The experience of surgeons treating unexplained pain after knee arthroplasty

Abstract

Aims

The aim of the present study was to understand the experience of surgeons treating patients with unexplained pain after knee arthroplasty and the role they considered revision surgery to have in the management of this condition.

Methods

Semi-structured interviews were performed with seven consultant knee surgeons in the NHS. Interviews were audio-recorded, transcribed verbatim, and de-identified before analysis using reflexive thematic analysis.

Results

Six themes were developed: 1) I need to understand a patient’s journey and their expectations; 2) A difficult consultation; 3) I’m the ‘fixer’; 4) It’s complicated asking for help; 5) I’m uncomfortable operating for truly unexplained pain; and 6) It’s a wound I carry with me.

Conclusion

This study has improved our understanding of the important considerations for surgeons when managing patients with unexplained pain after knee arthroplasty. Our study calls for a holistic approach to care that considers patients’ experiences, embraces modern pain theory, and fosters collaboration among healthcare providers.

Cite this article: Bone Jt Open 2025;6(9):1115–1121.

Introduction

Pain from osteoarthritis has a profound impact on patients’ lives.¹ For patients with knee osteoarthritis, joint arthroplasty surgery is highly effective, resulting in large improvements in pain and quality of life.^2,3 While outcomes following knee arthroplasty continue to improve, for around 10% of patients surgery does not meet their expectations.⁴ It is difficult to predict which patients will fall into this group, but many in this situation experience chronic pain.^5,6 Some do not seek help due to the belief that nothing further can be done.⁷ Those seeking help must navigate a complex path through the healthcare system to access care.⁸

Around two-thirds of patients with chronic pain after total knee arthroplasty (TKA) report improvement in symptoms in the first five years following surgery.⁹ Most are managed nonoperatively. This may include different therapeutic methods, such as physiotherapy, psychological treatment, and pain management.¹⁰ For patients who remain in chronic pain, a small proportion return to discuss whether revision surgery may help their symptoms. However, the evidence to support surgical intervention for unexplained pain is limited. It is estimated that around half of patients who undergo revision knee arthroplasty (rTKA) for unexplained pain experience a clinically meaningful improvement in pain and quality of life at six months, while half do not.¹¹ There is no evidence to indicate longer-term clinical outcomes following rTKA for unexplained pain.

A recent study from our group explored patients’ experiences with problematic knee arthroplasties and the impact of undergoing elective rTKA.¹² The aim of the present study was to understand the experiences of consultant knee surgeons treating patients with unexplained pain after knee arthroplasty and the role they considered revision surgery to have in the management of this condition.

Methods

Patient and public involvement

This study was designed with the input of the ‘SORE Knee’ patient and public involvement (PPI) group at the University of Oxford.

Ethical approval

Ethical approval was obtained from the Health Research Authority (22/WA/0090).

Study design

Seven consultant knee surgeons with a rTKA practice were purposively sampled. The sample was chosen to include different levels of consultant experience and operative caseloads. All surgeons had a NHS practice, while some also had a private practice. A senior orthopaedic surgical trainee (SAS) directly approached all surgeons via email and conducted semi-structured face-to-face interviews with participants. A topic guide was used to facilitate discussion around surgeons’ experiences treating patients with unexplained pain after knee arthroplasty (Table I). Each interview lasted around one hour and began with a 'get-to-know-you' question where the surgeon was invited to describe their current practice. This was followed by a broad invitation to describe their experience treating patients with unexplained pain after knee arthroplasty: "Tell me your experience of treating patients with unexplained pain after knee arthroplasty… You can share as much or as little as you wish."

Table I.

Surgeon interview schedule.

Tell me your experience of treating patients with unexplained pain after knee arthroplasty
Prompts (if appropriate):
How do you make this diagnosis?
Is there anything that you find challenging about these cases?
Do you feel well supported to treat these patients?
How do you feel when treating patients with unexplained pain?
Can you describe some of the potential causes of unexplained pain?
Tell me your thoughts on offering further surgery to some patients with unexplained pain
Prompts (if appropriate):
Can you describe a patient that you would consider to be unsuitable? And one who you think might really benefit?
What do you think are some of the risk factors for a poor outcome from further surgery?
Can you talk to me about any factors that may influence your decision beyond the clinical presentation?
What advice do you give to patients considering further surgery?
What would you consider to be a good outcome from further surgery? And, a bad outcome?
If you were to operate, what would be the important technical aspects of surgery?
Without identifying individuals, please can you share some examples of cases you have learnt from?
What advice would you give to other surgeons with less experience?

After gaining consent, interviews were audio-recorded and transcribed verbatim in-house. Each transcript was checked for accuracy against the original recording. Transcripts were de-identified by removing names, places, and other identifying data. Participants were given the opportunity to read their interview transcript and expand or redact sections as they felt appropriate (‘member-checking’).

Reflexive thematic analysis, as described by Braun and Clarke,¹³ was used to develop themes across participants. The six stages of analysis were: 1) familiarization; 2) coding; 3) generation of initial themes; 4) development and review of themes; 5) refining and naming of themes; and 6) manuscript preparation.

Interview transcripts were analyzed using NVivo v. 1.7.1 (QSR International, Australia). Each transcript was coded by the lead author (SAS), where a short phrase was assigned to a unit of meaning. Each code was then discussed with an experienced qualitative researcher (FT) to ensure that it encapsulated the meaning accurately and completely. Codes were then organized into initial themes around a central idea among the wider research team, which included orthopaedic surgeons, clinical academic physiotherapists, and qualitative researchers. The themes were developed by the research team through constant comparison and discussion.

Results

Seven consultant knee surgeons were recruited following direct invitation. Five worked at a major revision centre and two at a district general hospital within the NHS in England. Three surgeons had less than five years’ consultant experience, one five to ten years, and three more than ten years. One surgeon performed fewer than five rTKAs per year; two ten to 20 rTKAs per year; and four performed more than 20 rTKAs per year.

We report six themes drawn around surgeons’ experiences treating patients with unexplained pain after knee arthroplasty: 1) I need to understand a patient’s journey and their expectations; 2) a difficult consultation; 3) I’m the ‘fixer’; 4) it’s complicated asking for help; 5) I’m uncomfortable operating for truly unexplained pain; and 6) it’s a wound I carry with me.

I need to understand a patient’s journey and their expectations

This theme included the importance of understanding the 'journey' patients had taken through the healthcare system, recognizing it may have been difficult:

They’ve been pushed and pulled around… They’re at various stages of having lost trust or looking for new avenues in terms of how their symptoms and everything else can be dealt with.” (Surgeon E)

“They won’t have had an easy ride … They will have come back to follow up appointments being seen by juniors who, quite reasonably, haven’t got all the answers and may not have had a consistent message.” (Surgeon E)

Some surgeons felt they had been “'on the journey'” with the patient, especially if they had performed the original joint arthroplasty.

“If you’ve been treating them all along, it’s emotional… you’re disappointed for them… they’re disappointed with you. You wonder how much they trust you.” (Surgeon D)

Surgeons described the importance of honesty and trust in the doctor-patient relationship and, like any relationship, were mindful it may break down.

“The patient may lose faith in you… and the ability to look at things positively.” (Surgeon A)

“If a relationship has broken down, it’s important to get someone else in. There is a lot to gain by going outside a unit, because it’s very difficult to separate out a patient’s experience from the individual surgeon and everything else.” (Surgeon F)

A difficult consultation

Surgeons described the challenges associated with consultations for unexplained pain. They referenced the importance of the consultation for the patient.

“It’s the most important appointment of their life. They’ve got this terrible thing going on in their knee, they’ve waited and waited and waited… and finally met the person who can fix it.” (Surgeon C)

There was the 'juggle' of managing complex surgical decisions, fulfilling pastoral duties, and trying to meet patient expectations, while needing a 'clinic to run on time'.

“It can be a bit of a heart sink. You know that you are going to have a difficult conversation, and that you may not have an easy solution to offer… When I’ve got to the point of examining the patient, I’m already thinking about what I’m going to say and how I’m going to phrase it.” (Surgeon E)

“It would be useful to do a clinic where time was not pressured where you could spend time with these patients. You know that if someone comes in and says: ‘I have this problem, doctor’ and you say: ‘I’ve got an operation that will sort you out…’ That’s a three-minute consultation.” (Surgeon F)

For some surgeons, consultations for unexplained pain were 'out of their comfort zone', while others enjoyed their pastoral role.

“You have to remember the narrative of joint arthroplasty… it’s transformational. Without trying to talk it up too much, people say to me: ‘You’ve given me my life back’, and you get used to that, so this world is quite challenging for some surgeons, who are used to people being super happy.” (Surgeon C)

“Even for people like orthopaedic surgeons who use hammers and chisels, it is quite a social thing that we’re doing, isn’t it?” (Surgeon E)

Some surgeons referenced the difficulties around breaking bad news.

“They will have had many moments where someone says: ‘You need to see a doctor about your knee because your symptoms are so severe you can’t do X, Y, and Z’. And they come to see you, deliver all of that, and I have to turn around and say: ‘I’m very sorry but there is nothing much we can do for you’. That is a difficult conversation to have. It takes an extended period of time… There’s an emotional investment on both sides.” (Surgeon A)

For some surgeons, the combination of these difficulties was a disincentive to arranging further consultations.

“These are not friendly consultations… If you ask: ‘How are you doing?’ They are going to say: ‘B****y awful!’ You say: 'What do you want to do about it?' And they say: ‘I want to see you again.’ And you can go round and round, so it’s often easier to discharge the patient.” (Surgeon B)

I’m the ‘fixer’

Surgeons appeared to be most comfortable working within a biomedical model of health and illness: find a problem, and fix it. This included the need to identify a 'mechanical mandate' to justify an operation.

“Part of you thinks, I really hope that I find something wrong here that I can fix… but, at the same time, you don’t wish badly on the patient.” (Surgeon A)

Some described the weight of expectations from patients to 'do something', despite the evidence suggesting it may be best to observe the natural history of the condition.

“We know that there is evidence that if you stick with it for a few years then a moderate number of patients are going to improve. However, a significant number do not improve – and only time will tell for these patients. Patients often find that slightly difficult to accept. And, as surgeons, we also deal with this badly. We are very used to someone coming in where you say: ‘I can help you with that.’ We are proactive… and it’s a very personal interaction: ‘I can help you with that’. It’s not that: ‘I am going to give you this medicine…’” (Surgeon F)

“As surgeons, we would like to be able to do something to make people better. And, when you can’t operate on them, you can feel a bit helpless.” (Surgeon G)

Surgeons described the 'dilemma… as to how hard you investigate' chronic pain and the problems of imperfect diagnostic tests.

“The difficult balance is trying to avoid investigating unnecessarily, but you don’t want to discard patients who have a problem you could help with.” (Surgeon F)

“You need to counsel the patient quite carefully before requesting tests… We may find things that are abnormal and not know how to interpret them… Even if something comes up, I wouldn’t necessarily recommend revision surgery.” (Surgeon B)

People cling very tightly to a diagnosis: ‘a doctor told me that there was something wrong with my knee replacement’. It’s very easy to get people bogged down into this thinking”. (Surgeon F)

Several surgeons described the idea that greater experience provided them with the confidence to organize fewer diagnostic tests.

“Perhaps, earlier in your career, the more you will investigate things and, as you get older, you will be more blunt with people and say: ‘I could send you for a load of tests, but – in reality – if I send you for a hundred tests, two are going to come back positive and is this going to change what I would think is the right choice for you?’” (Surgeon E)

It’s complicated asking colleagues for help

Surgeons reported the benefits and pitfalls of asking for help from colleagues. On the one hand, there was the usefulness of the multidisciplinary team (MDT) meeting.

“Complex cases are much better shared… and their psychological baggage.” (Surgeon D)

“If I’ve run out of ideas and can’t help, maybe there is someone else who can?” (Surgeon B)

A caveat was that MDT meetings could over-simplify the problem and did not always include a patient voice.

“It is very easy to sit there and say: ‘Do this’, when the patient is not sat in front of you.” (Surgeon F)

Second opinions meant 'a fresh pair of eyes' to identify problems that may have been missed, a new start where a doctor-patient relationship had broken down and could provide a patient with confidence in the diagnosis. However, surgeons offering second opinions were concerned about consultations where patients had been set unrealistic expectations by their original surgeon.

“Patients often come to my service having been told: ‘You are going to see Mr/Miss X in the specialist centre and they are going to sort your knee out’. When patients then come and are told that there isn't anything surgically correctable within the knee, we aren't planning to offer an operation, and there isn't a magic bullet to take your pain away, they are clearly disappointed.” (Surgeon D)

Some surgeons were worried about scrutiny from colleagues when requesting second opinions and recognized this influenced their referral practice.

“If I am seeing a patient as a second opinion, I will frequently use the phrase: ‘I’ve been asked to see you because Mr/Miss So-and-so recognizes that we are in a difficult situation and, in those situations, two heads are better than one’. I think that’s a great way of trying to be non-derogatory about your colleagues and that starting afresh, having a fresh pair of eyes, is a good thing. But, it comes with complexities for whoever is providing that second opinion, because I know that I balk at sending patients to other hospitals where I may feel they are looking down on my practice.” (Surgeon E)

I’m uncomfortable operating for truly unexplained pain

Surgeons described the uncertainty when operating for unexplained pain.

“If I have a knee in front of me that moves well, is not infected, and has no other mechanical problem, I cannot see why a revision operation would work… I wouldn’t know what to do… which bits to take out, and what to put back in”. (Surgeon G)

Surgeons described a system set up to discourage revision surgery for unexplained pain.

“In years gone by, surgeons would sometimes operate for unexplained pain, often with the best of intentions, but the evidence showed that a lot of patients didn’t get better. And so, the guidelines have developed to reflect this. It would be a big thing now to go back and change this… You grow up, and go through training, being told never to operate on a painful knee without a diagnosis and so this would really be quite different.” (Surgeon A)

Several surgeons questioned whether colleagues would support them if they chose to operate for unexplained pain and worried about complications resulting from revision surgery.

“I think it comes down to: ‘Do no harm’. You are there in theatre with a knife in your hand, and for some of these patients you may make them much, much worse. It seems that, in surgery (compared to nonoperative management), you can lose a lot more.” (Surgeon B)

On the other side of the coin, surgeons worried that not offering revision surgery was “depriving some patients of the opportunity to get better”.

“It’s very difficult if someone says to you: ‘My knee’s not right. Will you do something?’ And you go: ‘No.’ And they say: ‘Well, if you do, is there any chance it could get better?’ And you would have to say: ‘Yes. We might find something, or we might not. And it might get better or not. And we might not know why.’ And then they go: ‘Well, if I don’t have it revised, is it going to get better?’ ‘Probably not’. There’d be a lot of patients who would say: ‘Well, I’m at a stage where I want you to take that on.’” (Surgeon D)

The thing you have to come to terms with is persuading someone to continue with a course of action where the likelihood is that they’re not going to improve. Your treatment options at four to five years down the line are: no change, or a punt with a 50 to 50 chance of an improvement in outcome. If you framed the question to patients, how many would choose surgery? I suspect a very high number…” (Surgeon C)

It’s a wound I carry with me

This theme describes the surgeon as a second victim. Surgeons described patients with unexplained pain as reminders of the limitations of their practice.

“If a patient is in pain after knee arthroplasty, I’m going to question: Was it my fault? Was it a technical error? How can I avoid this in the future?” (Surgeon A)

This burden weighed heavily on some surgeons.

“I think it’s really interesting to look at people who are doing craft specialties within medicine, those who are doing interventions to patients, how they manage their complications. I think most people take those complications with them. There are some people who take it with them so overtly that they cannot be surgeons, and they shouldn’t be surgeons, because it will destroy their lives… When you get older and start going to people's retirements, how they talk about when they stopped doing clinical medicine… how much release they got from that psychological burden of complications and problems they were constantly aware of.” (Surgeon D)

Some surgeons reflected on the limitations of a somewhat warped heuristic to evaluate the outcome of joint arthroplasty.

“We discharge a lot of patients… those that do get better, of course, never come back to tell us they have.” (Surgeon G)

Discussion

This study aimed to encapsulate the experience of surgeons treating patients with unexplained pain after knee arthroplasty. Our findings indicate the importance of understanding a patient’s journey through the healthcare system. Surgeons found consultations for unexplained pain challenging due to the complexity of the clinical assessment, while needing to adopt a pastoral role and communicate information sensitively to patients. Surgeons benefited from sharing complex decisions with colleagues, but worried about scrutiny of their practice. Surgeons reflected on their craft and patients returning with unexplained pain were reminders of the limitations of the interventions they offered. Surgeons were uncomfortable recommending surgery for unexplained pain: concerned about whether they would have the support of colleagues and worried about complications from surgical interventions that may have limited benefit.

The themes developed in this study resonate with those identified in an earlier qualitative evidence synthesis of healthcare professionals’ experiences treating people with chronic pain.¹⁴ A prominent shared theme was the pull of the biomedical model of health: find a diagnosis and treat it. For some surgeons, this was an acid test for what was perceived as a binary offer: an operation, or not. Other surgeons embodied a biopsychosocial model, recognizing ideas from modern pain theory, where chronic pain is not solely the result of tissue damage, but influenced by individual perceptions, coping mechanisms, and social contexts.¹⁵ Both this study and the earlier evidence synthesis¹⁴ described the challenges of consultations for chronic pain (“a difficult consultation”) and their emotional toll (“It’s a wound I carry with me”). Surgeons wishing to reflect on their experience treating patients with chronic pain may benefit from review of the conceptual model developed by Toye et al.¹⁴ Their model highlights the complexity of navigating therapeutic relationships. The current study sets out potential areas of dissonance in the doctor-patient relationship that may need to be tuned to better support patients with chronic pain. “It’s complicated asking for help” described clinicians’ experiences requesting second opinions and putting forward cases to MDT meetings. Most experiences were positive, including the opportunity to reset the doctor-patient relationship and to get new ideas on management. However, the theme also identified the stigma around asking colleagues for help¹⁶ and the potential for MDT meetings not to fully encapsulate the patient voice. We recently investigated patient experiences undergoing elective, aseptic revision knee arthroplasty.¹² We felt there was likely to be considerable overlap with the present study, and so did not explore patients’ experiences here. A recent qualitative evidence synthesis has also highlighted the similarities across a range of conditions in the experience of chronic pain.¹⁷

Our study has some limitations. These include the recruitment of a purposive sample of surgeons from a small geographical spread and within a NHS context. We may have found practices and attitudes to be different in other regions and healthcare systems. Our sample is similar in size to other studies investigating healthcare professional experiences using thematic analysis.¹⁴ The sample can be considered to have high 'information power'.¹⁸ This concept refers to the information held by the sample relevant to the aims of the study and is useful to guide adequate sample size for qualitative studies. Using the model proposed by Malterud et al,¹⁸ the items supportive of including fewer individuals include: a narrow aim; recruitment of participants with specific experiences relevant to the aim; use of existing theory; strong dialogue; and case-specific analysis, all of which apply in the present study. The prompts listed in Table I are indicative of our positionality going into the study: they reflect the topics we felt might be important. While not a limitation, we did not develop themes from each of these prompts. These may be areas for future research.

This study has important implications for practice. We have highlighted the need for evidence-based interventions for patients with chronic pain after knee arthroplasty. These need to be coupled with efficient referral pathways. Baroness Cumberlege¹⁹ recently described the current healthcare system in the UK as “disjointed, siloed, unresponsive, and defensive”. Recent evidence suggests that personalized referral pathways based on assessment of individuals’ needs may be more clinically-effective and cost-effective than the current standard of care.²⁰ An example of this might be simultaneous referrals to an orthopaedic surgeon, a physiotherapist, and a pain specialist, each communicating effectively with one another.

In conclusion, this study has improved our understanding of the important considerations for surgeons when managing patients with unexplained pain after knee arthroplasty. Our study calls for a holistic approach to care that considers patients’ experiences, embraces modern pain theory, and fosters collaboration among healthcare providers.

Take home message

- This study investigated the important considerations for surgeons when managing patients with unexplained pain after knee arthroplasty.

- A holistic approach to care that considers patients’ experiences, embraces modern pain theory, and fosters collaboration among healthcare providers is important in the management of unexplained pain after knee arthroplasty.

Data Availability

The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.