Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review

Vol 3 | Issue 2 | July-December 2022 | Page 56-75 | Kartik Sonawane, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.057

Authors: Kartik Sonawane [1], Jagannathan Balavenkatasubramanian [2]

[1] Department of Anaesthesia, Ganga Medical Centre & Hospitals Pvt. Ltd. , Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Jagannathan Balavenkatasubramanian,
Department of Anaesthesia, Ganga Medical Centre & Hospital, Coimbatore, Tamil Nadu, India.


Total knee replacement/arthroplasty (TKR/TKA) is considered a life-changing surgery as it not only corrects the pathology and associated joint deformity but also renders the patient pain-free allowing them to perform activities of daily living as before. Such favorable outcomes depend entirely on the perioperative pain management strategies. Structuring such strategies requires background knowledge of the goals set, the process of pain generation before and after the surgery, and innervations of the pain-generating components involved in each surgical step.
The multifactorial origin of TKR pain requires a multidimensional pain management strategy such as multimodal analgesia (MMA). It should incorporate all the essential ingredients that target each step of the pain generation process. Apart from pharmacological agents and nonpharmacological techniques, regional analgesia (RA) plays a very important role as an adjunct to MMA to provide quality analgesia that promotes enhanced recovery and mobility. However, the choice of RA technique remains dependent on its motor-sparing effect, procedure-specific analgesic coverage, opioid-sparing effect, and suitability for enhanced recovery after surgery (ERAS). Psychological analgesia is also an important aspect of MMA, aiding in resolving psychological concerns and postoperative pain management and empowering patients in their own pain management process by encouraging active participation. In addition to providing appropriate pain management services, assessing expected outcomes in the postoperative period is also important to close loopholes and provide rescue analgesics when needed.
This narrative review article highlights important aspects of pain management strategies and the essential requirements for implementing them to achieve desired outcomes. We believe this article will help readers design or modify their pain management strategy to meet all of their goals.
Keywords: Total knee replacement, Total knee arthroplasty, Pain management, Motor-sparing regional anesthetic technique, Multimodal analgesia, Procedure-specific analgesia.


[1] Filos KS, Lehmann KA. Current concepts and practice in postoperative pain management: need for a change? Eur Surg Res. 1999;31:97-107.
[2] Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467:1418-23.
[3] Parvataneni HK, Ranawat AS, Ranawat CS. The use of local periarticular injections in the management of postoperative pain after total hip and knee replacement: a multimodal approach. Instr Course Lect. 2007;56:125-31.
[4] Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg. 2002;10:117-29.
[5] Sonawane, K. , Dixit, H. . Regional Analgesia for Knee Surgeries: Thinking beyond Borders. In: Whizar-Lugo, V. M. , Saucillo-Osuna, J. R. , Castorena-Arellano, G. , editors. Topics in Regional Anesthesia [Internet]. London: IntechOpen; 2021 [cited 2022 Jul 12]. Available from:
[6] Campbell JN. APS 1995 Presidential address. Pain Forum.1996;5:85–8.
[7] Morone NE, Weiner DK. Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 1016; 2013;35(11):1728-1732:001.
[8] Lippe PM. The decade of pain control and research. Pain Med. 2000;1 (4):286.
[9] Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011; 5(5):342–8.
[10] Moningi S, Patki A, Padhy N, Ramachandran G. Enhanced recovery after surgery: An anesthesiologist’s perspective. J Anaesthesiol Clin Pharmacol. 2019;35(Suppl 1):S5–13.
[11] Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95.
[12] Johnson RL, Kopp SL. Optimizing perioperative management of total joint arthroplasty. Anesthesiol Clin. 2014;32 (4):865–80.
[13] Chan E-Y, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;(5):CD009941.
[14] Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10(6):329–35.
[15] Hirasawa Y, Okajima S, Ohta M, Tokioka T. Nerve distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop. 2000;24(1):1–4.
[16] Haus J, Halata Z. Innervation of the anterior cruciate ligament. Int Orthop. 1990;14(3):293–6.
[17] Krauspe R, Schmitz F, Zöller G, Drenckhahn D. Distribution of neurofilament-positive nerve fibres and sensory endings in the human anterior cruciate ligament. Arch Orthop Trauma Surg. 1995;114(4):194–8.
[18] Ikeuchi M, Wang Q, Izumi M, Tani T. Nociceptive sensory innervation of the posterior cruciate ligament in osteoarthritic knees. Arch Orthop Trauma Surg. 2012;132(6):891–5.
[19] Day B, Mackenzie WG, Shim SS, Leung G. The vascular and nerve supply of the human meniscus. Arthroscopy. 1985;1(1):58–62.
[20] Mine T, Kimura M, Sakka A, Kawai S. Innervation of nociceptors in the menisci of the knee joint: an immunohistochemical study. Arch Orthop Trauma Surg. 2000;120(3–4): 201–4.
[21] Institute of Medicine (US) Committee on Pain, Disability, and Chronic Illness Behavior. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Osterweis M, Kleinman A, Mechanic D, editors. Washington (DC): National Academies Press (US); 1987. PMID: 25032476.
[22] Bourne S, Machado AG, Nagel SJ. Basic anatomy and physiology of pain pathways. Neurosurg Clin N Am. 2014; 25(4):629–38.
[23] Felson DT. The sources of pain in knee osteoarthritis. Curr Opin Rheumatol. 2005 Sep;17(5):624-8.
[24] Eitner A, Hofmann GO and Schaible H-G (2017) Mechanisms of Osteoarthritic Pain. Studies in Humans and Experimental Models. Front. Mol. Neurosci. 10:349. doi: 10.3389/fnmol.2017.00349
[25] Schaible HG. (2013) Articular Nociceptors. In: Gebhart G.F., Schmidt R.F. (eds) Encyclopedia of Pain. Springer, Berlin, Heidelberg.
[26] Cummins TR, Sheets PL, Waxman SG. The roles of sodium channels in nociception: Implications for mechanisms of pain. Pain. 2007 Oct;131(3):243-257.
[27] McEntire DM, Kirkpatrick DR, Dueck NP, Kerfeld MJ, Smith TA, Nelson TJ, Reisbig MD, Agrawal DK. Pain transduction: a pharmacologic perspective. Expert Rev Clin Pharmacol. 2016 Aug;9(8):1069-80.
[28] Yam MF, Loh YC, Tan CS, Khadijah Adam S, Abdul Manan N, Basir R. General Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation. Int J Mol Sci. 2018 Jul 24;19(8):2164.
[29] Kirkpatrick DR, McEntire DM, Hambsch ZJ, Kerfeld MJ, Smith TA, Reisbig MD, Youngblood CF, Agrawal DK. Therapeutic Basis of Clinical Pain Modulation. Clin Transl Sci. 2015 Dec;8(6):848-56.
[30] Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 1993;77:1048-56.
[31] Buvanendran A., Kroin J. S. Multimodal analgesia for controlling acute postoperative pain. Current Opinions in Anaesthesiology. 2009;22(5):588–593.
[32] Young A., Buvanendran A. Recent advances in multimodal analgesia. Anesthesiology Clinics. 2012;30(1):91–100.
[33] Novello-Siegenthaler A, Hamdani M, Iselin-Chaves I, Fournier R. Ultrasoundguided continuous femoral nerve block: a randomized trial on the influence of femoral nerve catheter orifice configuration (six-hole versus end-hole) on postoperative analgesia after total knee arthroplasty. BMC Anesthesiol, 2018, 18: 191.
[34] Kim DH, Beathe JC, Lin Y, et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection
enhances postoperative pain control in total knee arthroplasty: a randomized controlled trial. Anesth Analg, 2019, 129: 526–535.
[35] Walder B, Schafer M, Henzi I, Tramèr MR. Efficacy and safety of patientcontrolled opioid analgesia for acute postoperative pain. A quantitative systematic review. Acta Anaesthesiol Scand, 2001, 45: 795–804.
[36] Dias AS, Rinaldi T, Barbosa LG. The impact of patients controlled analgesia undergoing orthopedic surgery. Braz J Anesthesiol, 2016, 66: 265–271.
[37] Song MH, Kim BH, Ahn SJ, et al. Peri-articular injections of local anaesthesia can replace patient-controlled analgesia after total knee arthroplasty: a randomised controlled study. Int Orthop, 2016, 40: 295–299.
[38] Rantasalo MT, Palanne R, Juutilainen K, et al. Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol. BMJ Open, 2018, 8: e025546.
[39] Yik JH, Tham WYW, Tay KH, Shen L, Krishna L. Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2019, 27: 2104–2110.
[40] Ryu JH, Jeon YT, Min B, Hwang JY, Sohn HM. Effects of palonosetron for prophylaxis of postoperative nausea and vomiting in high-risk patients undergoing total knee arthroplasty: a prospective, randomized, double-blind, placebocontrolled study. PLoS One, 2018, 13: e0196388.
[41] Borckardt JJ, Reeves ST, Milliken C, et al. Prefrontal versus motor cortex transcranial direct current stimulation (tDCS) effects on post-surgical opioid use. Brain Stimul, 2017, 10: 1096–1101.
[42] Pogatzki-Zahn EM, Zahn PK. From preemptive to preventive analgesia. Curr Opin Anaesthesiol, 2006, 19: 551–555.
[43] Grape S, Tramèr MR. Do we need preemptive analgesia for the treatment of postoperative pain? Best Pract Res Clin Anaesthesiol, 2007, 21: 51–63.
[44] Korean Knee Society. Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surg Relat Res. 2012;24(4):201-207.
[45] Sonawane K, Dixit H, Balavenkatasubramanian J. Regional analgesia technique for postoperative analgesia in total knee arthroplasty: have we hit the bull’s eye yet? Braz J
Anesthesiol. 2021 May-Jun;71(3):307-309.
[46] Momoli A, Giarretta S, Modena M, Micheloni GM. The painful knee after total knee arthroplasty: evaluation and management. Acta Biomed. 2017;88 (2S):60–7.
[47] Bannister K, Sachau J, Baron R, Dickenson AH. Neuropathic Pain: Mechanism-Based Therapeutics. Annu Rev Pharmacol Toxicol. 2020 Jan 6;60:257-274.
[48] Finnerup NB, Kuner R, Jensen TS. Neuropathic Pain: From Mechanisms to Treatment. Physiol Rev. 2021 Jan 1;101(1):259-301.
[49] St John Smith E. Advances in understanding nociception and neuropathic pain. J Neurol. 2018 Feb;265(2):231-238.
[50] Macario A, Weinger M, Carney S, Kim A Anesth Analg. 1999 Sep; 89(3): 652-8.
[51] Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC Anesthesiology. 2005 May; 102(5): 1001-7.
[52] lfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW Anesthesiology. 2006 Nov; 105(5): 999- 1007.
[53] Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and combined neuraxial/ general anesthesia compared to general anesthesia for major truncal and lower limb surgery: A systematic review and meta-analysis. Anesth Analg. 2017;125 (6):1931– 45.
[54] Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK. Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):102–5.
[55] Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK. Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64–101.
[56] Sonawane K, Balavenkatasubramanian J, Dixit H, Tayi H, Goel VK. Regional anesthesia for scapular fracture surgery: an educational review of anatomy and techniques. Reg Anesth Pain Med. 2021; 46(4):344–9.
[57] Sonawane K, Dixit H, Balavenkatasubramanian J, Gurumoorthi P (2021) Uncovering secrets of the beauty bone: A comprehensive review of anatomy and regional anesthesia techniques of clavicle surgeries. Open J Orthop Rheumatol 6(1): 019-029.
[58] Vas L, Pai R, Khandagale N, Pattnaik M. Pulsed radiofrequency of the composite nerve supply to the knee joint as a new technique for relieving osteoarthritic pain: a preliminary report. Pain Physician. 2014;17(6): 493–506.
[59] Priest , B.T. , B.A. Murphy , J.A. Lindia , C. Diaz , C. Abbadie , A.M. Ritter , P. Liberator
, L.M. Iyer , S.F. Kash , M.G. Kohler , et al . 2005 . Contribution of the tetrodotoxin- resistant voltage-gated sodium channel NaV1.9 to sensory transmission and nociceptive behavior. Proc. Natl. Acad. Sci. USA. 102 : 9382 – 9387 .
[60] Amaya , F. , H. Wang , M. Costigan , A.J. Allchorne , J.P. Hatcher , J. Egerton , T. Stean ,
V. Morisset , D. Grose , M.J. Gunthorpe , et al . 2006 . The voltage-gated sodium channel Na(v)1.9 is an effector of peripheral infl ammatory pain hypersensitivity. J. Neurosci. 26 : 12852 – 12860 .
[61] Gorczyca R, Filip R, Walczak E. Psychological aspects of pain. Ann Agric Environ Med. 2013;Spec no. 1:23-7. PMID: 25000837.
[62] McGrath PA. Psychological aspects of pain perception. Arch Oral Biol. 1994;39 Suppl:55S-62S.
[63] Weissman DE, Dahl JL, Beasley JW. The cancer pain role model program of the Wisconsin cancer pain initiative. J Pain Symptom Manage. 1993;8(1):29–35.
[64] Brown JK, Singh K, Dumitru R, Chan E, Kim MP. The benefits of enhanced Recovery After Surgery programs and their application in cardiothoracic surgery. Methodist Debakey Cardiovasc J. 2018;14(2):77–88.
[65] Tennant F. The physiologic effects of pain on the endocrine system. pain Ther. 2013;2(2):75-86.
[66] Sonawane K, Dixit H, Mistry T, Balavenkatasubramanian J. Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial. Cureus. 2021 Dec 17;13(12):e20488.

How to Cite this Article: Sonawane K, Balavenkatasubramanian J | Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 56-75.

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