What are the causes of pain in an older adult with a history of degenerative joint disease and multiple joint replacement surgeries?

Causes of Pain in Patients with Multiple Joint Replacements

Pain after multiple joint replacements stems from several distinct mechanisms: persistent postsurgical pain (affecting 44% of knee and 27% of hip replacement patients), progression of degenerative joint disease in non-replaced joints, prosthetic complications, and systemic pain vulnerabilities. 1

Primary Pain Mechanisms After Joint Replacement

Persistent Postsurgical Pain

• Persistent pain occurs in 44% of total knee replacement (TKR) patients and 27% of total hip replacement (THR) patients at 3-4 years post-surgery, with 15% of TKR and 6% of THR patients experiencing severe-extreme pain. 1
• The pain is most commonly described as aching, tender, and tiring rather than neuropathic (only 6% TKR and 1% THR report neuropathic qualities). 1
• Major depression and the presence of multiple other pain problems elsewhere in the body are significant independent determinants of persistent postsurgical pain severity. 1
• This suggests an underlying vulnerability to pain processing in affected patients, rather than purely mechanical causes. 1

Progression of Osteoarthritis in Non-Replaced Joints

• Patients with polyarticular osteoarthritis affecting multiple joints are at increased risk for developing osteoarthritis at additional sites (generalized osteoarthritis). 2
• Degenerative joint disease is characterized by pain worsened by movement, joint stiffness, and progressive disability in activities of daily living. 3
• Risk factors include advancing age, female sex, obesity, past trauma, and genetics—all of which continue to affect non-replaced joints. 3

Diagnostic Approach to Pain Localization

When Multiple Degenerative Sites Are Present

• When multiple sites of osteoarthritis or degenerative changes are detected on imaging, image-guided anesthetic injections (using fluoroscopy, CT, or ultrasound guidance) are effective for identifying the specific pain source and guiding surgical planning. 2
• Plain radiographs should be the initial imaging study, revealing osteoarthritis, osteophytes, joint space narrowing, and evidence of prior trauma. 2
• MRI without contrast is indicated when radiographs show degenerative changes but the clinical picture requires evaluation of cartilage integrity, bone marrow edema, and associated soft tissues (ligaments, tendons). 2

Laboratory and Imaging Considerations

• Laboratory testing usually does not help in diagnosing osteoarthritis, as synovial fluid in degenerative joint disease is non-inflammatory (clear with good viscosity and <2000 WBC/mm³). 4
• Important systemic diseases that can cause or accelerate degenerative joint disease include hemochromatosis, hyperparathyroidism, acromegaly, diabetes with neuropathic joints, and hypothyroidism—these should be considered in atypical presentations. 4

Pain Management Strategy for Multiple Joint Involvement

Pharmacologic Approach

• Begin with acetaminophen (paracetamol) 1000 mg every 6 hours on a scheduled basis (not exceeding 3-4 grams daily), as this is the first-line analgesic with the safest profile in older adults. 2, 5
• Topical NSAIDs (diclofenac gel) applied 3-4 times daily to affected joints provide localized pain relief while minimizing systemic exposure—critical in patients with cardiovascular disease, renal impairment, or heart failure. 2, 6
• Oral NSAIDs and COX-2 inhibitors should be used cautiously due to increased risk of serious cardiovascular thrombotic events, myocardial infarction, stroke, gastrointestinal bleeding, ulceration, and perforation—risks that increase with duration of use and are higher in elderly patients. 7
• If oral NSAIDs are necessary, use the lowest effective dose for the shortest duration, and consider adding a proton pump inhibitor for gastrointestinal protection. 2

Non-Pharmacologic Core Treatments

• Strengthening exercise and aerobic fitness training should be considered first-line treatment for every person with osteoarthritis, as exercise reduces pain and disability without medication risks. 2, 6
• Weight loss if overweight or obese is essential, as obesity worsens osteoarthritis symptoms and accelerates joint degeneration. 2, 6
• Local heat and cold applications, shock-absorbing shoes or insoles, and assistive devices provide mechanical support and symptom relief. 2
• Manual therapy (manipulation and stretching) and transcutaneous electrical nerve stimulation (TENS) are adjunctive options. 2

Interventional Options

• Intra-articular corticosteroid injections (triamcinolone hexacetonide) provide relief for moderate to severe pain, particularly during acute flare-ups with inflammation or effusion, lasting 4-8 weeks. 2, 6
• Hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods than corticosteroids. 6, 3
• Recent evidence (2025) recommends against routine use of most interventional spine procedures for chronic spine pain, suggesting these should not be first-line for axial pain in patients with multiple joint replacements. 2

Critical Pitfalls to Avoid

Medication-Related Risks

• NSAIDs cause fluid retention, exacerbate congestive heart failure, increase cardiovascular and renal risks, and were implicated in 23.5% of hospitalizations for adverse drug reactions in older adults—avoid in patients with cardiac or renal comorbidities. 5, 6, 7
• NSAIDs increase bleeding risk when combined with anticoagulants, which is common in elderly patients with cardiovascular disease. 5
• Opioids should be reserved strictly for breakthrough pain when non-opioid strategies have failed, using the shortest duration and lowest effective dose. 5

Psychological and Systemic Factors

• Do not overlook depression and psychological distress—major depression is an independent determinant of persistent postsurgical pain severity and should be actively screened and treated. 1
• The presence of multiple pain problems elsewhere in the body strongly predicts worse outcomes after joint replacement, suggesting underlying pain processing vulnerabilities. 1
• Patients with persistent pain may benefit from referral to pain specialists, psychologists, or psychiatrists for comprehensive pain management. 2

Surgical Considerations

• Referral for additional joint replacement surgery should be considered when joint symptoms substantially affect quality of life and are refractory to non-surgical treatment, but only after core treatment options have been offered. 2
• Patient-specific factors including age, sex, smoking, obesity, and comorbidities should not be barriers to referral for joint replacement surgery. 2
• Arthroscopic lavage and debridement should not be routinely offered for osteoarthritis treatment. 2