BMJ Open 2012 Beswick

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What proportion of patients reportlong-term pain after total hip or kneereplacement for osteoarthritis? A

systematic review of prospective studiesin unselected patients

Andrew David Beswick,1 Vikki Wylde,1 Rachael Gooberman-Hill,1 Ashley Blom,1

Paul Dieppe2

ABSTRACTBackground: Total hip or knee replacement is highly

successful when judged by prosthesis-related outcomes.However, some people experience long-term pain.

Objectives: To review published studies inrepresentative populations with total hip or kneereplacement for the treatment of osteoarthritisreporting proportions of people by pain intensity.

Data sources: MEDLINE and EMBASE databasessearched to January 2011 with no languagerestrictions. Citations of key articles in ISI Web ofScience and reference lists were checked.

Study eligibility criteria, participants andinterventions: Prospective studies of consecutive,unselected osteoarthritis patients representative of the

primary total hip or knee replacement population, withintensities of patient-centred pain measured after3 months to 5-year follow-up.

Study appraisal and synthesis methods: Twoauthors screened titles and abstracts. Data extractedby one author were checked independently againstoriginal articles by a second. For each study, theauthors summarised the proportions of people withdifferent severities of pain in the operated joint.

Results: Searches identified 1308 articles of which115 reported patient-centred pain outcomes. Fourteenarticles describing 17 cohorts (6 with hip and 11 with

knee replacement) presented appropriate data on painintensity. The proportion of people with anunfavourable long-term pain outcome in studies

ranged from about 7% to 23% after hip and 10% to34% after knee replacement. In the best qualitystudies, an unfavourable pain outcome was reported in

9% or more of patients after hip and about 20% ofpatients after knee replacement.

Limitations: Other studies reported mean values ofpain outcomes. These and routine clinical studies arepotential sources of relevant data.

Conclusions and implications of keyfindings: After hip and knee replacement, a significantproportion of people have painful joints. There is an

urgent need to improve general awareness of this

possibility and to address determinants of good andbad outcomes.

To cite: Beswick AD, Wylde

V, Gooberman-Hill R, et al.

What proportion of patientsreport long-term pain after

total hip or knee replacement

for osteoarthritis? A

systematic review of

prospective studies in

unselected patients. BMJ

Open2012;2:e000435.

doi:10.1136/

bmjopen-2011-000435

< Prepublication history and

additional appendices for this

paper are available online. To

view these files please visit

the journal online (http://dx.doi.org/10.1136/

bmjopen-2011-000435).

Received 7 October 2011

Accepted 9 January 2012

This final article is available

for use under the terms of

the Creative Commons

Attribution Non-Commercial

2.0 Licence; see

http://bmjopen.bmj.com

1School of Clinical Sciences,

University of Bristol, Bristol,

UK2Clinical Education Research

Group, Peninsula Medical

School, Plymouth, UK

Correspondence to

Andrew David Beswick;[email protected]

ARTICLE SUMMARY

Article focus- Total hip and knee replacement have good

clinical outcomes.- There is a perception that some people experi-

ence long-term pain after their joint replacement.- We aim to establish the proportion of patients

experiencing long-term pain after joint replacement.

Key messages- Well-conducted studies in representative popula-

tions of patients with total hip and knee joint rep-

lacement suggest that a significant proportion ofpeople continue to have painful joints after surgery.

- The proportion of people with an unfavourable

long-term pain outcome in studies ranged fromabout 7% to 23% after hip and 10% to 34% afterknee replacement. In the best quality studies, anunfavourable pain outcome was reported in 9%or more of patients after total hip and about 20%of patients after total knee replacement.

- There is an urgent need to improve generalawareness that some patients experience long-term pain after joint replacement and to addressthe determinants of good and bad outcomes.

Strengths and limitations of this study- Systematic review conducted according to

established methods and guidelines identified

17 studies in representative populations ofpatients with total hip or knee replacement.

- Pain outcome data are widely recorded as mean

values but only a minority of studies reportedoutcomes as proportions with pain at follow-up.

- The small number of studies and different pain

outcome measures precluded meta-analysis,calculation of a summary estimate and explora-tion of sources of heterogeneity.

Beswick AD, Wylde V, Gooberman-Hill R, et al. BMJ Open2012;2:e000435. doi:10.1136/bmjopen-2011-000435 1

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INTRODUCTIONSymptoms of osteoarthritis are managed in thecommunity, but if pharmacological and conservativetreatments provide inadequate relief, then total jointreplacement is commonly performed. In England andWales during the year ending March 2010, therewere 71 021 primary total hip and 79 263 primary total

knee replacement operations recorded in the NationalJoint Registry.1 In the USA in 2006, the estimatednumbers of hospital discharges after total hip or kneereplacement procedures were 231000 and 542 000,respectively,2 with demand predicted to increasesubstantially.3

Total hip or knee replacement is highly successfulwhen judged by prosthesis-related outcomes, such as theradiographic appearance of the prosthesis,4 implantsurvival5 or surgeon-assessed outcome.6 Nevertheless,many people continue to experience significant painand functional problems after total joint replacement.Woolhead and colleagues7 conducted in-depth inter-

views with 10 patients 6-months after their total kneereplacement. Although patients considered their jointreplacement successful, eight of the 10 patients stillexperienced pain and immobility. In a Europeancollaborative study of 1327 patients with total hipreplacement, Judge and colleagues8 applied threerecognised criteria for general symptomatic improve-ment with symptom severity based on pain, stiffness andphysical function according to the WOMAC osteoar-thritis index.9 The different criteria suggested thatbetween 14% and 36% of patients did not improve orwere worse 12 months after surgery.

Pain is the most important factor in the decision torecommend total joint replacement.10 Furthermore,patient-reported pain is now widely assessed usingdisease-specific outcome measures. In the USA, theimportance of patient-reported outcomes in assessingquality of care is recognised,11 and in England, followingthe report of Lord Darzi,12 information is routinelycollected after elective surgery.13

Reporting of pain outcomes in the orthopaedic liter-ature frequently emphasises improvement in meanscores. An example of this is the study of Bachmeier andcolleagues14 where the improvement of mean WOMACpain scores at 3, 6, 9 and 12 months after hip or kneereplacement is clearly demonstrated. However, at alltime points, the mean pain score has an associated SDimplying that a proportion of patients still reported pain.To advise both patients and their healthcare profes-sionals, it is important to have a clear understanding ofthe frequency and extent of pain following total hip orknee replacement.

We have used systematic review methods to identifystudies reporting the proportion of people with signifi-cant long-term pain after total hip or knee replacement.We aimed to identify studies in populations representa-tive of contemporary clinical practice. Some information

on all patients in cohorts is required as patients lost to

follow-up may have experienced poorer or at leastsimilar outcomes to those followed up.15e18

METHODSWe used systematic review methods in accordance withthe MOOSE proposal for reporting systematic reviewsand meta-analyses of observational studies.19 A MOOSE

checklist is shown in online appendix 1.

Data sources and searchesMEDLINE and EMBASE databases were searched frominception to 31 January 2011. A general search wasperformed to identify quantitative research in primarytotal hip or knee replacement. The MEDLINE searchstrategy is shown in online appendix 2. Search termsrelated to hip or knee replacement and studies with anepidemiological design including prospective andlongitudinal studies. No language restrictions wereapplied.

Within titles, abstracts and keywords of articles iden-tified, we searched for text words relating to osteoar-thritis and disease-specific patient-centred pain outcomemeasures used in osteoarthritis and joint replacement.Specifically these were Western Ontario and McMasterUniversities Arthritis Index (WOMAC), Arthritis Impact(AIMS), Lequesne, Oxford hip or Oxford knee score,Hip Osteoarthritis Outcome Score (HOOS) or KneeOsteoarthritis Outcome Score (KOOS), pain visualanalogue scales (VAS) and self-appraisal. Outcomes notconsidered patient centred were Harris Hip, AmericanKnee Society and Bristol Knee Scores. We did notinclude generic health measures including the Health

Assessment Questionnaire, EuroQol, London HandicapScale, Medical Outcomes Study Short Form-36 (SF-36),Disease Repercussion Profile, Sickness Impact Profileand WHOQol-BREF.

We also checked citations of key articles in ISI Web ofScience and reference lists. Studies reported only asabstracts were excluded. References were managed in anEndnote X3 database.

Study selectionWe included prospective studies of consecutive unse-lected patients representative of the primary total hip orknee replacement population. Studies reportinga specific implant or component were eligible if thepopulation studied was not clearly selected, that is, thegroup was likely to be representative of the total jointreplacement population.

Study designs excluded were cross-sectional andretrospective studies, randomised controlled trials andevaluations of specific technologies. Randomisedcontrolled trials and many evaluations of new technolo-gies comprise selected populations, and furthermore, itis outside the scope of this review to assess whether thesereflect best clinical practice.

We made an a priori decision to limit follow-up to

between 3 months and 5 years. In evaluating the

2 Beswick AD, Wylde V, Gooberman-Hill R,et al. BMJ Open2012;2:e000435. doi:10.1136/bmjopen-2011-000435

Long-term pain after total hip or knee replacement



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effectiveness of primary total hip or knee replacement inreducing pain from osteoarthritis, we are concerned withoutcomes when recovery can be considered maximal14

and not later issues of joint loosening and revision.20

Study titles, abstracts and, where necessary, full articleswere checked independently for eligibility by tworesearchers experienced in systematic reviews (ADB)

and rheumatology (PD). Disagreements were resolved bydiscussion. Validity of the database was confirmed bychecking against reference lists provided by local expe-rienced researchers in orthopaedic outcomes.

While we recognise that studies may include patientswith other joint replacement surgery, we excludedstudies specifically describing outcomes of revisionoperations and partial joint replacements (eg, unicom-partmental or patellofemoral knee replacement and hipresurfacing).

Data extractionThe pain measure relating to the operated hip or knee

was considered in the review. No attempt was made tocontact authors of studies who did not have appropriatedata. In the previous reviews we have conducted onlya minority of authors contacted have provided additionaldata for analyses. Although contact with authors is a well-recognised approach in systematic reviews,21 a survey ofreview authors indicated that many systematic reviewersdo not do so because of poor response rates and vari-ability in the quality of information collected this way.22

Authors of studies with appropriate data but with specificmissing information were contacted.

Data from eligible articles were recorded on an Excel

spreadsheet by one reviewer (ADB) and checked againstoriginal articles by a second (VW). Data were extractedon indication (all or majority of patients with osteoar-thritis), pain outcome, baseline dates, country, studydesign, how group selected, age, number of patientsrecruited, number who died and the number lost tofollow-up. We recorded the number of people at follow-up with no pain or mild pain, moderate or severe pain(or with little improvement in pain from preoperative),revision or dislocations or deep infection and contra-lateral or other joint replacement or treatment forfracture.

Data synthesis and analysisAs studies reported different pain measures, wesummarised pain outcomes in a way that was applicableto all measures. The proportions of people with differentseverities of pain were summarised as favourable,unfavourable or uncertain outcomes. Favourableoutcome includes people with no pain or mild pain atfollow-up, while unfavourable outcome includes thosewith moderate-to-severe pain or for whom surgery hadnot relieved pain. The uncertain outcome includes allpatients for whom we cannot be sure of their pain levelsat follow-up. These include patients who died, had revi-

sion surgery, contralateral surgery or dislocation andwere not followed up with questionnaires and those lost

to follow-up. We also included as uncertain thosepatients with a degree of reported pain, which we couldnot classify as a favourable or unfavourable outcome.

Quality assessmentOnly studies with unselected patients and completereporting of losses to follow-up were included. To

describe the quality of studies, we used the features ofthe Cochrane risk of bias table applicable to longitudinalstudies.21 Specifically, these were blind outcome assess-ment (self-completed patient-reported outcomemeasure), incompleteness of outcome data collection(losses to follow-up low 20%) and other sources of bias (representative-ness of study population).

RESULTSThe review process is summarised infigure 1. Searchesidentified 1308 studies reporting patient-centred

outcomes in patients with osteoarthritis. Of these, 115studies included data on patient-centred pain outcomesin representative population samples studied prospec-tively for between 3 months and 5 years. Fourteen arti-cles describing 17 cohorts (6 in hip and 11 in kneepatients) presented results classifiable as proportions ofpeople with different extents of pain at follow-up. Themain reasons for exclusion at this stage were lack ofa pain outcome separate from an overall outcome scoreor the presentation of results as means only.

Patient and study characteristics and outcomes areshown in table 1. The proportions of people withdifferent pain outcomes are summarised infigure 2.

Total hip replacementSystematic searches identified six studies from Canada,Denmark, Spain, Sweden, UK and USA including a totalof 13 031 patients. Pain outcome measures were basedon the WOMAC pain scale or authors own methods.The measures used and the definition of unfavourablepain outcome are summarised for each study in onlineappendix 3.

Study qualityIssues relating to study quality are summarised in online

appendix 4.Studies described data collected prospectively in

consecutive patients with primary total hip replacement.One study was in patients recruited from a national jointregistry.23 Two studies were in multiple centres24 25 andthree were studies in single centres.26e28 Cohorts weregenerally similar with regard to patient age (range ofmeans or medians 65.0e73.0 years) and sex (range ofpercentage female 48.3%e63%), and the indication wasosteoarthritis in 87% of patients or more when specified.One national registry study from Denmark included onlypatients treated with a postero-lateral surgical

approach.

23

However, the posterior or lateral approachwas used in 99% of patients according to another





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publication from the Danish Hip Registry.37 Otherwise,no inclusion or exclusion criteria suggested that thepatients studies would not have been representative ofthe overall total hip replacement population. All studiesused self-completed patient reported outcome measures.Losses to follow-up ranged from 5.8% to 47.6%. Weconsidered two markers of better representativeness asindicators of study quality: studies with multiplecompared with single centres and by lower losses tofollow-up.

WOMAC painJones and colleagues24 followed up a cohort of 242consecutive patients receiving total hip replacement ina health region 6 months after total hip replacement.Patients undergoing hemiarthroplasty, revisions andemergency surgery were excluded. Losses to follow-upwere low at under 5.8%. Results were presentedcombined with a total knee replacement cohort, andwith the consent of the author, we assumed that equalproportions of hip and knee patients were followed up.The WOMAC outcome used to define a poor painoutcome was an improvement of


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T

able1

Studiesoftotalhiporkneereplacementreportingproportionofpa

tientswithpainatfollow-up

A

uthor,country

d

ateofbaseline

Indication

,

population

,age

Follow-up

,study

design

,losses

tofollow-up

Painoutcome

measure

Numberofpatientswith

Favourab

le

outcome

Uncertain

outcome

Unfavourable

outcome

H

ipreplacement

Nikolajson

etal,23

Denmark,

2003

PrimaryTHR,

degenerativehip

arthritis

N1231questionn

aire

follow-upofconsecutive

patients

Meanage71.6years

(SD8.7)

12e18-month

follow-up

Jointregistry

5.9%

lostto

follow-up

Authorsownscaleof

presenceofhippain

andimpactondailylife

754(hippainnot

present)

4died

117lostto

follow-up

62bilateral

orfurther

operation

167hippain

stillpresent

withno/mild

impacton

dailylife

127(painwith

moderate,

severeorvery

severeimpact

ondailylife)

Jones

etal,24

Canada,

1995e1997

PrimaryTHR,94%

OA

N242consecutive

patients(includes

estimatedlostto

follow-upbasedon

equalproportionship/

kneelost)

Meanage68.2years

(SD11.1)

6-monthfollow-up

Prospective

5.8%

lostto

follow-up

ordied(Lossesto

follow-upestimated

proportionatelyas

notreportedforhip

andkneeseparately)

WOMACpain

Lossestofollow-up

estimatedproportionately

asnotreportedforhip

andkneeseparately

208(nop

ain/mildpain

definedasmorethan

a10-poin

tgainonthe

100-point

WOMACpain

dimension)

14lostto

follow-up

(estimated)

20(moderate/

severepaindefined

asagainof30 on a 100-mm VAS pain scale, wasreported in 17.6% of patients (uncertain 15.7%).

In the study of Brander and colleagues,

36

116 consec-utive patients treated with primary total knee replace-ment by a single surgeon were followed prospectively forup to 12 months. Using a VAS scale, the authors identi-fied significant knee pain (defined as a VAS score of>40) in 12.9% of patients (uncertain 2.6%). No patientswere lost to follow-up.

OVERVIEWTotal hip replacementOverall, an unfavourable pain outcome was seen in atleast 4.8% and up to 20.5% of patients after hip

replacement (figure 2). However, these are likely to beunderestimates as we do not have information on theoutcomes in between 5.8% and 52.7% of patients.

As indicators of studies with more representativepopulations, the three studies in multiple centresreported an unfavourable pain outcome relating to theoperated hip in 8.3%, 10.3% and 16.3% of patientsfollowed up. Studies with low losses to follow-upreported an unfavourable pain outcome in 8.3%, 10.3%and 20.5% of patients. Even considering studies withsome degree of outcome consistency involving minimalclinically important differences, the range of unfav-ourable pain outcome was wide with at least 8.1% and up

to 20.5% of patients affected.Applying the conservative assumption that an equal

proportion of patients with missing data had an unfav-ourable pain outcome, we estimate that at least 7%e23%of patients experienced long-term pain after hipreplacement. In three higher quality studies as judged byrepresentativeness, this would reflect an unfavourablepain outcome in 9%, 13% and 20% of patients, and inthree studies with low losses to follow-up in 9%, 13% and23% of patients. Two studies with both indicators of beststudy quality suggested that 9%e13% of patients had anunfavourable pain outcome after total hip replacement.

Total knee replacementAfter knee replacement, an unfavourable pain outcomewas seen in at least 8.0% and up to 26.5% of patients(figure 2). Three studies followed up populations frommultiple centres and unfavourable pain outcomesrelating to the operated knee were reported in 16.8%,18.5% and 25.1% of patients. In four studies with lowlosses to follow-up, an unfavourable pain outcome wasreported in 8.0%, 12.9%, 16.2% and 18.5% of patients.Considering studies with some degree of outcomeconsistency, the range of unfavourable pain outcome

was wide with at least 14.3% and up to 25.1% of patientsaffected.

These are likely to be underestimates as we do nothave outcome information on between 2.6% and 54.7%of patients. Assuming conservatively that the patientswith missing data had similar pain outcomes, studiessuggested that at least 10%e34% of patients experiencelong-term pain after knee replacement. Applying thisassumption in the higher quality studies with potentially

more representative populations, at least 19%, 20% and31% of patients had an unfavourable pain outcome aftertotal knee replacement. In four studies with low losses tofollow-up, 10%, 13%, 17% and 20% of patients reportedan unfavourable pain outcome at follow-up. In one studyconducted in multiple centres with low losses to follow-up, 20% of patients reported an unfavourable painoutcome at follow-up.

DISCUSSIONThese data show that many people with a total hip orknee replacement complain of pain in the operated joint

in the early years after surgery. This was particularlyevident after total knee replacement.

Although we have interpreted pain outcomes asfavourable, unfavourable or uncertain, we do not believethat the data justify combination to provide summaryvalues. In the studies identified in our review, severaldifferent outcome measures were reported, and in studieswith similar outcomes, different methods of analysiswere used. Without specific information on responsive-ness and correlation between methods, an importantadditional source of heterogeneity may be introduced.38

Previous reviews have looked at functional and health-related quality of life after joint replacement. Kane andcolleagues39 reported functional outcomes after totalknee replacement in a literature review of 62 studiespublished between 1995 and 2003. They concluded thatknee replacement leads to improved function as shownby large effect sizes in studies but that larger benefitswere perceived by physicians than experienced bypatients. Ethgen and colleagues40 identified 74prospective cohort studies published between 1980 and2003 that included quality of life outcomes. The authorshighlighted the value of health-related quality of life datain improving management of patients undergoing hip orknee replacement. They concluded that total hip and

knee arthroplasties were quite effective in improvinghealth-related quality of life dimensions. In a largeEuropean cohort, Judge and colleagues8 concluded that14%e36% of patients had no symptomatic improvement12 months after total hip replacement.

The results we present are consistent with thosereporting satisfaction as an outcome. For example,Bourne and colleagues41 reported satisfaction with painrelief in a study in knee replacement patients. Satisfac-tion with pain relief ranged from 72% for going up ordownstairs to 85% for walking on a flat surface.

In systematic reviews, publication bias is important in

assessing the validity of the results. In this review, weidentified 95 studies where the proportion of people with





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pain at follow-up could have been estimated by authorswith access to original data. In previous reviews that wehave conducted, replies to requests for additional datahave been patchy and we chose not to pursue thisapproach. Nevertheless, we encourage study authors toperform and publish appropriate analyses of their data.Similarly, a wealth of patient-centred outcome data is now

collected routinely and merits wide dissemination.The majority of studies included in our reviewreported outcomes of patients after total joint replace-ment. A few studies followed up patients listed for totaljoint replacement, and it is possible that these studiesincluded patients who subsequently received othersurgical treatments including unicompartmental kneereplacement or hip resurfacing.

In this review, we were unable to apply a standarddefinition of pain severity at follow-up and the need toimprove assessment and measurement of musculoskel-etal pain in the clinical setting is recognised.42 In thearticles we included there were several interpretations of

pain as an unfavourable outcome. These included lackof improvement in postoperative pain scores, pain atrest, persistent pain, night pain and lack of detectableclinical improvement.

Although having a standard outcome has advantages,our more encompassing approach allows us to includestudies from wide time periods and different countrieswith different favoured methods for outcome assessment.However, the different outcome measures and smallnumber of studies precluded exploration of sources ofheterogeneity relating to patient characteristics, surgicalmethod, peri-operative care and rehabilitation.

In the studies included in this review, the measuresmay not fully describe chronic postsurgical pain.Measures that focus on pain during specific activitiesmay not reflect the intermittent and intense pain thathas the greatest impact on quality of life.43Another issuein considering pain as an outcome after replacement isthat no account is made for the effect of analgesics andassistive aids on the reporting of pain. Self-reportedanalgesic use is high with 40% of men and 58% ofwomen taking pain medications after knee replace-ment44 and 30% of patients taking analgesics daily afterhip replacement because of pain in their replacedjoint.23We used disease-specific instruments focusing onthe operated joint rather than generic measures of pain.In the replacement population, there are likely to behigh levels of morbidity due to osteoarthritis and otherconditions common in old age.

Our data suggest that many hip and knee replacementpatients are likely to be in pain at the time when recoveryfrom surgery should be optimal. In a cohort of 194patients following hip or knee replacement surgery, painwas seen to achieve its lowest level by 3 months aftersurgery.14

While acknowledging probable underestimates of theextent of pain after surgery reported in the literature, we

should recognise the effectiveness of replacement for

many. However, a significant proportion of people havepainful joints despite surgery and strategies to improveoutcomes merit research.

Many determinants of long-term outcome after hipand knee replacement are described and interventionsevaluated. Better general health, physical, emotional andsocial function, motivation and self-efficacy and lower

levels of pain before surgery and during the rehabilita-tion period are associated with improved short- andmedium-term outcomes.26 45e47 However, the evidencefor benefit of presurgical and rehabilitation interven-tions is limited, particularly as few studies have beenadequately powered or of sufficient duration.48e52

Another approach is the identification of patients beforesurgery who are at risk of a poor pain outcome. Kalkmanand colleagues53 developed a multivariable model topredict short-term pain after surgical procedures. Use ofa predictive model based on presurgical or postsurgicalfactors might allow targeting of additional pain manage-ment and rehabilitation to patients likely to benefit.

In conclusion, persistent pain in a hip or knee jointthat has been replaced is not uncommon. For patients toparticipate in decisions about their care, it is importantthat they are informed and aware of both the likelybenefits of surgery and the possibility of a less favourableoutcome. With this knowledge, they may contributemore fully to the replacement process including prepa-ratory strategies and long-term rehabilitation. It is clearthat the current move to a greater interest in patient-centred outcomes after replacement is necessary andthat there is an urgent need to address the determinantsof good and bad outcomes.

Contributors PD conceived the review. All authors contributed to the design of

the review. ADB identified and acquired reports of studies. ADB and PD

checked studies for eligibility. ADB and VW extracted and checked data. ADB

analysed and interpreted the data. ADB drafted the manuscript. All authors

contributed to the final version of the manuscript. All authors contributed to

revision of the manuscript. All authors approved the final version of the

manuscript.

Funding This article outlines independent research commissioned by the

National Institute for Health Research (NIHR) under its Programme Grants for

Applied Research funding scheme (RP-PG-0407-10070). The views expressed

are those of the authors and not necessarily those of the NHS, the NIHR or the

Department of Health.

Competing interestsNo financial support or other benefits have been received

by any of the authors that could create a potential conflict of interest withregard to the work.

Patient consent We only used grouped patient data reported in published

studies.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statementData extracted from articles included in the review are

available from author ADB.

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Andrew David Beswick, Vikki Wylde, Rachael Gooberman-Hill, et al.prospective studies in unselected patientsosteoarthritis? A systematic review ofpain after total hip or knee replacement forWhat proportion of patients report long-term

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