What is the best course of action for a 53-year-old female with a history of left knee replacement, multiple chronic conditions (depression, hypertension, fluid retention, gastroesophageal reflux disease (GERD), vitamin D deficiency, macrocytic anemia, chronic eczema, overactive bladder, nausea, and allergies), and recent onset of left knee pain and swelling after increased workload, who has been using ibuprofen and gabapentin with limited relief?

Management of Post-Knee Replacement Pain with Suspected Lateral Muscle Overuse

This patient requires urgent orthopedic re-evaluation to exclude prosthetic joint infection (PJI) before any pharmacologic escalation, given the combination of persistent knee swelling, recent wound breakdown with drainage, and history of prior incision dehiscence. 1

Immediate Priority: Exclude Prosthetic Joint Infection

Red Flags Present in This Case

• Non-pitting edema with tenderness in a post-arthroplasty knee, even without warmth or fever, does not exclude PJI 1
• Recent wound breakdown with yellow-clear drainage in a patient with prior incision dehiscence creates significant infection risk 1
• The absence of fever, purulent drainage, or warmth does NOT rule out chronic low-grade PJI, which can present insidiously 1, 2

Required Diagnostic Workup Before Treatment Escalation

• Obtain knee radiographs (AP and lateral views) immediately to assess for prosthetic loosening, periprosthetic fracture, or signs of infection 3, 1
• ESR and CRP are essential screening tests—elevated inflammatory markers in a post-arthroplasty patient with effusion warrant arthrocentesis 3
• If inflammatory markers are elevated or clinical suspicion remains, urgent orthopedic referral for possible joint aspiration is mandatory before initiating any anti-inflammatory therapy or corticosteroid injection 3

Critical Pitfall: Never initiate corticosteroid therapy, increase immunosuppressive medications, or perform therapeutic aspiration before excluding infection with appropriate imaging and laboratory studies 3

Wound Management

Current Wound Assessment

• The 2mm open area with yellow-clear drainage requires direct visualization and possible culture, even without overt signs of infection 1
• History of incision dehiscence places this patient at higher risk for deep infection tracking from superficial wound 1
• Patient-induced trauma (peeling scab) may have introduced bacteria into a healing surgical site 1

Wound Care Approach

• Obtain wound culture if any drainage is present, even if minimal and non-purulent 1
• Ensure proper wound care with daily inspection, keeping area clean and dry, and covering with sterile dressing 1
• Instruct patient explicitly to avoid manipulating the wound site 1

Pain Management Strategy (Only After Infection Excluded)

Current Medication Optimization

• The patient is significantly undertreating with ibuprofen "once daily"—NSAIDs require scheduled dosing (not PRN) at therapeutic levels for anti-inflammatory effect 4
• Ibuprofen should be dosed 600-800mg three times daily with food (maximum 2400mg/day) if no contraindications exist 4
• Given her hypertension, GERD, and fluid retention, assess cardiovascular and GI bleeding risk before escalating NSAID therapy 4

Important Consideration: This patient has multiple comorbidities (hypertension, GERD, fluid retention) that significantly increase NSAID-related adverse events, particularly cardiovascular complications and GI bleeding 4

Gabapentin Request Assessment

• Gabapentin is NOT indicated for mechanical musculoskeletal pain or post-arthroplasty pain related to overuse 5
• FDA-approved indications are postherpetic neuralgia and adjunctive seizure treatment—this patient has neither 5
• The patient's belief that "gabapentin helped in the past" requires clarification about what type of pain was treated and whether neuropathic features were present 5
• Current presentation (lateral knee pain, mechanical exacerbation, no numbness/tingling/burning) does not suggest neuropathic pain 5, 2

Gabapentin carries significant risks in this patient: somnolence (21% vs 5% placebo), dizziness (28% vs 8% placebo), and increased fall risk—particularly concerning given her knee instability and work requiring prolonged standing 5

Non-Pharmacologic Management (First-Line Approach)

Strongly Recommended Interventions

• Exercise therapy is the cornerstone of post-arthroplasty pain management and lateral muscle overuse—specifically quadriceps strengthening and range-of-motion exercises 4
• Formal physical therapy referral is essential for proper exercise prescription, particularly given the history of knee replacement and current functional limitations 4
• Physical therapist can provide targeted lateral stabilizer strengthening, gait training, and workplace ergonomic assessment 4

Activity Modification

• Work-related prolonged standing and walking clearly precipitated this exacerbation—workplace accommodations should be explored 4
• Temporary reduction in weight-bearing activities until acute inflammation resolves 4
• Gradual return to full activity under PT supervision 4

Adjunctive Modalities

• Continue ice application (15-20 minutes every 2-3 hours) during acute inflammatory phase 4
• Elevation when possible to reduce swelling 4
• Consider knee sleeve or brace for lateral support during work activities, fitted by PT or orthotist 4

Referral Management

Orthopedic Referral (Urgent)

• Given persistent pain months after surgery, non-resolving effusion, and wound concerns, orthopedic re-evaluation should occur within 1-2 weeks, not routine scheduling 1, 2
• Orthopedics should assess for: 1, 2
  • Prosthetic positioning and stability
  • Component wear or loosening
  • Periprosthetic fracture
  • Chronic low-grade infection
  • Soft tissue impingement

Dermatology Referral

• Annual dermatology screening for chronic eczema is appropriate and should be scheduled 1
• Dermatologist can also evaluate the healing surgical site if concerns persist 1

Algorithmic Approach Summary

1. Immediate (Today): Order knee radiographs, ESR, CRP, and wound culture if drainage present 3, 1

2. If inflammatory markers elevated OR imaging concerning: Urgent orthopedic referral for possible arthrocentesis before any treatment changes 3

3. If infection excluded: 4

   • Optimize NSAID dosing (scheduled, not PRN) with GI protection if needed
   • Initiate formal physical therapy for exercise program
   • Provide work restrictions/modifications
   • Consider topical NSAIDs as alternative if oral contraindicated

4. Do NOT prescribe gabapentin for mechanical musculoskeletal pain without neuropathic features 5

5. Schedule orthopedic follow-up within 1-2 weeks regardless of initial workup results, given chronicity and functional impact 1, 2

6. Schedule routine dermatology as requested 1

The multimodal approach emphasizing exercise, proper NSAID dosing, and specialist evaluation takes precedence over adding gabapentin, which lacks indication and carries significant adverse effect risk in this clinical scenario. 4, 5