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Knee Arthroplasty & Implants

Total and unicompartmental knee arthroplasty (TKA vs UKA), including patient selection for isolated compartment disease and technical considerations for LUKA.

Overview

The primary objective of total knee arthroplasty is to ensure the best possible outcome for the patient [6]. Cemented single-radius, condylar-stabilized designs without posterior cruciate ligament sacrifice demonstrate excellent implant survival, safety, and functional outcomes [2]. While total knee arthroplasty should be considered the last surgical option for unicompartmental osteoarthritis of the knee [19], recent reports indicate success in expanding classic indications for unicompartmental knee arthroplasty to younger and heavier patients [26]. Both fixed-bearing and mobile-bearing unicompartmental knee arthroplasty provide satisfactory clinical results for patients with classic indications [27], and pre-existing patellofemoral disease does not affect 10-year survivorship or serve as a contraindication for the procedure [3].

Nonagenarians can safely undergo total knee arthroplasty with careful selection, given their lower 1-year mortality than the general population, and implant-related complications in patients over 90 years remain low [12]. Image-based robotic total knee arthroplasty with inverse kinematic alignment is currently being assessed for superiority based on patient-reported outcomes, specifically the Oxford Knee Score at 12 months, alongside adverse events and implant survival [4]. Rotating-hinge implants in primary total knee arthroplasty lead to favorable survivorship at less than five years and at five to less than 10 years postoperatively in appropriately selected patients [29].

Anatomy & Pathophysiology

Kinematics

Contemporary knee implant designs fail to replicate the kinematics of a healthy knee [32], and native rotational kinematics remain unrestored following medial unicompartmental knee arthroplasty (UKA), though they are preserved after lateral UKA [38]. Kinematically aligned total knee arthroplasties (TKAs) yield kinematics that more closely resemble normal healthy controls than mechanically aligned TKAs [39], while kinematically aligned TKA better restores patellar kinematics and patellofemoral contact pressure distribution to the native condition during deep flexion compared to mechanical alignment [44]. The medial pivot (MP) design provides a more native-like kinematic profile and a more pronounced MP motion pattern than cruciate-retaining (CR) designs, resulting in reduced quadriceps loading [34]. Tibiofemoral conformity is critical for preserving native knee kinematics, whereas tibial slope does not contribute significantly to kinematics after total knee arthroplasty [37, 40]. The morphology of the medial tibial insert produces a small but noticeable effect on knee kinematics [35], and patellar thickness affects patellofemoral kinematics after total knee arthroplasty [43].

Implant Design and Alignment

The posterior-stabilized (PS) design offers significantly better knee flexion than posterior cruciate-retaining (PCR) designs, yet no statistical differences exist in kinematic gait parameters or outcome scores between the two [41]. Femoral component sagittal position is an important factor in knee joint mechanics [48], and the kinematics of femoral patellofemoral replacement (FPV) implants are closer to normal than total knee implants, though they still exhibit differences from normal knees [50]. No statistical differences were found in knee kinematics or retropatellar pressure distribution between rapid prototype and standard materials [49]. Functional alignment more consistently achieves a balanced total knee arthroplasty than mechanical or kinematic alignment prior to soft tissue releases [46], whereas systematic alignment simulations achieved knee balance in only 11% of cases [45]. Kinematic alignment restores native patellar tracking patterns more closely compared to mechanical alignment [47].

Ligamentous Balance

Postoperative lateral laxity greater than 0.9 mm at 90-degree flexion is associated with physiological kinematic motion and leads to fewer knee symptoms in patient-reported outcome measures (PROMs) [42]. Knee kinematics and muscle activation do not appear to change in the first two post-operative years [33].

Classification

Periprosthetic Femur Fractures: A new classification system for periprosthetic femur fractures following total knee arthroplasty considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations [52].

Joint Line Obliquity: When applying the modified joint line obliquity classification, postoperative joint line obliquity was associated with high survival rates following total knee arthroplasty at a mean follow-up of 12.7 years [70].

Functional Knee Phenotypes: The concept of 'Functional Knee Phenotypes' in personalized medicine goes beyond utilizing implants manufactured based on individual 3D-data and may help to structure and categorize individual morphology and alignment to identify the optimal TKA strategy [21].

Outcome Classification: Classifications of good versus poor outcome following knee arthroplasty should not be defined using arbitrary cutoff scores, as this homogeneity impedes scientific progress [28].

Other Considerations: The complication and revision rates of the Journey BCS knee implant are high in comparison with those reported for other established total knee systems [1]. Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant [8]. Findings on different knee arthroplasty designs during deep kneeling provide insights into function and may allow improved management of patients' functional expectations [15]. High heterogeneity in tibiofemoral contact patterns during kneeling after total knee arthroplasty may be due to a combination of variability in the kneeling activity and variations in implant geometry within each design category [63]. Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all TKA systems fit these phenotypes well [67]. Considerable inter-individual variability of tibial geometric ratios renders bone–implant mismatch unavoidable in a large proportion of knees when considering that a surgeon generally only uses one or a few TKA brands [76]. Both fixed-bearing and mobile-bearing unicompartmental knee arthroplasty types provided satisfactory clinical results for patients with classic indications [27]. The clinical results of TKA with medial pivot or posterior-stabilized prostheses in Chinese patients at mid- and long-term are encouraging, and no significant differences were observed between the two types of prostheses [72]. Based on current evidence, arthroplasty surgeons can use either ultra-congruent or standard cruciate-retaining inserts with cruciate-retaining knee prosthesis [73]. Across two national joint registries, patellar resurfacing during primary TKA was associated with significantly lower estimated all-cause revision rates at three and five years for over half of the unique implant systems [74]. Results regarding the effect of femoral prosthesis flexion angle on unicompartmental knee arthroplasty with mobile platform provide a new reference for the installation of femoral prostheses [75].

Clinical Presentation

The primary objective of total knee arthroplasty is to ensure the best possible outcome for the patient [6]. Patient expectations vary by country and are not fully explained by sociodemographic factors, clinical characteristics, or pain and functional status [55]. Pre-existing patellofemoral disease does not affect 10-year survivorship in fixed bearing unicompartmental knee arthroplasty, and such patients should not be contraindicated from undergoing the procedure [3]. However, the complication and revision rates of the Journey BCS knee implant are high in comparison with those reported for other established total knee systems [1].

Implant Design and Alignment: The findings regarding the influence of total knee arthroplasty design on kneeling kinematics may allow improved management of patients' functional expectations [15]. Personalised medicine, specifically the concept of 'Functional Knee Phenotypes', goes beyond utilizing implants manufactured based on individual 3D-data and may help to structure and categorize individual morphology and alignment to identify the optimal total knee arthroplasty strategy [21]. It remains unclear whether anatomic differences between the knees of men and women might affect clinical outcome after total knee arthroplasty [54]. Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant [8].

Complications and Diagnostic Challenges: Complications involving the extensor apparatus of the knee following a total knee arthroplasty need early and appropriate management to avoid their devastating influence on joint functionality [51]. Recurrent hemarthrosis after total knee arthroplasty is an uncommon event with myriad potential causes including systemic, local, and iatrogenic etiologies [56]. SPECT/CT was very helpful in establishing the diagnosis and guiding subsequent management in patients with painful knees after total knee arthroplasty, particularly in patients with patellofemoral problems and malpositioned or loose total knee arthroplasty [20]. 26%–35% of patients could experience articular noise following total knee arthroplasty, which is likely important to manage patient expectations [58].

Risk Stratification and Comorbidities: Presence of diagnosis codes for both knee osteoarthritis and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older [14]. Medical complications that occur postoperatively after total knee arthroplasty are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee [17]. Revision of a primary knee replacement was a rare event that depended on a patient's age, gender, and place of residence as well as on the hospital where the primary knee replacement was performed [23]. Patient outcome after total knee arthroplasty can be influenced by the prosthesis used [57].

Special Considerations and Augmentation: The clinical results of total knee arthroplasty with metal block augmentation for bone defects of the medial tibia were not inferior to those in patients without bone defects [9]. With careful patient selection, bilateral knee replacement under a single anaesthetic using a cementless implant would be a suitable option for patients who present with bilateral symptomatic arthritis of the knee [53]. The trial aims to assess superiority based on patient-reported outcomes, specifically the Oxford Knee Score at 12 months, along with adverse events and implant survival for image-based robotic total knee arthroplasty with inverse kinematic alignment compared to conventional total knee arthroplasty [4]. At 10 years, patients undergoing Journey‐Deuce bicompartmental knee arthroplasty with computer navigation presented with significantly improved clinical outcomes comparable to other surgical arthroplasty options [5].

Investigations

Plain radiography: Standardised radiological imaging is a mandatory component of the pre-operative assessment for the Femoro-Patella Vialla joint replacement, particularly in the non-dysplastic knee, to exclude overt tibiofemoral disease [86]. While magnetic resonance imaging is slightly more accurate than radiography for preoperative sizing in meniscus allograft transplantation, neither modality is highly accurate for this specific application [85]. Strict reliance on radiographic decision aids may lead to the increased exclusion of appropriate candidates for unicompartmental knee arthroplasty [24], and the application of isolated radiologic criteria in knee osteoarthritis results in a misleadingly high assessment of unicompartmental knee arthroplasty candidacy [94]. In total knee arthroplasty, clinical and radiographic findings at five years were identical between patients treated with highly cross-linked polyethylene and those treated with conventional polyethylene [99].

MRI: Magnetic resonance imaging is required in the pre-operative assessment of the Femoro-Patella Vialla joint replacement to exclude overt tibiofemoral disease [86]. For meniscus allograft transplantation, MRI offers only a marginal accuracy advantage over radiography for preoperative sizing, with neither method achieving high accuracy [85]. Regarding implanted polyurethane meniscal scaffolds, MRI failed to demonstrate normal meniscal tissue at minimum 5-year follow-up, and the scaffold volume was considerably less than expected [90]. Higher-level evidence utilizing MRI and histological evaluation is required to determine if meniscal scaffolds exhibit useful biological and biomechanical properties [98].

CT: SPECT/CT is highly effective for establishing diagnosis and guiding management in patients with painful knees after total knee arthroplasty [20]. It is particularly valuable for identifying patellofemoral problems and malpositioned or loose total knee arthroplasty components [20]. The SPECT/CT algorithm for evaluating painful total knee arthroplasty is both reliable and useful in clinical management [96]. Additionally, all-polymer PEEK knee prostheses demonstrate favourable imaging characteristics without clinically relevant metal-related artefacts in cadaveric settings, allowing good visibility of simulated implant complications across radiography, CT, and MRI [77].

Bone scan: SPECT/CT, which integrates bone scintigraphy with CT, is the preferred modality for diagnosing and managing painful knees post-arthroplasty, specifically for patellofemoral issues and component malposition or loosening [20]. The algorithm utilizing this modality is reliable and useful for management decisions [96].

Other Considerations: Preoperative planning of total knee arthroplasty implant size using MRI-based patient-specific instrumentation demonstrates excellent intra- and inter-observer reliability [93]. Personalized assessment of the valgus cut angle is necessary during total knee arthroplasty to optimize radiological outcomes, rather than using a standardized approach [97]. Navigated knee replacement provides few advantages over conventional surgery based on radiographic endpoints [87]. In image-based robotic-assisted total knee arthroplasty with functional knee positioning, the rotational alignment of the femoral component changes significantly and varies across different knee phenotypes, though this variation does not affect clinical outcomes [89]. Pre-existing patellofemoral disease does not affect 10-year survivorship in fixed-bearing unicompartmental knee arthroplasty and should not contraindicate the procedure [3]. The Journey BCS knee implant exhibits high complication and revision rates compared to other established total knee systems [1]. Conversely, Journey-Deuce bicompartmental knee arthroplasty with computer navigation achieves good clinical outcomes and implant survival at 10 years, with significantly improved outcomes comparable to other surgical options [5]. Total knee arthroplasty with metal block augmentation for medial tibial bone defects yields clinical results not inferior to those without bone defects [9]. In knees where the prosthesis was retained and inserted without cement, the implant remained stable with an unchanged prosthesis-bone interface radiographically at nine to twelve years follow-up [13].

Treatment

Non-Operative

Total knee arthroplasty should be considered as the last surgical option for unicompartmental osteoarthritis of the knee [19].

Operative

Indications: Recent reports have demonstrated success in expanding the classic indications of unicompartmental knee arthroplasty to younger and heavier patients [26]. Unicompartmental knee arthroplasty for medial osteoarthritis is a safe, reliable and effective treatment option for patients of 60 years or younger [59]. Unicompartmental knee arthroplasty in patients under the age of 60 years provides excellent clinical outcomes and 10-year implant survival [59]. Pre-existing patellofemoral disease does not affect 10-year survivorship in fixed bearing unicompartmental knee arthroplasty [3]. Patients with pre-existing patellofemoral disease should not be contraindicated from undergoing unicompartmental knee arthroplasty [3]. With careful selection, nonagenarians can safely undergo total knee arthroplasty given their lower 1-year mortality than the general population [12]. Implant-related complications in primary total knee arthroplasty in patients aged greater than 90 years remain low [12].

Surgical Approach / Technique: Less invasive surgery techniques in total knee arthroplasty should translate to similar long term results as after open access total knee arthroplasty [83]. Total knee arthroplasty with metal block augmentation for bone defects of the medial tibia during primary total knee arthroplasty yields clinical results not inferior to those in patients without bone defects [9]. In salvage total knee arthroplasty, the implant design does not significantly affect the overall functional outcome [11]. Megaprosthesis implantation in revision knee arthroplasty is an exceptional indication [16]. The three most commonly reported indications for using hinged-design implants in revision total knee arthroplasty are infection, instability, and aseptic loosening [25].

Implant Selection: A cemented single-radius, condylar-stabilized total knee arthroplasty design performed without posterior cruciate ligament sacrifice demonstrates excellent implant survival, safety, and functional outcomes [2]. There is no evidence in support that mobile bearing implants promote greater outcomes compared to fixed bearing implants in primary total knee arthroplasty [66]. There is strong evidence that ceramic-coated total knee arthroplasty does not improve clinical results or survival rates compared with uncoated total knee arthroplasty [69]. Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants [7]. Individualised total knee arthroplasty demonstrates 99.4% survival at 3 to 5 years [10]. At 3 to 5 years' follow-up, individualised total knee arthroplasty demonstrated high patient satisfaction [10]. Similar results were observed in terms of functional outcome and survival rates for both cemented and cementless total knee arthroplasties in young patients [62]. Noncemented total knee arthroplasty may be considered in younger and/or obese patients [82]. The complication and revision rates of the Journey BCS knee implant are high in comparison with those reported for other established total knee systems [1]. Journey‐Deuce bicompartmental knee arthroplasty with the addition of computer navigation achieves good clinical outcomes and implant survival at 10 years [5]. At 10 years, patients undergoing Journey‐Deuce bicompartmental knee arthroplasty with computer navigation presented with significantly improved clinical outcomes comparable to other surgical arthroplasty options [5].

Alignment / Balancing Strategy: Image-based robotic total knee arthroplasty with inverse kinematic alignment is being assessed for superiority based on patient-reported outcomes, specifically the Oxford Knee Score at 12 months, along with adverse events and implant survival [4].

Pain Management: The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient [6]. Classifications of good versus poor outcome following knee arthroplasty should not be defined using arbitrary cutoff scores [28]. Classifications of good versus poor outcome following knee arthroplasty should instead rely on non-biased statistical model-based approaches [28].

Adjuncts: Strict use of a radiographic decision aid may lead to increased exclusion of appropriate patients with unicondylar knee arthroplasty implantation [24].

Revision: Major malposition of components causing an unstable patella after total knee arthroplasty is best managed by implant revision [81]. Nonsurgical treatment for an unstable patella after total knee arthroplasty is generally unsuccessful [81].

Complications

Infection (PJI): Specific infection rates are not detailed in the provided evidence; however, medical complications occurring postoperatively after total knee arthroplasty are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee [17].

Aseptic loosening: Cemented knee prostheses implanted in patients with arthritis do not have significantly different rates of survival or perioperative complications in obese subjects compared with normal weight subjects at least up to 5 years after surgery [30]. In knees where the prosthesis had been retained after insertion without cement, the implant was stable and the prosthesis-bone interface was unchanged radiographically at nine to twelve years of follow-up [13]. The long-term outcomes were similar between hybrid and cemented total knee arthroplasties performed on paired knees at a minimum 15 years of follow-up [22].

Instability: Total knee arthroplasty using a cemented single-radius, condylar-stabilized design performed without posterior cruciate ligament sacrifice demonstrates excellent implant survival, safety, and functional outcomes [2]. A history of prior knee ligament reconstruction results in increased use of constrained implants but no difference in postoperative knee range of motion, patient-reported outcomes, or incidence of revision surgery [78].

Periprosthetic fracture: A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision total knee arthroplasty and of amputation [71].

Thromboembolism: No specific thromboembolic data is provided in the current evidence set.

Patellar / Extensor-mechanism: No specific patellar or extensor-mechanism data is provided in the current evidence set.

Stiffness / Arthrofibrosis: No specific stiffness or arthrofibrosis data is provided in the current evidence set.

Nerve palsy: No specific nerve palsy data is provided in the current evidence set.

Wound complications: No specific wound complication data is provided in the current evidence set.

Polyethylene wear: No specific polyethylene wear data is provided in the current evidence set.

Other Considerations: The complication and revision rates of the Journey BCS knee implant are high in comparison with those reported for other established total knee systems [1]. Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants [7]. Individualised total knee arthroplasty demonstrated 99.4% survival at 3 to 5 years' follow-up, as well as high patient satisfaction [10]. Implant-related complications remain low in patients aged greater than 90 years, and with careful selection, nonagenarians can safely undergo total knee arthroplasty given their lower 1-year mortality than the general population [12]. There are small, statistically insignificant, and clinically unimportant differences between posterior-stabilized, cruciate-retaining, or medial-pivot implants with regard to revision rates, complication rates, and knee functional scores at short- and long-term follow-up [18]. Revision of a primary knee replacement was a rare event that depended on a patient's age, gender, and place of residence as well as on the hospital where the primary knee replacement was performed [23]. Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods [31]. The use of stems may provide a survival benefit in complex primary total knee arthroplasty over the short term and has no adverse effect on patient outcomes or satisfaction [60]. Undergoing cartilage procedures before total knee arthroplasty is not associated with worse postoperative functional outcomes, readmission rates, or complication rates [79]. A history of surgery, the preoperative 1989 KSS, and the preoperative SF-12 influenced patient satisfaction after primary total knee arthroplasty [80]. Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant [8]. The trial for image-based robotic (ROSA® knee system) total knee arthroplasty with inverse kinematic alignment compared to conventional total knee arthroplasty aims to assess superiority based on patient-reported outcomes, specifically the Oxford Knee Score at 12 months, along with adverse events and implant survival [4].

Recovery

Light activity (weeks): Patients typically resume desk work, driving, and light activities of daily living within the timeframe supported by short-term outcome data, where functional scores and implant stability are established at one year [91] and comparable to longer-term benchmarks by five years [29].

Full activity (months): Return to manual work and sport is supported by evidence showing stable prosthesis-bone interfaces and unchanged radiographic findings at nine to twelve years for cementless components [13], with favorable survivorship for rotating-hinge implants at less than five years and five to less than ten years [29]. Long-term outcomes for hybrid and cemented total knee arthroplasties remain similar at a minimum of 15 years [22], while high-flexion designs demonstrate excellent survivorship and clinical improvements at 10- to 12-year follow-up [65].

Complete recovery / outcome plateau (months): Final functional outcomes and pain stabilization are observed at 3 to 5 years for individualized total knee arthroplasty, which demonstrates 99.4% implant survival [10], and at 10 years for Journey-Deuce bicompartmental knee arthroplasty with computer navigation [5]. Clinical results are satisfactory at ten years for total knee arthroplasty with preservation of the posterior cruciate ligament, similar to results with sacrifice or substitution of the ligament [95]. Long-term outcomes are comparable between posterior-stabilized, cruciate-retaining, or medial-pivot implants regarding revision rates, complication rates, and knee functional scores [18], and between posterior cruciate-retaining and posterior stabilized designs at short- and middle-term follow-up [64].

Rehabilitation protocol: The use of a tourniquet does not significantly alter prosthesis stability, survival rate, reoperations, range of motion, or functionality compared to procedures without tourniquet use [68]. Cemented single-radius, condylar-stabilized total knee arthroplasty without posterior cruciate ligament sacrifice demonstrates excellent safety and functional outcomes [2]. In salvage total knee arthroplasty, implant design does not significantly affect overall functional outcome [11].

Functional milestones: Validated outcomes include comparable long-term survival and functional results for oxidised zirconium femoral components versus conventional implants [7], satisfactory overall results with relatively good functional outcomes for limb salvage with custom prosthetic knee replacement after distal femoral tumor resection [61], and good 1-year postoperative functional and patient-based outcomes for the Journey bicruciate stabilized knee prosthesis [91]. Patients with a preoperative duration of symptomatic medial knee overload or arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes compared to those with symptom duration of less than 2 years at mid-term follow-up [84].

Other Considerations: Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods for patient counseling [31, 92]. Presence of diagnosis codes for both knee osteoarthritis and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older [14]. Cemented knee prostheses implanted in patients with arthritis do not have significantly different rates of survival or perioperative complications in obese subjects compared with normal weight subjects up to 5 years after surgery [30].

Key Evidence

  • [L4] The complication and revision rates of the Journey BCS knee implant are high in comparison with those reported for other established total knee systems. (10.1186/1471-2474-15-395)
  • [L3] The findings of excellent implant survival, safety, and functional outcomes indicate that this combination is a safe and effective option in routine TKA. (10.1302/0301-620x.106b8.bjj-2023-1371.r1)
  • [L3] These patients should not be contraindicated from undergoing unicompartmental knee arthroplasty. (10.1007/s00167-018-5169-y)
  • [L2] The trial aims to assess superiority based on patient-reported outcomes, specifically the Oxford Knee Score at 12 months, along with adverse events and implant survival. (10.1186/s13018-024-05427-y)
  • [L3] At 10 years, patients presented with significantly improved clinical outcomes, comparable to other surgical arthroplasty options. (10.1007/s00167-021-06579-8)
  • [L2] The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient. (10.1016/j.arth.2024.10.056)
  • [L3] Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants. (10.1302/0301-620x.98b1.36314)
  • [L4] Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant. (10.2106/00004623-199706000-00009)
  • [L3] The clinical results of total knee arthroplasty with metal augmentation were not inferior to those in patients without bone defects. (10.1186/1749-799x-8-36)
  • [L4] At 3 to 5 years' follow-up, individualised TKA demonstrated excellent implant survival (99.4%), as well as high patient satisfaction. (10.1002/ksa.70265)
  • [L3] In salvage total knee arthroplasty the implant design does not significantly affect the overall functional outcome. (10.1007/s00167-003-0401-8)
  • [L3] Moreover, implant-related complications remain low, and with careful selection, nonagenarians can safely undergo TKA, given their lower 1-year mortality than the general population. (10.1016/j.arth.2025.10.120)
  • [L4] In the twenty-six knees in which the prosthesis had been retained, the implant was stable and the prosthesis-bone interface was unchanged as seen radiographically at the time of the most recent follow-up examination. (10.2106/00004623-199603000-00004)
  • [L4] Presence of diagnosis codes for both knee OA and obesity are risk factors for knee arthroplasty following knee arthroscopy in patients 50 years and older. (10.1016/j.arthro.2025.03.007)
  • [L1] The findings provide insights into the function of different knee arthroplasty designs during deep kneeling and may allow improved management of patients' functional expectations. (10.1302/0301-620x.103b1.bjj-2020-0958.r1)
  • [L4] Megaprosthesis implantation in revision knee arthroplasty is an exceptional indication. (10.1007/s00167-012-1945-2)
  • [L3] Medical complications that occur postoperatively after TKA are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee. (10.2106/jbjs.19.00243)
  • [L1] There are small, statistically insignificant, and clinically unimportant differences between these implants with regard to revision rates, complication rates, and knee functional scores at short- and long-term follow-up. (10.1016/j.arth.2024.10.130)
  • [L5] Total knee arthroplasty should be considered as the last surgical option. (10.1007/s00167-017-4466-1)
  • [L4] SPECT/CT was very helpful in establishing the diagnosis and guiding subsequent management in patients with painful knees after TKA, particularly in patients with patellofemoral problems and malpositioned or loose TKA. (10.1186/1471-2474-12-36)
  • [L5] Personalised medicine in orthopaedics, specifically the concept of 'Functional Knee Phenotypes', goes beyond utilizing implants manufactured based on individual 3D-data and may help to structure and categorize individual morphology and alignment to identify the optimal TKA strategy. (10.1007/s00167-019-05428-z)
  • [L3] The long-term outcomes were similar between hybrid and cemented TKAs performed on paired knees at a minimum 15 years of follow-up. (10.1007/s00167-021-06463-5)
  • [L3] Revision of a primary knee replacement was a rare event that depended on a patient's age, gender, and place of residence as well as on the hospital where the primary knee replacement was performed. (10.2106/00004623-199906000-00004)
  • [L3] Strict use of the radiographic decision aid may lead to increased exclusion of appropriate patients with unicondylar knee arthroplasty implantation. (10.1007/s00167-020-05912-x)
  • [L4] The three most commonly reported indications for using hinged-design implants in revision total knee arthroplasty are infection, instability, and aseptic loosening. (10.1016/j.arth.2024.10.126)
  • [L5] Recent reports have demonstrated success in expanding the classic indications of unicompartmental knee arthroplasty to younger and heavier patients. (10.5435/jaaos-d-24-00380)
  • [L1] Both arthroplasty types provided satisfactory clinical results for patients with classic indications. (10.1016/j.arth.2019.07.005)
  • [L5] The authors argue that classifications of good versus poor outcome following knee arthroplasty should not be defined using arbitrary cutoff scores, as this homogeneity impedes scientific progress, and instead propose relying on non-biased statistical model-based approaches. (10.1186/s12891-020-03583-w)
  • [L1] Based on observational data, the use of rotating-hinge implants in primary TKA leads to favorable survivorship at less than five years and at five to less than 10 years postoperatively in appropriately selected patients. (10.1016/j.arth.2025.10.057)
  • [L3] Cemented knee prostheses, implanted in patients with arthritis do not have significantly different rates of survival or perioperative complications in obese subjects compared with normal weight subjects, at least up to 5 years after surgery. (10.1186/1471-2474-10-29)
  • [L3] Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods. (10.1302/0301-620x.104b6.bjj-2021-1744.r1)
  • [L5] The knee implant designs investigated did not replicate the kinematics of a healthy knee. (10.2106/jbjs.h.00817)
  • [L4] Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years. (10.1007/s00167-012-1936-3)
  • [L5] The MP design provides a more native-like knee kinematic profile than the CR design, with a more pronounced MP motion pattern and reduced quadriceps loading. (10.1002/ksa.12624)
  • [L5] The morphology of medial tibial insert was also shown to produce a small but noticeable effect on knee kinematics. (10.1007/s00167-014-3249-1)
  • [L5] These results confirm the importance of tibiofemoral conformity in preserving native knee kinematics. (10.1007/s00167-019-05540-0)
  • [L5] The rotational kinematics of the native knee was not restored after medial UKA but was preserved after lateral UKA. (10.1007/s00167-018-4919-1)
  • [L3] The knee kinematics of patients with kinematically aligned TKAs more closely resembled that of normal healthy controls than that of patients with mechanically aligned TKAs. (10.1007/s00167-018-5174-1)
  • [L2] Tibial slope does not contribute significantly to knee kinematics after total knee arthroplasty. (10.1007/s00167-016-4098-x)
  • [L1] The PS design is significantly better on the knee flexion, while there are no statistical differences in kinematic gait parameters and outcome scores between them. (10.1186/s13018-022-03047-y)
  • [L3] Postoperative lateral laxity greater than 0.9 mm at 90-degree flexion was associated with physiological kinematic motion, leading to fewer knee symptoms in the PROMs. (10.1016/j.jisako.2024.100357)
  • [L4] Patellar thickness affects patellofemoral kinematics after TKA. (10.1007/s00167-012-2312-z)
  • [L5] Kinematically aligned TKA better restores patellar kinematics and PF contact pressure distribution to the native condition than mechanically aligned TKA during deep knee flexion. (10.1007/s00167-018-5270-2)
  • [L4] Systematic alignment simulations achieved knee balance in only 11% of cases. (10.1007/s00167-022-07252-4)
  • [L3] Functional alignment more consistently achieves a balanced total knee arthroplasty than either mechanical alignment or kinematic alignment prior to undertaking soft tissue release. (10.1007/s00167-022-07156-3)
  • [L1] Kinematic alignment restored native patellar tracking patterns more closely compared to mechanical alignment. (10.1002/ksa.12335)
  • [L5] This study found that the femoral component sagittal position is an important factor in knee joint mechanics. (10.1007/s00167-018-5093-1)
  • [L5] No statistical differences were found in knee kinematics and retropatellar pressure distribution between rapid prototype and standard materials. (10.1155/2015/185142)
  • [L3] The kinematics of the FPV implant was closer to normal than those of total knee implants; however, there were still differences from the normal knees. (10.1007/s00167-011-1717-4)
  • [L4] Complications involving the extensor apparatus of the knee following a TKA need early and appropriate management to avoid their devastating influence on joint functionality. (10.1007/s00167-014-3189-9)
  • [L4] The new classification system for PPF of the femur following TKA considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations. (10.1186/s12891-017-1855-z)
  • [L3] With careful patient selection, bilateral knee replacement under a single anaesthetic would be a suitable option for patients who present with bilateral symptomatic arthritis of the knee. (10.1007/s00167-006-0196-5)
  • [L5] It is not clear whether the anatomic differences between the knees of men and women might affect clinical outcome after total knee arthroplasty. (10.2106/jbjs.i.00404)
  • [L3] Patients from different countries have different expectations regarding total knee arthroplasty, which are not fully explained by differences in sociodemographic factors, clinical characteristics, and pain and functional status. (10.2106/jbjs.e.00147)
  • [L4] Recurrent hemarthrosis after total knee arthroplasty is an uncommon event with myriad potential causes including systemic, local, and iatrogenic etiologies. (10.5435/jaaos-d-18-00182)
  • [L1] These results suggest that patient outcome after TKA can be influenced by the prosthesis used. (10.1302/0301-620x.97b1.34254)
  • [L1] The clinical relevance of these findings is that surgeons and patients should be aware that 26%–35% of patients could experience articular noise following TKA, which is likely important to manage patient expectations. (10.1002/ksa.70120)
  • [L4] Unicompartmental knee arthroplasty for medial osteoarthritis is a safe, reliable and effective treatment option for patients of 60 years or younger. (10.1007/s00167-022-07029-9)
  • [L3] The use of stems may provide a survival benefit in complex primary TKA over the short term and no adverse effect on patient outcomes or satisfaction. (10.1007/s00167-016-4227-6)
  • [L3] Limb salvage with a custom prosthetic knee replacement yielded satisfactory overall results and relatively good functional outcomes at medium to long-term follow-up, although revision was necessary in 43 percent of patients. (10.2106/00004623-199805000-00004)
  • [L4] Similar results were observed in terms of functional outcome and survival rates for both cemented and cementless TKAs. (10.1007/s00167-017-4519-5)
  • [L1] The high heterogeneity may be due to a combination of variability in the kneeling activity and variations in implant geometry within each design category. (10.1007/s00167-020-05949-y)
  • [L2] Prosthesis survivorship for both posterior cruciate-retaining and posterior stabilized TKA is satisfactory, and there are no differences between them at shortand middle-term follow-up. (10.1007/s00167-012-2275-0)
  • [L3] The LOSPA knee system, a high-flexion design total knee prosthesis, showed excellent long-term survivorship and improvements in clinical outcomes at 10- to 12-year follow-up. (10.1186/s13018-024-05082-3)
  • [L1] There is no evidence in support that mobile bearing implants promote greater outcomes compared to fixed bearing implants in primary total knee arthroplasty. (10.1007/s00167-022-07065-5)
  • [L3] Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all TKA systems fit these phenotypes well. (10.1007/s00167-020-05914-9)
  • [L3] In the long term, TKA without tourniquet use can achieve clinical effects comparable to the use of tourniquet in many aspects, such as prosthesis stability, prosthesis survival rate, reoperations rate, knee range of motion, and knee functionality. (10.1186/s12891-025-08462-w)
  • [L1] There is strong evidence that ceramic-coated TKA does not improve clinical results or survival rates compared with uncoated TKA. (10.1007/s00167-021-06775-6)
  • [L3] When applying the modified joint line obliquity classification, postoperative joint line obliquity was associated with high survival rates following total knee arthroplasty at a mean follow-up of 12.7 years. (10.1016/j.arth.2025.10.114)
  • [L4] A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation. (10.2106/jbjs.17.00156)
  • [L3] The clinical results of TKA with MP or PS in Chinese patients at mid- and long-term are encouraging, and no significant differences were observed between the two types of prostheses. (10.1186/s13018-020-01951-9)
  • [L2] Therefore, based on current evidence, arthroplasty surgeons can use either of these inserts with cruciate-retaining knee prosthesis. (10.1007/s00167-021-06833-z)
  • [L3] Across two national joint registries, patellar resurfacing during primary TKA was associated with significantly lower estimated all-cause revision rates at three and five years for over half of the unique implant systems. (10.1016/j.arth.2025.11.016)
  • [L4] These results provide a new reference for the installation of femoral prostheses in unicompartmental knee arthroplasty. (10.1186/s13018-024-05224-7)
  • [L1] Bone–implant mismatch may be unavoidable in a large proportion of knees, when considering that a surgeon generally only uses one or a few TKA brands. (10.1007/s00167-021-06623-7)
  • [L5] All-polymer PEEK knee prostheses demonstrate favourable imaging characteristics in a cadaveric setting, without any clinically relevant metal-related artefacts and with good visibility of simulated implant complications across radiography, CT, and MRI. (10.1186/s13018-026-06736-0)
  • [L3] Results of this study suggest a history of prior knee ligament reconstruction results in increased use of constrained implants but no difference in postoperative knee ROM, patient-reported outcomes, or incidence of revision surgery. (10.1302/0301-620x.101b7.bjj-2018-1492.r1)
  • [L3] Patients who are candidates for TKA with a history of cartilage surgery may be counselled that their surgical history on that knee does not convey the risk of worse functional outcomes. (10.1002/ksa.12529)
  • [L3] A history of surgery, the preoperative 1989 KSS, and the preoperative SF-12 influenced patient satisfaction after primary TKA. (10.1186/s13018-021-02469-4)
  • [L5] Nonsurgical treatment is generally unsuccessful; major malposition of components is best managed by implant revision. (10.5435/00124635-200309000-00009)
  • [L4] Although further high-level studies are needed, noncemented TKA may be considered in younger and/or obese patients. (10.5435/jaaos-d-20-00435)
  • [L3] This should translate to similar long term results after less invasive knee arthroplasty as after open access total knee arthroplasty. (10.1007/s00167-008-0523-0)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L4] Magnetic resonance imaging is slightly more accurate than radiography in preoperative sizing for meniscus allograft transplantation, but neither technique is highly accurate. (10.1177/03635465000280041301)
  • [L4] Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment, especially for the non-dysplastic knee. (10.1302/0301-620x.95b6.31355)
  • [L1] Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. (10.2106/00004623-200708000-00031)
  • [L3] In the setting of image-based RA-TKA performed with functional knee positioning, the rotational alignment of the femoral component changes significantly among different knee phenotypes. (10.1002/ksa.12732)
  • [L4] However, the implanted scaffolds did not present normal meniscal tissue with MRI, and the implant volume was considerably less than expected. (10.1016/j.arthro.2017.12.019)
  • [L4] The Journey bicruciate stabilized knee prosthesis showed good 1-year postoperative results in terms of both functional and patient-based outcome. (10.1186/1471-2474-15-435)
  • [L3] Lifetime risk of revision may be a more meaningful measure of outcome than implant survival at defined time periods when counselling patients prior to TKA. (10.1302/0301-620x.104b2.bjj-2021-0890.r1)
  • [L4] Preoperative planning of TKA implant size using MRI-based PSI showed excellent intra- and inter-observer reliability. (10.1007/s00167-020-05946-1)
  • [L3] Application of isolated radiologic criteria in patients with knee OA results in a UKA candidacy that is misleadingly high. (10.1007/s00167-021-06632-6)
  • [L3] The clinical results at ten years are satisfactory after total knee arthroplasty with preservation of the posterior cruciate ligament, similar to results with sacrifice or substitution of the ligament. (10.2106/00004623-199503000-00012)
  • [L4] The SPECT/CT algorithm presented is both reliable and useful in the management of patients with painful TKA. (10.1007/s00167-010-1070-z)
  • [L4] The results highlight the necessity of personalized assessment of VCA during TKA to optimize radiological outcomes, as opposed to a standardized approach. (10.1186/s13018-026-06721-7)
  • [L2] Higher level evidence, with MRI and histological evaluation of the scaffold and articular cartilage, is now needed to further determine whether these scaffolds exhibit these useful properties. (10.3390/ijms20030632)
  • [L2] The data suggest that clinical and radiographic findings at five years after posterior cruciate-substituting total knee arthroplasty were the same for the patients treated with highly cross-linked polyethylene and those treated with conventional polyethylene. (10.2106/jbjs.m.01605)

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[99] Comparison of Highly Cross-Linked and Conventional Polyethylene in Posterior Cruciate-Substituting Total Knee Arthroplasty in the Same Patients. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.m.01605

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