University Osteoarthritis Index.  This questionnaire is used to assess the quality of life of the osteoarthritis patients after a surgery for the total knee replacement. The results of the assessment show that pain had become a significant factor in the reduction in quality of life. In conclusion, a well-designed multimodal analgesic regimen should be incorporated into the patient's rehabilitation care, which in turn will intensify the patient's quality of life, lessen the hospital stay, and minimize the socio-economic burden


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Litwic A, Edwards MH, Dennison EM, Cooper C. Epidemiology and burden of osteoarthritis. British Medical Bulletin, 105, 185–199 (2013).
Merskey H, Bogduk N. A Current List with Definitions and Notes on Usage: Classification of Chronic Pain, 2nd edition. International Association for the Study of Pain (IASP) Task Force on Taxonomy Part III. Pain Terms, 209–214 (1994).
Felson DT. Osteoarthritis of the knee. The New England Journal of Medicine, 354, 841–848 (2006).
Murray DW, Frost SJ. Pain in the assessment of total knee replacement. The Journal of Bone and Joint Surgery, 80, 426–31 (1998).
Gerbershagen HJ, Pogatzki-Zahn E, Aduckathil S, Peelen LM, Kappen TH, Wijck AJMV, Kalkman CJ, Meissner W. Procedure-specific risk factor analysis for the development of severe postoperative pain. Anesthesiology, 120, 1237–1245 (2014).
Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt K D, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh H, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage, 18, 476–499 (2010).
Aasvang EK, Luna IE, Kehlet H. Challenges in post discharge function and recovery: the case of fast-track hip and knee arthroplasty. British Journal of Anaesthia, 115, 861-866 (2015).
Baker PN, VanderMeulen JH, Lewsey J, Gregg PJ. The role of pain and function in determining patient satisfaction after total knee replacement, Data from the National Joint Registry for England and Wales. Journal of Bone and Joint Surgery, 89, 893–900 (2007).
Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. Journal of Bone and Joint Surgery, 92, 1253–1258 (2010).
Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain, 152, 566–572 (2011).
Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. Clinical Orthopaedics and Related Research, 441, 250–255 (2005).
Skinner HB, Shintani EY. Results of a multimodal analgesic trial involving patients with total hip or total knee arthroplasty. American Journal of Orthopaedics, 33, 85–92 (2004).
Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol: what makes the difference?. Journal of Arthroplasty, 18, 27–30 (2003).
Hansen VJ, Gromov K, Lebrun LM, Rubash HE, Malchau H, Freiberg AA. Does the Risk Assessment and Prediction Tool predict discharge disposition after joint replacement? Clinical Orthopaedics and Related Research, 473, 597–601 (2015).
Filos KS, Lehmann KA. Current concepts and practice in postoperative pain management: need for a change?. European Surgical Research, 31, 97–107 (1999).
The Center for Disease Control and Prevention. National Hospital Discharge Survey: 2010 table. Inpatient Surgery Data for the U.S.
[http://www.cdc.gov/nchs/fastats/inpatient- surgery.htm]
Viscusi ER. Emerging techniques in the treatment of postoperative pain. American Journal of Health System and Pharmacy, 61, S11-4(2004).
Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics, resource use, and patient satisfaction in an urban teaching hospital. Anesthesia and Analgesia, 94, 130-137 (2002).
Forst J, Wolff S, Thamm P, Forst R. Pain therapy following joint replacement. A randomized study of patient-controlled analgesia versus conventional pain therapy. Archives of Orthopaedic and Trauma Surgery, 119, 267-70 (1999).
Schwinghammer AJ, Isaacs AN, Benner RW, Freeman H, O'Sullivan JA, Nisly SA. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. The Annals of Pharmacotherapy, 51, 451-456 (2017).
Elmallah RK, Chughtai M, Khlopas A, Newman JM, Stearns KL, Roche M, Kelly MA, Harwin SF, Mont MA. Pain Control in Total Knee Arthroplasty. The Journal of Knee Surgery, 31, 504-513 (2017).
Barastegui D, Robert I, Palau E, Haddad S, Reverte-Vinaixa M, Lorente L, Cots M. Can local in-filtration analgesia increase satisfaction in postoperative short- term pain control in total knee arthroplasty? Journal of orthopedic surgery, 25, 1-7 (2017).
Volk T. New and evidence-based aspects of postoperative pain therapy. Der Orthopade, 37, 953–958 (2008).
Chan E , Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. The Cochrane Database of Systemic Reviews, 5, CD009941, (2014).
Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Current Medical Research Opinion, 30, 149–160 (2014).
Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block. The Journal of American Academy of Orthopaedic Surgeons, 14, 126–135 (2006).
Brown JE, Chatterjee N, Younger J, Mackey S. Towards a Physiology-Based Measure of Pain: Patterns of Human Brain Activity Distinguish Painful from Non-Painful Thermal Stimulation. PLOS ONE, 6, e24124 (2011).
Correll DJ. The Measurement of Pain: Objectifying the Subjective. Pain Management waldman 2nd. Philadelphia: Saunders Elsevier, 197-211 (2007).
Dahl JL. Effective pain management in terminal care. Clinics in Geriatric Medicine, 12, 279–300 (1996).
McCaffery M, Pasero C. Assessment: Underlying complexities, misconceptions, and practical tools. Pain: Clinical Manual, 2nd edition. St. Louis: Mosby, 35–102 (1999).
Webb CAJ, Edward R Mariano. Best multimodal analgesia protocol for total knee arthroplasty. Pain Management, 5, 185–196 (2015).
Mammoto T, Fujie K, Mamizuka N, Taguchi N, Hirano A, Yamazaki M, Hashimoto K. Effects of postoperative administration of celecoxib on pain management in patients after total knee arthroplasty: study protocol for an open-label randomized controlled trial. Trials, 17, 45 (2016).
Elmallah R, Chughtai M, Khlopas A, Newman J, Stearns K, Roche M, Mont M. Pain Control in Total Knee Arthroplasty. The Journal of Knee Surgery, 31, 504–513 (2017).
Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. Journal of Pain Symptom Management, 41, 1073–1093 (2011).
Benzon HT, Raja SN, Molloy RE, Liu SS, Fishman SM. Essentials of Pain. Third USA: Elsevier Saunders 2nd edition, 28-33 (2011).
Jensen MP, Karoly P. Self report scales and procedures for assessing pain in adults. Handbook of Pain Assessment, 2011.
Chanques G, Viel E, Constantin JM, Jung B, De-Lattre S, Carr J, Cisse M, Lefrant J, Jaber S. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain, 151, 711–721 (2010).
Bird J. Selection of pain measurement tools. Nursing Standard, 18, 33–39 (2003).
Huskisson EC. Measurement of pain. Lancet, 2, 1127–1131 (1974).
Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain, 16, 87–101 (1983).
Hawksley H. Pain assessment using a visual analogue scale. Professional Nurse, 15, 593–597 (2000).
Hartrick CT. A four-category verbal rating scale (VRS-4), an 11-point numeric rating scale (NRS-11), and a 100-mm visual analog scale (VAS) were compared in the assessment of acute pain after oral surgery. The Clinical Journal of Pain, 17, 104–105 (2001).
Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopaedic patients. Journal of Pain and Symptom Management, 18, 438–446 (1999).
Jensen MP, Miller L, Fisher LD. Assessment of pain during medical procedures: A comparison of three scales. Clinical Journal of Pain, 14, 343–349 (1998).
Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nursing, 20, 88–93 (1997).
Dalton JA, McNaull F. A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale. Cancer Nursing, 21, 46–49 (1998).
Holm B, Bandholm T, Lunn TH, Husted H, Aalund PK, Hansen TB, Kehlet H. Role of preoperative pain, muscle function, and activity level in discharge readiness after fast-track hip and knee arthroplasty. Acta Orthopaedica, 85, 488–492 (2014).
Ramlall Y, Andrion JJD, Cameron HU, Sawhney M. Examining pain before and after primary total knee replacement (TKR): A retrospective chart review. International Journal of Orthopaedic and Trauma Nursing, 34, 43–47 (2019).
Monticone M , Ferrante S, Rocca B, Salvaderi S, Fiorentini R, Restelli M, Foti C. Home-based functional exercises aimed at managing kinesiophobia contribute to improving disability and quality of life of patients undergoing total knee arthroplasty: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 231–239 (2013).
Forrest GP, Roque JM, Dawodu ST. Decreasing length of stay after total join arthroplasty: effect on referrals to rehabilitation units. Archives of Physical Medicine and Rehabilitation, 80, 192–194 (1999).
Mahomed NN, Koo Seen Lin MJ, Levesque J, Lan S, Bogoch ER. Determinants and outcomes of inpatient versus home-based rehabilitation following elective hip and knee replacement. Journal of Rheumatology, 27, 1753– 1758 (2000).
Benedetti MG, Sarti D, Bonfiglioli Stagni S, Marian E. Setting, clinical pathways, fast-track and rehabilitation following primary knee arthroplasty: a literature review. The Open Rehabilitation Journal, 8, 17–24 (2015).
Coudeyre E, Lefevre-Colau MM, Griffon A, Camilleri A, Ribinik P, Revel M, F Rannou. Is there predictive criteria for transfer of patients to a rehabilitation ward after hip and knee total arthroplasty? Elaboration of French clinical practice guidelines. Annales de Readaptation et de Medecine Physique, 50, 317–326 (2007).
Slover J, Mullaly K, Karia R, Bendo J, Ursomanno P, Galloway A, Iorio R, Bosco J. The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program. International Journal of Surgery, 38, 119–122 (2017).
Oldmeadow LB, McBurney H, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. Journal of Arthroplasty, 18, 775–779 (2003).
Oldmeadow LB, McBurney H, Robertson VJ, Kimmel L, Elliott B. Targeted Postoperative care improves discharge outcome after hip or knee arthroplasty. Archives of Physical Medicine and Rehabilitation, 85, 1424–1427 (2004).
Wylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. Chronic pain after total knee arthroplasty. EFORT Open Reviews, 03, 461- 470 (2018).
Vina ER, Hannon MJ, Kwoh CK. Improvement following total knee replacement surgery: Exploring preoperative symptoms and change in preoperative symptoms. Seminars in Arthritis and Rheumatism, 45, 547–555 (2016).
Ebrahimzadeh MH, Makhmalbaf H, Birjandinejad A, Keshtan FG, Hoseini HA, Mazloumi SM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in Persian speaking Patients with Knee Osteoarthritis. The Archives of Bone and Joint Surgery, 2, 57-62 (2014).
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology, 15,1833–1840 (1988)
Wolfe F, Kong SX. Rasch analysis of the Western Ontario MacMaster questionnaire (WOMAC) in 2205 patients with osteoarthritis, rheumatoid arthritis, and fibromyalgia. Annals of the Rheumatic Diseases, 58, 563–568 (1999).
Clement ND, Weir DJ, Holland J, Deehan DJ. Is there a Threshold Preoperative WOMAC Score That Predicts Patient Satisfaction after Total Knee Arthroplasty? The Journal of Knee Surgery, 2019.
Faschingbauer M, Kasparek M, Schadler P, Trubrich A, Urlaub S, Boettner F. Predictive values of WOMAC, KOOS, and SF‑12 score for knee arthroplasty: data from the OAI. Knee Surgery, Sports Traumatology, Arthroscopy, 25, 3333-3339 (2016).
Naili JE, Wretenberg P, Lindgren V, Iversen MD, Hedstrom M, Brostrom E. Improved knee biomechanics among patients reporting a good outcome in knee-related quality of life one year after total knee arthroplasty. BMC Musculoskeletal Disorders, 18, 122 (2017).
Papakostidou I, Dailiana ZH, Papapolychroniou T, Liaropoulos L, Zintzaras E, Karachalios TS, Malizos KN. Factors affecting the quality of life after total knee arthroplasties: a prospective study. BMC Musculoskeletal Disorders, 13, 116 (2012).


2020-11-11 — Updated on 2020-11-11


How to Cite

M. Ranga Priya, M. Karthika, Meril Lucy Shibu, B. Kowsalya, & Lini Jacob. (2020). Quality of life in total knee replacement (TKR) patients – A review. Journal of Applied Pharmaceutical Research, 8(4), 16-23. https://doi.org/10.18231/j.joapr.2020.v.8.i.4.16.23