Total Knee Replacement¶

Total knee arthroplasty for end-stage degeneration, including management of PJI, component malalignment, and aseptic loosening.

Overview¶

The primary objective of total knee arthroplasty is to ensure the best possible outcome for the patient [1]. For the vast majority of patients, a standard conventional total knee arthroplasty with a familiar surgical approach and standard components leads to satisfactory long-term clinical outcomes [6]. There is no single 'best' way to perform total knee arthroplasty [6]. Indication criteria for total hip or knee arthroplasty in osteoarthritis are based on limited evidence [13]. Total knee arthroplasty should be considered as the last surgical option for unicompartmental osteoarthritis of the knee [8].

Nearly 20% of patients are dissatisfied following well-performed total knee arthroplasty with good functional outcomes, often due to unfulfilled expectations [84]. The health benefits of kinematic total knee arthroplasty were maintained after a minimum duration of follow-up of ten years [74]. In cases with failed arthroplasty after total knee arthroplasty, data did not allow definite treatment recommendations for periprosthetic joint infection [88].

Anatomy & Pathophysiology¶

Knee Joint Kinematics and Ligamentous Anatomy¶

The knee functions as a hinge joint incorporating gliding and rolling motions [33]. The "screw-home" mechanism involves external rotation of the tibia by 5 degrees in the final 15 degrees of extension [33].

Anterior Cruciate Ligament (ACL): The ACL comprises two bundles named for tibial insertions: the anteromedial and posterolateral bundles [33]. The femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral condyle, divided by the bifurcate ridge and bordered by the intercondylar ridge [33]. The tibial insertion is a broad, irregular, oval area immediately medial to the anterior horn of the lateral meniscus and posterior to the tubercle of the anterior horn of the medial meniscus [33]. The anteromedial bundle originates proximal to the bifurcate ridge, is tight in flexion, and primarily acts as an anterior restraint [33]. It resists anterior tibial translation in knee flexion and varus translation in knee extension [33]. The posterolateral bundle originates distal to the bifurcate ridge, is tight in extension, and primarily acts as a rotatory restraint [33]. It resists rotatory loads in knee extension and varus translation in knee extension [33].

Posterior Cruciate Ligament (PCL): The PCL has codominant anterolateral (AL) and posteromedial (PM) bundles [33]. It resists posterior tibial translation at all degrees of knee flexion [33]. Beyond 90 degrees of flexion, it resists tibial internal and external rotation and varus translation [33].

Medial Collateral Complex: The superficial medial collateral ligament (sMCL) proximal division (femur to proximal tibia) resists valgus tibial translation [33] and tibial external rotation as a secondary function [33]. The sMCL distal division (proximal to distal tibia) resists tibial external rotation in knee extension [33] and tibial internal rotation as a secondary function [33]. The deep MCL resists valgus translation and tibial internal and external rotation [33]. The posterior oblique ligament resists tibial internal rotation, especially in knee extension, and tibial external rotation as a secondary function [33].

Lateral and Posterior Structures: The lateral collateral ligament resists varus tibial translation and tibial external rotation, especially at 30 degrees of knee flexion [33]. The popliteus tendon resists tibial external rotation, especially in knee flexion, and varus tibial translation as a secondary function [33]. The popliteofibular ligament resists tibial external rotation, especially in knee flexion, and posterior tibial displacement as a secondary function [33]. The oblique popliteal ligament resists knee hyperextension and varus tibial translation as a secondary function [33].

Patellofemoral Anatomy and Instability¶

Patellar instability exists on a spectrum from frank dislocation to subtle subluxation [65]. Etiologies include traumatic MPFL rupture, patellar and trochlear dysplasia, patella alta, ligamentous laxity, and muscular imbalance such as VMO weakness [65]. Dislocation is typically lateral and a frequent cause of hemarthrosis [65]. The recurrence rate following a first-time dislocation is between 15% and 60% [65]. Younger age, female sex, patella alta, and trochlear dysplasia increase recurrence risk [65]. Articular cartilage on the medial facet of the patella is the most commonly injured site during reduction [65]. Symptoms may be exacerbated in adolescents with femoral anteversion, genu valgum, and pronated feet ("miserable malalignment syndrome") [65]. Instability may result from external tibial rotation with a planted foot or a direct blow to the medial knee [65].

Clinical Examination and Imaging: Findings may include a positive patellar apprehension test, the J sign, and three to four quadrants of lateral patellar glide [65]. Trochlear dysplasia is identified on lateral radiographs by a crossing sign or supratrochlear spur [65]. The trochlear groove line normally intersects the anterior femoral cortex; a crossing sign occurs when it intersects the anterior femoral condyle and is associated with patellar instability [65]. Dysplasia is classified by the Dejour system [65]. CT measures the tibial tubercle–trochlear groove (TT–TG) distance, quantifying tibial tubercle lateralization [65]. Normal TT–TG values are 9–13 mm; 15–20 mm is questionably abnormal; >20 mm is highly associated with instability [65]. MRI in complete dislocation often shows bone bruising of the lateral femoral condyle and medial patella, with MPFL disruption most frequently at the patellar insertion [65].

Surgical Considerations: The Schottle point identifies the femoral MPFL attachment: 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the Blumensaat line on lateral radiograph [65]. If the femoral tunnel is too proximal, the graft is tight in flexion; if too distal, it is loose in flexion [65]. Isolated lateral release should not be performed for patellar instability [65]. Distal realignment (tibial tubercle anterior medialization) is indicated for increased Q angle or TT-TG >20 mm [65]. Proximal arthrosis of the medial patellar facet is a contraindication to distal realignment [65]. MPFL reconstruction complications include medial patellar instability or osteoarthritis from overtightening [65]. Patellofemoral pain syndrome, an extremely common cause of anterior knee pain in adolescents, manifests as pain worsened by activities increasing compressive loads [65].

Knee Arthritis and Imaging¶

Patient assessment includes physical examination and diagnostic radiography [20]. Pain with weight bearing is aggravated by stairs, inclines, and sit-to-stand transitions [20]. Bowing deformity and instability appear later in clinical presentation [20]. A knee thrust indicates ligament stretch-out on the convex side and occurs later in presentation [20]. A varus thrust pushes the knee outward during stance, overloading the medial compartment and accelerating degeneration by increasing the adductor moment (ankle adducted relative to knee) [20]. A valgus thrust pushes the knee inward during stance, overloading the lateral compartment and accelerating degeneration by increasing the abductor moment (ankle abducted relative to knee) [20].

Radiographic Evaluation: Radiographs are the standard for initial evaluation [20]. Initial images should include weight-bearing AP and lateral views, a 45-degree flexed posterior-anterior view (plate parallel to tibia), a sunrise (Merchant) view, and extension/flexion lateral views [20]. Standing full-length AP radiographs from hip to ankle evaluate limb alignment, deformity, and femoral/tibial bone deformity (developmental or traumatic) [20].

Kellgren-Lawrence (KL) Grading: The KL system is the most common grading system for OA [20]. It grades OA extent on AP radiographs based on primary features: osteophytes (periarticular and tibial spine) and joint space narrowing [20]. Additional features include subchondral sclerosis with/without cysts, altered periarticular bone shape, flattened condylar contours, and articular bone loss [20]. KL Grade 0: Normal knee features with no OA [20]. KL Grade 1: OA possibly present [20]. KL Grade 2: OA present with minimal severity [20]. KL Grade 3: OA present with moderate severity [20]. KL Grade 4: OA present with severe severity; knee arthroplasty is recommended [20].

Advanced Imaging: MRI is grossly overused in arthritic patients and not indicated if joint space is significantly narrowed on radiograph [20]. MRI is used when osteonecrosis is suspected [20]. Three-dimensional CT with remodeling is used for preoperative planning in dysplasia, post-trauma, and complex TKA [20].

Total Knee Arthroplasty Alignment and Kinematics¶

Alignment Philosophies: Mechanical alignment is the most common philosophy [77]. It aims for a neutral mechanical limb line (Mikulicz) passing through the knee center to provide symmetrical implant loading and minimize overload [77]. The distal femoral cut is perpendicular to the mechanical axis of the femur (MAF), resulting in a mechanical lateral distal femoral angle (mLDFA) of 90 degrees [77]. The proximal tibial cut is perpendicular to the mechanical axis of the tibia (MAT), resulting in a mechanical proximal tibial angle (mPTA) of 90 degrees [77]. Ligament balancing is performed in coronal and sagittal planes [77]. A disadvantage is that two-plane balancing is difficult, potentially causing instability, dysfunction, and pain [77].

Kinematic alignment aims to maintain native limb alignment, as ligaments and capsule function in the current alignment [77]. The Mikulicz line is left unchanged [77]. The distal femoral cut is made at the native mLDFA [77]. The proximal tibial cut is made at the native mPTA [77]. Ligament balancing is not required in coronal and sagittal planes [77]. A disadvantage is that recreating individualized alignment can lead to alignment issues [77].

Tibial Cutting Techniques: The MAT is a line from the proximal tibia center to the ankle center [77]. The proximal tibia is cut perpendicular to the MAT for even loading [77]. The tibial cut angle is the angle between the anatomic axis of the tibia (AAT) and the MAT [77]. In intramedullary guidance, the cut is perpendicular to the MAT [77]. Usually, AAT and MAT are coincident, yielding a zero cut angle [77]. With tibial deformity, AAT and MAT diverge; the cut angle is measured to ensure the end cut is perpendicular to the MAT [77]. In extramedullary guidance, the jig bypasses deformity to define the MAT [77]. The proximal cutting slot is perpendicular to the jig's long axis [77].

Kinematic Outcomes: Static native tibial alignment optimizes whole-body gait kinematics [26]. Subtle joint line modifications contribute to widespread kinematic adaptations [26]. Contemporary implants do not replicate healthy knee kinematics [28]. Combined flexion influences biomechanics in robotic TKA, but its direct impact on clinical outcomes is unclear [29]. Mechanical alignment results in more balanced load distribution and kinematics resembling the native knee in constitutional varus [32]. The tibial cut influences varus alignment, femoral roll-back, and tibiofemoral rotation in constitutional varus [32]. Knee kinematics and muscle activation do not change in the first 2 post-operative years with a highly congruent mobile-bearing prosthesis [34]. Posterior-stabilized TKA standing/sitting kinematics differ from normal, deriving from the Bi-Surface PS design [35]. Kinematically aligned knees show greater multi-planar mobility, higher sagittal moments, and more physiological gait than mechanically aligned knees [36]. Cruciate stabilizing (CS) and cruciate retaining (CR) TKAs have comparable kinematics [38]. The medial pivot (MP) design provides a more native-like profile than CR, with pronounced MP motion and reduced quadriceps loading [39]. Non-constrained prostheses preserve nearly normal kinematics, improve function, and minimize shear stresses at the component-cement-bone interface [40]. Medial tibial insert morphology produces a small but noticeable effect on kinematics in MP prostheses [41]. Kinematics is not the sole or most relevant parameter to predict knee function post-TKA [44]. PCL retention alone may not achieve physiological kinematics post-TKA [46]. Implant malpositioning biomechanics can be investigated using a six-degree-of-freedom joint simulator without modifying physical setup [47]. There is a considerable difference between TKA design and healthy knee kinematics [48]. Anatomy-mimetic design preserves natural kinematics in patient-specific mobile-bearing unicompartmental knee arthroplasty, confirming the importance of tibiofemoral conformity [49]. Native rotational kinematics is restored after lateral UKA but not medial UKA [52]. Kinematically aligned TKA kinematics more closely resemble normal controls than mechanically aligned TKA [53]. Tibial slope does not significantly contribute to knee kinematics post-TKA [54]. The posterior stabilized (PS) design is significantly better for knee flexion than CR designs, with no statistical differences in kinematic gait parameters or outcome scores [55].

Classification¶

Periprosthetic Femur Fracture (PPF): A new classification system for PPF following total knee arthroplasty considers fracture location and implant type [64]. This system is easy to use [64], demonstrates good interobserver reliability [64], and allows conclusions to be drawn on treatment recommendations [64].

Revision Knee Complexity Classification (RKCC): The RKCC offers a common-sense approach to recognize increasing complexity in revision total knee replacement cases [67]. It provides a methodological assessment to support regional clinical networking and triage of appropriate cases to specialist centres [67].

Other Considerations: Advancements in total knee arthroplasty require a multifaceted approach that recognizes variations in knee morphometry and phenotypes [3]. Functional knee phenotypes of osteoarthritis patients undergoing total knee arthroplasty are significantly more varus or valgus than in a non-osteoarthritic reference population [76]. Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, meaning not all total knee arthroplasty systems fit these phenotypes well [99].

There is a wide variety of definitions for poor outcome after total knee arthroplasty, highlighting a lack of consensus [21]. Standardized definitions are needed to improve comparability of outcomes across studies [21]. Classifications of good versus poor outcome should not be defined using arbitrary cutoff scores, as these impede scientific progress by creating homogeneity [83]. Instead, outcome classifications should rely on non-biased statistical model-based approaches [83]. The WOMAC score can be reliably used to classify patient satisfaction after total knee arthroplasty, with post-operative classifications of excellent, good, fair, and poor defined for the components and total scores [71].

Several countries' Diagnosis-Related Groups (DRG) systems could be improved by introducing classification variables for revision of knee replacement [51]. DRG systems could also be improved by introducing classification variables for the presence of complications or comorbidities [51]. Evaluation of data from multiple national joint registries demonstrated that the revision rate for a contemporary knee system was comparable to other total knee arthroplasty systems at latest follow-up [85]. A novel hinged knee system is a highly durable option for complex and revision knee arthroplasty [91]. Both the Genesis II and Vanguard prosthesis systems showed good clinical results at 2 years postoperatively [93]. Current evidence was reviewed to determine what defines a 'balanced knee replacement' and how this relates to the native knee [97]. Experts propose using thorough literature reviews using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty [98].

Clinical Presentation¶

The primary goal of total knee arthroplasty is to ensure the best possible outcome for the patient [1]. This intervention requires a multifaceted approach that recognizes variations in knee morphometry and phenotypes, as not all knees are the same [3]. Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes [16]. A well-structured, algorithmic approach in the management of patients with a painful total knee arthroplasty is essential in correctly diagnosing the patient and optimizing clinical outcomes [10].

A complete and accurate history, physical examination, and radiographic assessment are critical for determining a specific diagnosis and treatment plan for pain after total knee replacement [37]. The source of pain after total knee arthroplasty may be difficult to determine, requiring evaluation for infection, neurogenic pain, referred pain from the hip or back, and mechanical sources of pain [142]. Evaluation for post-total knee arthroplasty pain should include a thorough history and physical examination, laboratory studies, and plain radiographs [142]. MRI utility in working up a painful arthroplasty is demonstrated when history, physical examination, and other diagnostic utilities fail to provide answers [19]. Additional nuclear medicine studies or specialized imaging may be necessary in the workup of post-total knee arthroplasty pain [142].

Pain Patterns and Etiologies: * Inflammatory/Neurogenic Source: A history of pain that develops immediately after surgery and then persists without a pain-free interval suggests an inflammatory and/or neurogenic source of pain [142]. Pain with rest as well as weight bearing suggests an inflammatory and/or neurogenic source of pain [142]. Pain described as burning or numbness and nonfocal on examination supports the diagnosis of neurogenic pain [142]. * Mechanical Source: Pain during weight-bearing activity or knee motion is consistent with a mechanical source of pain [142]. * Soft-Tissue Inflammation: Pain associated with localized warmth and swelling that occurs more after activity and is relieved with rest is less consistent with infection and more typical of soft-tissue inflammation resulting from postsurgical rehabilitation [142].

Infection: Infection is a common source of pain after total knee arthroplasty and must be ruled out first in all patients [142]. Infection is usually associated with an elevated erythrocyte sedimentation rate and C-reactive protein level [142]. Infection can be detected by aspiration, including cell count with differential and culture [142]. False-negative and false-positive results can occur in infection detection, and additional imaging studies may be necessary [142]. Late hematogenous infection can occur and should be included in the differential diagnosis for late pain after total knee arthroplasty [142].

Mechanical Causes: Mechanical causes of early pain after total knee arthroplasty include patellar maltracking, patellar clunk or crepitus, tibiofemoral instability, periprosthetic fracture, or occult implant loosening [142]. Patellar problems are usually evident on physical examination because the location of pain is restricted to the patellofemoral joint [142]. Patients with patellar problems may present with reduced knee range of motion and flexion [142]. Patellar clunk is a complication of posterior-stabilized total knee arthroplasty that occurs when a fibrous nodule at the inferior pole of the patella catches in the trochlear groove during knee extension [142]. Patellar clunk was a problem with older implant designs but is rarely described with newer ones [142]. Patellar crepitus is more common with current posterior-stabilized designs and may cause anterior knee pain [142]. Symptoms of patellar clunk are relieved by open or arthroscopic excision of the fibrous nodules and synovium [142]. Patellar maltracking and subluxation may result from dehiscence of the medial retinacular arthrotomy, femoral or tibial component internal rotation, or patellar component malpositioning [142]. Rotational orientation of the femoral implant is better quantitated using CT with metal artifact reduction than assessed on an axial view of the patella [142]. Symptomatic patellar subluxation or maltracking resulting from internal rotation of the femoral or tibial components requires revision of the malaligned components [142].

Instability and Dislocation: A history of pain and effusion that occurs after activity and is relieved with rest is consistent with flexion instability [142]. Flexion instability caused by intact but attenuated soft-tissue constraints can be detected on physical examination by varus and valgus stress testing [142]. Laxity in flexion instability is typically more evident in flexion than full extension as the posterior capsule and hamstrings contribute to stability in extension [142]. Flexion instability is more common with cruciate-retaining total knee arthroplasties than with posterior-stabilized total knee arthroplasties [142]. Flexion instability is associated with paradoxic motion or rolling forward of the femoral implant, which can be seen on flexion lateral radiographs as anterior subluxation of the distal femur on the tibia [142]. Complete dislocation of a posterior-stabilized knee presents with gross instability in flexion on physical examination and posterior displacement of the tibia on the femur [142]. Complete dislocation of a posterior-stabilized knee is more common when excessive posterior slope occurs with the tibial cut and with some posterior-stabilized-designed total knee arthroplasties [142].

Late Pain: Pain that develops late after total knee arthroplasty is more often associated with loosening or ultra-high-molecular-weight polyethylene wear [142]. Wear can be seen radiographically as asymmetric height of the tibial plateaus [142]. Rotation and flexion of the knee can alter the projected height of the joint space, making radiographic measurements of wear inaccurate [142]. Loosening occurs when subsidence or displacement of the component or a complete or progressive radiolucency at the implant and bone interface occurs [142].

Persistent pain remains common after total knee arthroplasty, and improvement does not equate to cure [69]. Almost a third of patients continued to have residual knee pain at 2 years post-total knee arthroplasty [60]. Factors such as gender, presence of ischaemic heart disease, and implant type are significantly associated with the development of residual knee pain and/or poorer functional outcome scores [60]. Most patients can be successfully treated with total knee arthroplasty, but a certain number remain unhappy, requiring careful analysis of whether symptoms are surgery-related or patient-related [62]. More than half the patients presenting for total knee arthroplasty had mild-to-severe contralateral knee pain [61]. Patients with contralateral knee pain were significantly less likely to be satisfied with their total knee arthroplasty, although they experienced a clinically meaningful improvement in WOMAC score [61].

The influence of total knee arthroplasty design on kneeling kinematics provides insights into function during deep kneeling and may allow improved management of patients' functional expectations [63]. The KSPQ is a valid questionnaire to assess patients' expected and desired outcomes of knee replacement surgery, their perception of their current abilities and function, and the discrepancy between these [68]. 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 [70]. Improvement in knee pain after total knee arthroplasty is associated with a reduction in pain in other bodily regions, suggesting a potential physiological link [69].

With careful patient selection, bilateral knee replacement under a single anaesthetic is a suitable option for patients who present with bilateral symptomatic arthritis of the knee [72]. Pain symptoms of moderate or severe pain are unequivocal when considering a total knee arthroplasty [73]. There is a lack of consensus on definitions for poor outcome after total knee arthroplasty, highlighting the need for standardized definitions to improve comparability across studies [21]. Revision total knee arthroplasty requires a correct diagnosis of the original cause of failure and a detailed plan [58]. Revision total knee arthroplasty texts cover diverse opinions and experiences on diagnosis, implant selection, techniques, and management of complications like infection [59]. The 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 [50].

Investigations¶

Preoperative Assessment and Imaging¶

Plain radiography: Weight-bearing anteroposterior (AP) and lateral radiographs constitute the standard for initial evaluation of knee pain [20]. The standard radiographic evaluation also includes a weight-bearing knee flexed at 45 degrees imaged posterior to anterior with the X-ray plate parallel to the tibia, a sunrise (Merchant) view, and extension and flexion lateral views [20]. Standing full-length AP radiographs from the hip to the ankle joint evaluate limb alignment and knee deformity, and identify developmental or traumatic femoral and/or tibial bone deformity [20].

The Kellgren-Lawrence (KL) grading system is the most commonly used system for assessing osteoarthritis severity on AP knee radiographs [20]. Primary features for KL rating include osteophytes (periarticular and tibial spine) and joint space narrowing, subchondral sclerosis with or without subchondral cysts, and altered periarticular bone shape such as flattening of condylar contours or articular bone loss [20]. KL Grade 0 indicates normal features; Grade 1 suggests osteoarthritis is possibly present; Grade 2 indicates minimal severity; Grade 3 indicates moderate severity; and Grade 4 indicates severe severity [20]. Knee arthroplasty is recommended when KL Grade 4 findings are present [20].

MRI: MRI is grossly overused in the arthritic patient population and is not indicated if the joint space is significantly narrowed on radiograph [20]. It is indicated when osteonecrosis is suspected [20]. In the postarthroplasty setting, while its role is not clearly defined, MRI utility is demonstrated when history, physical examination, and other diagnostics fail to provide answers for a painful arthroplasty [19]. Preliminary evidence suggests MRI has noteworthy value in distinguishing suspected periprosthetic joint infection, though specific MRI features for this diagnosis lack consensus and standardization [145]. Routine screening for osteonecrosis is not necessary, but patients with persistent hip or knee pain should be assessed with MRI [150]. For non-dysplastic knees, standardized radiological imaging with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment [144]. In total knee arthroplasty for secondary osteoarthritis, thorough preoperative investigation, especially MRI, is required to determine the role of each patellar layer to decide between fusion, preservation, removal, or resurfacing [153].

CT: Three-dimensional CT with remodeling is used for preoperative planning in reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [20].

Prognostic and Functional Considerations: Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis [141]. Radiographic severity can predict knee-specific functional improvement following total knee arthroplasty, but it cannot predict the extent of global functional improvement [157]. Low preoperative grading of osteoarthritis severity is associated with a lower functional level after total knee replacement, though low radiological severity is not associated with pain 12 months postoperatively [162]. Radiographic findings including joint space narrowing, MRI-detected bone marrow lesions, synovitis, and effusion are significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [146]. Baseline radiographic severity grade is only associated with future total knee arthroplasty risk in the absence of a full-thickness cartilage defect; full-thickness cartilage defects are important independent predictive factors for progression to total knee arthroplasty in older adults with minimal to moderate osteoarthritis [130]. The use of routinely available preoperative radiology reports has promising potential to help screen suitable candidates for total hip arthroplasty, but not for total knee arthroplasty [143].

Advanced Imaging for Painful Arthroplasty and Loosening¶

MRI: As noted above, MRI is useful in working up a painful arthroplasty when other diagnostics fail [19].

Bone scan: MRI and SPECT/CT demonstrate, with low certainty of evidence, the highest diagnostic accuracy for aseptic knee arthroplasty loosening [127]. The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven [148]. SPECT/CT is very helpful in establishing the diagnosis and guiding subsequent management in patients with painful knees after total knee arthroplasty, particularly in those with patellofemoral problems and malpositioned or loose total knee arthroplasty [164].

Tomosynthesis: Tomosynthesis is superior to fluoroscopically guided plain radiography, CT, and MRI for the early detection of small periprosthetic bone defects after total knee arthroplasty in terms of sensitivity, specificity, radiation dose, and cost [154].

Postoperative Surveillance¶

Plain radiography: Routine radiographic surveillance did not detect any true abnormalities during the first year after primary total joint arthroplasty [155]. A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy [159].

Alignment and Phenotype Considerations¶

Advancements in total knee arthroplasty require a multifaceted approach that recognizes variations in knee morphometry and phenotypes, as not all knees are the same [3]. In image-based robotic-assisted total knee arthroplasty performed with functional knee positioning, the rotational alignment of the femoral component changes significantly among different knee phenotypes [156].

Instrumentation: Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points [15]. There is no difference in aseptic loosening or revision rates at midterm follow-up comparing standard total knee arthroplasty instrumentation with patient-specific instrumentation (PSI), digitally navigated, or robotic-assisted total knee arthroplasty [4]. Evidence supports not using intraoperative navigation because there is no difference in pain or complications [4]. Evidence also supports not using patient-specific instrumentation compared to conventional instrumentation because there is no difference in pain or functional outcomes [4].

Treatment¶

Non-Operative¶

Total knee replacement combined with physical and medical therapy is more effective than nonsurgical treatment alone for knee osteoarthritis, though it is associated with more serious adverse events [104]. This represents the first randomized controlled trial to investigate the efficacy of TKA as an adjunct to optimized non-surgical treatment in patients with knee osteoarthritis [87].

Operative¶

Indications: Total knee arthroplasty (TKA) consistently provides substantial improvements in pain, function, and patient satisfaction with excellent survivorship after failure of conservative care for knee osteoarthritis [24]. TKA is a highly cost-effective surgical treatment and remains the mainstay of surgical approaches for addressing advanced arthritis [24]. High BMI should not be considered a contraindication for TKA when used for appropriate indications [43]. Total knee arthroplasty among nonagenarians can be performed more safely than previously reported, with perioperative morbidity and mortality that is acceptable to both patient and surgeon [106]. Obese patients experience less improvement in outcomes with TKA [4].

Surgical Approach / Technique: For the vast majority of patients, a standard conventional TKA with a familiar surgical approach and standard components leads to satisfactory long-term clinical outcomes, and there is no single 'best' way to perform the procedure [6]. Minimally invasive techniques for TKA are encouraged based on meta-analysis findings showing better outcomes compared to the standard invasive medial parapatellar approach [7]. Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic endpoints [15]. No studies have convincingly shown that minimally invasive techniques or newer technologies, such as patient-specific instrumentation (PSI), can lead to improved outcomes or decreased complications [24]. There is no difference in aseptic loosening or revision rates at midterm follow-up comparing standard TKA instrumentation with PSI TKA, digitally navigated TKA, or robotic-assisted TKA [5].

Implant Selection: There is no difference in outcomes or complications between posterior stabilized and posterior cruciate retaining TKA designs [5]. Cruciate-retaining and posterior-stabilized TKA techniques both provide good results with no difference in surgical complications, range of motion, patient-reported outcome scores, or implant survivorship [24]. Bicruciate retaining (BCR) knee arthroplasty has been proposed to preserve intra-articular proprioception and native joint kinematics, but adoption has been limited due to some studies showing high early failure rates [24]. Single-surgeon studies have shown good outcomes after BCR TKA, but it is a technically demanding surgery [24].

There are no significant differences in pain, function, quality of life, complication, or revision rates between fixed-bearing and mobile-bearing implant designs [24]. Mobile bearing TKA implants were developed to allow for increased tibiofemoral contact area with reduced polyethylene contact stress and wear, but studies have not demonstrated improved survivorship compared to traditional fixed-bearing implants [24]. Careful attention must be paid to gap balancing when using mobile bearing implants, as bearing spin-out can occur in the presence of a loose flexion gap [24]. All-polyethylene or metal-backed monoblock tibial components have shown good long-term outcomes and are reasonable options for implant choice [24].

Alignment / Balancing Strategy: The femoral component should never be internally rotated during TKA to avoid relative lateral tilt of the patella and inward-facing patellar groove [125]. Internal rotation of the femoral component results in an asymmetric (trapezoidal) flexion gap, causing a loose lateral compartment and tight medial compartment [125]. The goal of femoral component rotation is slight external rotation to create a rectangular (balanced) flexion gap and optimize patellar tracking [125]. There are five established techniques to determine proper femoral component rotation: AP axis method, epicondylar axis method, posterior condylar axis method, tibial alignment axis method, and gap balance axis method [125].

Pain Management: Multimodal analgesia has become the standard for perioperative pain management in TKA, integrating various drugs and modalities to minimize opioid consumption and enhance analgesic efficacy [100]. Implementation of multimodal pain management regimens after TKA has increased patient satisfaction, decreased pain scores, and facilitated faster recovery [115]. A multimodal perioperative analgesia protocol that included infiltration of a local anesthetic offered improved pain control and minimal side effects to patients undergoing TKA [90]. Local infusion analgesia using an intra-articular double lumen catheter after TKA provided clinically significant analgesic effects and rapid recovery, although larger studies are needed to examine its safety [101]. Adding steroid to local anesthetics in local infiltration analgesia reduced inflammation both locally and systemically, resulting in significant early pain relief and rapid recovery in TKA [122].

Peripheral nerve blockade for TKA decreases postoperative pain and opioid requirements [4]. Use of periarticular local anesthetic infiltration in TKA decreases pain and opioid use [4]. Administration of IV or oral acetaminophen does not increase risk of complications following primary total joint arthroplasty [5]. An oral NSAID administered either preoperatively and/or in the early postoperative period reduces pain and opioid consumption following primary TJA [5]. Administration of IV ketorolac preoperatively, intraoperatively, or within 24 hours postoperatively reduces pain and opioid consumption postoperatively (within the first 48 hours) following primary TJA [5]. On the basis of a meta-analysis, there is no evidence to support the routine use of gabapentinoids in the management of acute pain following TKA [121].

Adjuncts: With no known contraindications, treatment with tranexamic acid (TXA) decreases postoperative blood loss and reduces the need for postoperative transfusions via IV or topical application [4]. TXA is a lysine analog that reversibly binds to four to five lysine receptors on plasminogen, blocking conversion to plasmin, with a half-life of approximately 3 hours and renal excretion of 95% as the original molecule [5]. TXA reduces net blood loss and transfusion in arthroplasty procedures without increasing the risk of venous thromboembolic (VTE) events in patients with a history of thromboembolic disease [5]. There is no increase in cardiovascular events, including myocardial infarction, ischemic stroke, and death, associated with TXA use [5]. Studies show safety with TXA in high-risk populations, including those with a history of myocardial infarction or stroke, presence of coronary artery bypass graft and/or coronary artery stent, and prothrombotic states such as factor V Leiden, protein C deficiency, protein S deficiency, and antiphospholipid antibody syndrome [5]. Contraindications for TXA include known anaphylaxis, seizure disorder (due to lysine competing with glycine receptors in the brain causing disinhibition), and known defective color vision (as TXA can exacerbate the condition) [5].

Evidence supports not using intraoperative navigation because there is no difference in pain or complications [4]. Evidence supports not using patient-specific instrumentation compared to conventional instrumentation for TKA because there is no difference in pain or functional outcomes [4]. Evidence supports not using a drain with TKA because there is no difference in complications or outcomes [4]. Use of a tourniquet increases short-term postoperative pain [4]. Continuous passive motion after knee arthroplasty does not improve outcomes [4]. Rehabilitation started on the day of TKA reduces the length of hospital stay [4].

Setting of Care: Rehabilitation started on the day of TKA reduces the length of hospital stay [4].

Revision: Revision total knee arthroplasty is a challenging procedure requiring a comprehensive understanding of anatomy and surgical techniques to achieve good outcomes [27]. Revision total knee arthroplasty presents numerous technical challenges requiring careful preoperative planning, meticulous surgical technique to preserve host bone, and attention to gap balancing [31]. Stems should be used routinely in revision TKA, and it is recommended that the stem engage the femoral diaphysis both for alignment and fixation reasons [22]. Implants with increased varus–valgus constraint and hinged implants should be available in revision TKA, since ligamentous insufficiency is common in this setting [22]. Revision of femoral components typically requires metal augmentation because of the inevitable bone deficiency associated with component removal [22]. Commercially available metaphyseal sleeves and trabecular metal cones can be useful for managing capacious metaphyseal defects in revision TKA [22]. Revision total knee arthroplasty with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation, which is helpful as more patients undergo revision TKA with greater bone loss [134]. Modular knee arthroplasties offer the advantage of intraoperative customization and improved fixation, but the trade-off is the potential for failure (disengagement or fracture) especially at the modular junction [133].

In cases where there is not enough bone to support a traditional revision, even with the use of diaphyseal engaging stems, a modular megaprosthesis (distal femoral replacement) is performed [22]. Careful dissection of the residual distal femoral bone is performed during megaprosthesis implantation to avoid vascular injury [22]. Cement fixation is typically used in megaprosthesis implantation for distal femoral fractures above a loose implant [22]. Revision TKA with intramedullary femoral stems that engage the diaphysis and simultaneously stabilize the fracture can be used for periprosthetic fractures around loose implants [22]. When soft-tissue sleeves in a previously fused knee are carefully preserved intraoperatively, they can provide adequate stability after TKA with a posterior stabilized prosthesis, making it a reasonable alternative to more constrained implants [123]. Conversion of a fused knee to total knee arthroplasty resulted in good long-term fixation and high patient satisfaction [117]. Simultaneous revision and contralateral primary total knee arthroplasty is a safe and favorable alternative to a staged procedure consisting of revision and subsequent contralateral primary total knee arthroplasty [42].

Other Considerations: There is no difference in pain or function with or without patellar resurfacing in TKA [5]. Debate remains over treatment of the patella, with studies showing good outcomes with and without patellar resurfacing [24]. To keep knee bearing contact stress below the yield strength of UHMWPE (12–20 mPA), the polyethylene (PE) must be at least 6 to 8 mm thick in traditional designs [138]. Current knee prosthetic systems are designed to ensure that PE thickness in the thinnest areas of the insert is at least 6 mm [138]. Flat PE articular geometry should be avoided because it results in a thin line of joint contact during loading, creating high contact loads that exceed the yield strength of UHMWPE [138]. Goals of current tibial articular designs are to maximize contact area and minimize contact loads [138]. Sliding movements are least pronounced in a posterior stabilized (PS) or anterior stabilized (AS) knee design with a congruent PE insert [138]. In laboratory testing, sliding wear across the tibia created surface and subsurface cracking with high wear, and current knee prosthetic systems are designed to minimize tibial sliding wear [138].

Outcome studies of modern noncemented TKA implants show survivorship and functional outcomes equivalent to cemented prostheses [24]. There is no evidence to support that fixation techniques alone affect the durability of a total knee arthroplasty when design-related failure in TKAs was excluded [111]. Uncemented fixation with titanium fiber mesh coating of the femoral component in TKA works equally as well as cemented fixation up to 10 years [126]. After a minimum follow-up of 15 years, hybrid fixation of primary TKA for osteoarthritis provides significantly higher clinical benefits compared with cemented fixation, although the differences were not clinically relevant [136]. At 24 months after revision TKAs, cemented and hybrid-fixation replacements were equally stable [128]. Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both implant revision knee surgery indicated for mechanical complications [119]. Knee motion during cement polymerization is associated with significant decreases in tibial implant fixational strength [137]. There is no difference in outcomes with use of all polyethylene or modular tibial components in knee arthroplasty [4]. Similar functional outcomes and complication rates exist in tibial component fixation that is cemented or cementless [4].

A well-structured, algorithmic approach in the management of patients with a painful total knee arthroplasty is essential in correctly diagnosing the patient and optimizing clinical outcomes [10]. Nonoperative management led to clinical improvement in only a third of patients with flexion instability after primary TKA [116]. A customized, aggressive regimen of noninvasive and invasive therapeutic modalities reduced symptoms and restored function in 92% of patients with functional problems after total hip or knee arthroplasty [135]. Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes [16].

Complications¶

Infection (PJI): Periprosthetic joint infection (PJI) remains a formidable challenge with incidence rates of 0.4% to 2% after primary total knee replacement [172]. Infection rates are increasing, driven by both increased primary arthroplasty volumes and a rise in PJI occurring within 90 days [186]. Risk factors for PJI include obesity, which is associated with less improvement in outcomes [4]; prior knee surgery, which predisposes to higher postoperative complication rates [163]; rheumatoid arthritis, which carries a significantly higher rate of deep periprosthetic infections compared to osteoarthritis patients [190]; and a history of treated periprosthetic joint infection [173]. Aseptic reoperation within 1 year of primary total knee arthroplasty is also associated with a notably increased risk of subsequent PJI [174]. Primary total knee arthroplasty can be performed in patients with resolved prior bone or joint sepsis, but the rate of periprosthetic infection (9.7%) remains a significant concern [168]. Perioperative prophylaxis with vancomycin appeared effective in decreasing PJI rates and may result in infections with less virulent organisms when they occur [185].

Aseptic loosening: High-viscosity cement is associated with higher odds of revision for aseptic loosening when used in primary total knee arthroplasty [169]. Revisions for osteolysis and polyethylene wear were higher for primary total knee arthroplasties performed prior to 2000, while revisions for infection and instability were higher for those performed after 2000 [152]. Revisions performed within the first 24 months after primary arthroplasty had a higher rate of any-cause failure [151]. Estimates of the rates of revision knee replacement after almost seven years ranged from a low of 4.3 percent to a high of 8.0 percent [200]. Isolated and full component revision total knee arthroplasty for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years [161]. The cumulative incidence of subsequent revision for aseptic loosening and instability was very low at five years with fixed-bearing varus-valgus constraint implants in revision total knee arthroplasties [166].

Instability: Varus-valgus constraint in primary total knee arthroplasty raises concerns for significant revision risk with extended follow-up, especially beyond 5 years [201]. Mechanisms of failure for revision total knee arthroplasties differ from primary procedures, with revisions for infection being 4 times more likely to fail than revisions for aseptic loosening [183].

Thromboembolism: Deep vein thrombosis (DVT) is common in patients over 60 years of age after total knee arthroplasty, with multivariable influences on its pathogenesis [178]. Prior venous thromboembolism significantly increases the risk of 90-day DVT, pulmonary embolism, and 2-year PJI after total knee arthroplasty [170]. Alcohol use disorder is significantly associated with the development of venous thromboembolism, longer lengths of stay, and higher costs of care after primary total knee arthroplasty [182]. The prospective use of the first-generation American Academy of Orthopaedic Surgeons guidelines resulted in a low incidence of clinically important thromboembolic events in total hip and total knee arthroplasty patients [165]. In primary total joint arthroplasty patients treated with aspirin, the cumulative incidence of venous thromboembolism was less than 1% at 90 days [176]. No differences were found in the incidence, location, or characteristics of DVT following total knee arthroplasty with or without pharmacological prophylaxis [181]. At the institution studied, 1% of patients undergoing primary total joint arthroplasty accessed the emergency department for concern for DVT at substantial cost, with only a small portion testing positive [147].

Other Considerations: Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements [180]. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications [197]. A 2.5-fold increased risk of death at a mean of 5 years exists for patients with cerebrovascular accident sequelae following primary total hip or knee arthroplasty [171]. Total knee arthroplasty after distal femoral osteotomy has a high complication rate secondary to problems with balancing the knee [179]. Repeat two-stage revision for recurrent knee periprosthetic joint infection yields low infection control rates and major morbidity, including a 23% amputation rate [187]. Survivorship of aseptic conversion total knee arthroplasty was similar to that of primary total knee arthroplasty for up to 10 years and significantly better than that of first-time revision total knee arthroplasty [160]. Revision total knee arthroplasty results in a similar quality-adjusted life year gain as primary total knee arthroplasty [206]. The incidence of early post-operative morbidity after aseptic knee revisions is similar to that reported after primary procedures [158]. Revision free survivorship and arthroplasty related complications at two years following revision unicompartmental knee arthroplasty are lower than that for primary total knee arthroplasty, but higher than that for aseptic revision total knee arthroplasty [177]. Pooled data from nine epidemiological studies encompassing more than 140,000 total hip and knee replacements indicate no apparent increase in the risk of cancer following total joint arthroplasty compared with the general population [194].

Recovery¶

The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient [1]. Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary total knee arthroplasty [86], although further research from diverse populations is essential to establish robust evidence-based clinical guidelines and uncover optimal interventions for at-risk populations [107]. Early physical activity parameters of patients after total knee arthroplasty following an outpatient surgery pathway were similar to those following the standard enhanced recovery pathway [96]. Further multicenter, long-term randomized controlled trials are required to validate findings on outpatient versus home-based rehabilitation and provide robust evidence to inform early rehabilitation choices post-knee arthroplasty [75].

Light activity (weeks): Patients undergoing primary total knee arthroplasty returned to driving considerably earlier than previously reported [30]. Return to driving after primary total knee arthroplasty is highly variable, most commonly occurring around 4 weeks but ranging between 2 and 8 weeks [66]. Driving may be resumed 4 weeks after a right knee replacement, but patients must drive at low or moderate speed, and step counts are the best predictor of safe driving [57]. Advice regarding return to driving following hip or knee arthroplasty should be individualized for each patient, with the ultimate responsibility resting on the patient feeling safe and maintaining legal control of the vehicle [82]. If working pre-operatively, patients aged under 50 years invariably returned to work following total knee arthroplasty, but only half of those aged between 50 to 60 years returned [129].

Full activity (months): Most patients can expect to resume physical activity or sports within a short timeframe after knee arthroplasty, particularly to low-impact activities [193]. The findings on recommended sports activities may serve as a basis for answering patient questions on timing and giving recommendations for returning to sports following standard primary total knee arthroplasty [189]. There is a trend toward improvement in cardiovascular fitness one year after total knee arthroplasty and a significant improvement two years postoperatively for patients who had been able to resume routine functional activities because of the arthroplasty [195]. Functional recovery after unicompartmental knee replacement continues beyond 6 months and even up to 2 years [184]. The majority of patients returned to sports and recreational activity after unicompartmental knee arthroplasty [198]. Eighty-six percent of patients return to duty following total joint arthroplasty [109].

Complete recovery / outcome plateau (months): Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty [132]. Patients who have undergone total knee replacement demonstrate a response shift in the measurement of their outcome at six months postoperatively [94].

Rehabilitation protocol: Future rehabilitation protocols should consider the replaced knee as well as the non-replaced knee and surrounding joints [95]. Results from randomized trials on exercise treatment methods will inform recommendations on exercise programs to improve physical function and activity for patients at the later stage post-total knee replacement and help tailor interventions according to patients' characteristics [78].

Functional milestones: Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors [110].

Key Evidence¶

[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)
[L5] Advancements in total knee arthroplasty require a multifaceted approach that recognizes variations in knee morphometry and phenotypes, as not all knees are the same. (10.1302/0301-620x.106b12.bjj-2023-1269.r1)
[L5] For the vast majority of patients, a standard conventional total knee arthroplasty with a familiar surgical approach and standard components leads to satisfactory long-term clinical outcomes, and there is no single 'best' way to perform the procedure. (10.1016/j.arth.2020.04.031)
[L1] The present meta-analysis encourages the use of minimally invasive techniques for total knee arthroplasty. (10.1007/s00167-020-06306-9)
[L5] Total knee arthroplasty should be considered as the last surgical option. (10.1007/s00167-017-4466-1)
[L4] A well-structured, algorithmic approach in the management of patients with a painful total knee arthroplasty is essential in correctly diagnosing the patient and optimizing clinical outcomes. (10.5435/jaaos-d-18-00083)
[L2] The indication criteria for THA/TKA are based on limited evidence. (10.1186/s12891-016-1325-z)
[L1] Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. (10.2106/00004623-200708000-00031)
[L5] Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes. (10.2106/jbjs.20.02260)
[L4] Although the role for MRI in the postarthroplasty knee has yet to be clearly defined, its utility in working up a painful arthroplasty when history, physical examination, and other diagnostic utilities fail to provide answers is clearly demonstrated in this case. (10.1016/j.arth.2010.01.004)
[L2] This inventory review identifies a wide variety of definitions for poor outcome after total knee arthroplasty, highlighting the lack of consensus and the need for standardized definitions to improve comparability across studies. (10.1186/s12891-020-03406-y)
[L3] These findings underscore the integrated nature of gait biomechanics and suggest that subtle modifications to the knee joint line may contribute to widespread kinematic adaptations. (10.1002/ksa.70356)
[L5] Revision total knee arthroplasty is a challenging procedure requiring a comprehensive understanding of anatomy and surgical techniques to achieve good outcomes. (10.1302/2058-5241.1.000024)
[L5] The knee implant designs investigated did not replicate the kinematics of a healthy knee. (10.2106/jbjs.h.00817)
[L3] Although combined flexion influences knee biomechanics, its direct impact on clinical outcomes remains unclear. (10.1002/ksa.12660)
[L2] Overall, patients undergoing primary TKA returned to driving considerably earlier than previously reported. (10.2106/jbjs.24.01177)
[L5] Revision total knee arthroplasty presents numerous technical challenges requiring careful preoperative planning, meticulous surgical technique to preserve host bone, and attention to gap balancing. (10.5435/00124635-201106000-00001)
[L5] Mechanical alignment seems to result in more balanced load distribution and kinematics more closely resembling the native knee. (10.1007/s00167-020-05996-5)
[L4] Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years. (10.1007/s00167-012-1936-3)
[L4] This study demonstrated that the knee motion kinematic patterns observed in this study were not similar to normal knee kinematics and derived from the unique design of the Bi-Surface PS. (10.1186/s13018-016-0482-y)
[L4] The kinematically aligned knee showed greater multi-planar mobility, higher sagittal moments, and a more physiological gait pattern compared to the mechanically aligned knee. (10.1186/s12891-025-09445-7)
[L5] A complete and accurate history, physical examination, and radiographic assessment are critical for determining a specific diagnosis and treatment plan for pain after total knee replacement. (10.2106/00004623-200300001-00006)
[L1] The kinematics of CS and CR TKJR are comparable. (10.1177/2325967116s00091)
[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)
[L4] Nearly normal kinematics of the knee can be preserved, function of the knee can be improved, and shear stresses at the component-cement-bone interface can be minimized when such a prosthesis is utilized. (10.2106/00004623-198365070-00005)
[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)
[L3] These results suggest that this combined procedure is a safe and favorable alternative to a staged procedure consisting of revision and subsequent contralateral primary total knee arthroplasty. (10.2106/00004623-200310000-00020)
[L3] When TKA was used for appropriate indications, high BMI should not be considered as a contraindication. (10.1186/s12891-022-05634-w)
[L5] The results confirm the hypothesis that kinematics is not the only and also not the most relevant parameter to predict or explain knee function after TKA. (10.1007/s00167-015-3514-y)
[L3] The BCS cohort showed expected knee joint kinematics. (10.2106/jbjs.20.00024)
[L5] The paper presents a method to investigate the effect of different implant positions on the biomechanics of the knee after total knee arthroplasty using a VIVO joint simulator without modifying the physical setup. (10.1186/s42836-025-00351-w)
[L2] Furthermore, the considerable difference between TKA design and the kinematics of healthy knee were highlighted in this study. (10.1186/s42836-023-00165-8)
[L5] These results confirm the importance of tibiofemoral conformity in preserving native knee kinematics. (10.1007/s00167-019-05540-0)
[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)
[L3] Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. (10.1007/s00167-013-2374-6)
[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)
[L4] Driving may be resumed 4 weeks after a right knee replacement but had to drive at low or moderate speed, and the best predictor of safety driving is step counts. (10.1186/1471-2474-15-198)
[L5] Revision total knee arthroplasty is a challenging procedure requiring a correct diagnosis of the original cause of failure and a detailed plan. (10.1302/2058-5241.6.210018)
[L3] Almost a third of the patients continued to have residual knee pain at 2 years post-TKA, with factors such as gender, presence of ischaemic heart disease, and implant type significantly associated with the development of residual knee pain and/or poorer functional outcome scores. (10.1007/s00167-014-2910-z)
[L3] More than half the patients presenting for TKA had mild-to-severe contralateral knee pain, most of whom had a clinically meaningful improvement but were significantly less likely to be satisfied with their TKA. (10.1302/0301-620x.102b1.bjj-2019-0328.r1)
[L5] Most patients can be successfully treated with total knee arthroplasty, but a certain number remain unhappy, requiring careful analysis of whether symptoms are surgery-related or patient-related. (10.1007/s00167-011-1545-6)
[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] 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)
[L2] Return to driving a car after a primary TKA or THA is highly variable, most commonly occurring around 4 weeks but ranging between 2 and 8 weeks. (10.1155/2020/8921892)
[L5] The revision knee complexity classification offers a common-sense approach to recognize increasing complexity in revision TKR cases, providing a methodological assessment to support regional clinical networking and triage of appropriate cases to specialist centres. (10.1007/s00167-019-05462-x)
[L3] The KSPQ is a valid questionnaire to assess patients' expected and desired outcomes of knee replacement surgery and their perception of their current abilities and function, and discrepancy between these. (10.1007/s00167-014-3432-4)
[L5] Improvement in knee pain after total knee arthroplasty is associated with a reduction in pain in other bodily regions, suggesting a potential physiological link, though persistent pain remains common and improvement does not equate to cure. (10.2106/jbjs.23.00839)
[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)
[L3] This study has defined a post-operative classification of excellent, good, fair and poor for the components and total WOMAC scores after TKA. (10.1007/s00167-018-4879-5)
[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)
[L3] Pain symptoms of moderate or severe pain are unequivocal when considering a TKA. (10.1007/s00167-015-3961-5)
[L1] Despite these findings, further multicenter, long-term randomized controlled trials are required to validate these findings and provide robust evidence to inform early rehabilitation choices post-knee arthroplasty. (10.1186/s13018-023-04160-2)
[L3] The distribution of functional phenotypes of the knee in patients undergoing total knee arthroplasty is different from those found in a reference non-osteoarthritic population. (10.1007/s00167-021-06687-5)
[L2] Results will inform recommendations on exercise programs to improve physical function and activity for patients at the later stage post TKR and help tailor interventions according with patients' characteristics. (10.1186/s12891-015-0761-5)
[L5] Advice regarding return to driving following hip or knee arthroplasty should be individualized for each patient; ultimately the patient must feel safe to drive knowing that they have a legal responsibility to remain in control of the vehicle at all times. (10.1016/j.arth.2022.10.024)
[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)
[L5] Nearly 20% of patients are dissatisfied following well-performed total knee arthroplasty with good functional outcomes, often due to unfulfilled expectations. (10.5435/jaaos-d-14-00049)
[L3] Evaluation of data from multiple national joint registries demonstrated the revision rate for this contemporary knee system to be comparable to other TKA systems at latest follow-up. (10.1016/j.arth.2019.09.018)
[L1] Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA. (10.1007/s00167-012-2349-z)
[L1] This is the first randomised controlled trial to investigate the efficacy of TKA as an adjunct treatment to optimised non-surgical treatment in patients with KOA. (10.1186/1471-2474-13-67)
[L3] In case of failed arthroplasty after total knee arthroplasty, data did not allow definite treatment recommendations. (10.1016/j.arth.2020.04.078)
[L1] This multimodal perioperative analgesia protocol that included infiltration of a local anesthetic offered improved pain control and minimal side effects to patients undergoing total knee arthroplasty. (10.2106/jbjs.e.00173)
[L4] This novel hinged knee system is a highly durable option for complex and revision knee arthroplasty. (10.1016/j.arth.2019.12.024)
[L3] Both knee systems showed good clinical results at 2 years postoperatively. (10.1007/s00402-014-1944-5)
[L1] Patients who have undergone total knee replacement demonstrate a response shift in the measurement of their outcome at six months postoperatively. (10.2106/jbjs.f.00283)
[L3] The early physical activity parameters of patients after total knee arthroplasty following the outpatient surgery pathway were similar to those following the standard enhanced recovery pathway. (10.1007/s00167-016-4256-1)
[L5] The authors reviewed the current evidence to determine what defines a 'balanced knee replacement' and how this relates to the native knee. (10.1302/2058-5241.3.180008)
[L5] The authors propose a World Expert Meeting to decipher evidence from eminence by having experts perform thorough literature reviews using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty. (10.1016/j.arth.2024.03.031)
[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)
[L2] Multimodal analgesia has become the standard for perioperative pain management in TKA, integrating various drugs and modalities to minimize opioid consumption and enhance analgesic efficacy. (10.1186/s13018-024-05324-4)
[L1] The local infusion analgesia alone provided clinically significant analgesic effects and rapid recovery in total knee arthroplasty, although larger studies are needed to examine its safety. (10.1007/s00167-012-2004-8)
[L1] In patients with knee osteoarthritis, total knee replacement plus a 12-week nonsurgical treatment program was more effective than nonsurgical treatment alone but was associated with more serious adverse events. (10.2106/jbjs.16.00208)
[L5] While prehabilitation has the potential to optimize outcomes for total knee arthroplasty patients, further research from diverse populations is essential to establish robust evidence-based clinical guidelines and uncover optimal interventions for at-risk populations. (10.1016/j.arth.2024.12.021)
[L3] Eighty-six percent of patients return to duty following total joint arthroplasty. (10.1016/j.arth.2013.02.028)
[L2] Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors. (10.1007/s00167-018-4987-2)
[L1] There is no evidence to support that fixation techniques alone affect the durability of a total knee arthroplasty when design-related failure in TKAs was excluded. (10.1007/s00167-013-2806-3)
[L5] Implementation of multimodal pain management regimens after total knee arthroplasty has increased patient satisfaction, decreased pain scores, and facilitated faster recovery. (10.2106/jbjs.19.01035)
[L4] Nonoperative management led to clinical improvement in only a third of patients with flexion instability after primary TKA. (10.1016/j.arth.2022.02.069)
[L4] Conversion of a fused knee to total knee arthroplasty resulted in good long-term fixation and high patient satisfaction. (10.2106/jbjs.25.00149)
[L3] Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both implant revision knee surgery indicated for mechanical complications. (10.5435/jaaos-d-23-01184)
[L1] On the basis of this meta-analysis, we found no evidence to support the routine use of gabapentinoids in the management of acute pain following total knee arthroplasty. (10.2106/jbjs.15.01202)
[L1] Adding steroid to local anaesthetics in local infiltration analgesia reduced inflammation both locally and systemically, resulting in significant early pain relief and rapid recovery in total knee arthroplasty. (10.1007/s00167-013-2367-5)
[L4] When soft-tissue sleeves in a previously fused knee are carefully preserved intraoperatively, they can provide adequate stability after total knee arthroplasty with a posterior stabilized prosthesis, making it a reasonable alternative to more constrained implants. (10.2106/00004623-200306000-00009)
[L1] Uncemented fixation with titanium fiber mesh coating of the femoral component in total knee arthroplasty works equally as well as cemented fixation up to 10 years. (10.1007/s00167-018-5227-5)
[L3] Based on a low certainty of evidence, MRI and SPECT/CT are currently the most accurate modalities available to aid the diagnosis of aseptic loosening of knee arthroplasty components. (10.1002/ksa.12206)
[L1] At 24 months after revision TKAs, cemented and hybrid-fixation replacements were equally stable. (10.2106/jbjs.15.00909)
[L3] If working pre-operatively, patients aged < 50 years invariably returned to work following TKA, but only half of those aged between 50 to 60 years returned. (10.1302/0301-620x.99b8.bjj-2016-1364.r1)
[L4] Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect. (10.2106/jbjs.17.01657)
[L4] Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty. (10.1007/s00167-014-3212-1)
[L4] Modular knee arthroplasties offer the advantage of intraoperative customization and improved fixation; however, the trade-off is the potential for failure (disengagement or fracture) especially at the modular junction. (10.1007/s00167-011-1652-4)
[L4] Short-term stable fixation can be achieved with sleeves, which is helpful as more patients undergo revision total knee arthroplasty with greater bone loss. (10.1007/s00167-017-4493-y)
[L4] A customized, aggressive regimen of noninvasive and invasive therapeutic modalities reduced symptoms and restored function in 92% of patients with functional problems after total hip or knee arthroplasty. (10.2106/jbjs.e.00628)
[L3] After a minimum follow-up of 15 years, hybrid fixation of primary TKA for osteoarthritis provides significantly higher clinical benefits compared with cemented fixation, although the differences were not clinically relevant. (10.1007/s00167-020-06028-y)
[L5] Knee motion during cement polymerization is associated with significant decreases in tibial implant fixational strength. (10.1016/j.arth.2022.02.091)
[L1] Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. (10.1007/s00167-021-06487-x)
[L4] The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for THA, but not for TKA. (10.1302/0301-620x.106b7.bjj-2024-0136)
[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)
[L2] There is preliminary evidence that MRI has a noteworthy value of distinguishing suspected periprosthetic joint infection in patients with total knee arthroplasty or total hip arthroplasty, but the definition of specific MRI features related to PJIs diagnosis lacks consensus and standardization. (10.1186/s12891-023-06926-5)
[L2] Radiographic findings including joint space narrowing and MRI detected bone marrow lesions, synovitis and effusion were all significantly associated with the long term risk of TKA in persons with knee osteoarthritis. (10.1186/s12891-017-1871-z)
[L4] At the institution, 1% of patients undergoing primary total joint arthroplasty accessed the ED for concern for DVT at substantial cost, with only a small portion testing positive for DVT. (10.5435/jaaos-d-20-00878)
[L3] The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven. (10.1177/2325967116s00051)
[L3] Routine screening is not necessary, but patients with persistent hip or knee pain should be assessed with MRI. (10.1016/j.arth.2007.01.006)
[L3] Those revisions performed within the first 24 months after primary arthroplasty had a higher rate of any-cause failure. (10.1016/j.arth.2024.07.031)
[L4] The proportion of revisions for osteolysis and polyethylene wear was higher for primary TKAs performed prior to 2000, while revisions for infection and instability were higher for those performed after 2000. (10.1186/s42836-022-00134-7)
[Case_report] A thorough preoperative investigation, especially MRI, is required to determine the role of each layer to make the correct decision between fusion, preservation, removal, or resurfacing of the patella. (10.1016/j.jisako.2022.01.004)
[L4] Routine radiographic surveillance did not detect any true abnormalities during the first year after primary total joint arthroplasty. (10.1016/j.arth.2021.02.050)
[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] Patients can be counselled that although radiographic severity of arthritic changes can predict knee-specific functional improvement, the extent of their global functional improvement cannot. (10.1007/s00167-015-3806-2)
[L3] The incidence of early post-operative morbidity after aseptic knee revisions is similar to that reported after primary procedures. (10.1302/0301-620x.96b12.33621)
[L4] A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy. (10.1016/j.arth.2020.10.021)
[L3] Survivorship of aseptic conversion TKA was similar to that of primary TKA for up to 10 years and significantly better than that of first-time revision TKA. (10.1016/j.arth.2025.06.041)
[L3] Isolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. (10.1016/j.arth.2022.09.006)
[L3] A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively. (10.1302/0301-620x.96b11.33726)
[L4] Prior knee surgery is a clinical condition predisposed to a higher postoperative complication rate in primary TKA compared to the no prior surgery group. (10.1007/s00167-012-2139-7)
[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)
[L4] The prospective use of the first-generation American Academy of Orthopaedic Surgeons guidelines resulted in a low incidence of clinically important thromboembolic events in total hip and total knee arthroplasty patients. (10.2106/jbjs.m.00503)
[L3] The cumulative incidence of subsequent revision for aseptic loosening and instability was very low at five years with this fixed-bearing VVC implant in revision TKAs. (10.1302/0301-620x.102b4.bjj-2019-0719.r2)
[L3] Although high-viscosity cement is an attractive option for use in primary total knee arthroplasty, this appropriately controlled study demonstrates higher odds of revision for aseptic loosening when using high-viscosity cement with multiple different implant types. (10.1016/j.arth.2019.08.023)
[L3] Prior VTE significantly increased the risk of 90-day DVT, PE, and 2-year PJI after TKA. (10.1016/j.arth.2026.02.013)
[L3] A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients. (10.1016/j.arth.2022.06.026)
[L3] A history of PJI predisposes patients to subsequent PJI in primary THA or TKA. (10.1007/s11999-015-4174-4)
[L3] Aseptic reoperation within 1 year of primary TKA was associated with a notably increased risk of subsequent PJI. (10.1016/j.arth.2020.06.054)
[L3] In 3512 primary TJA patients treated with ASA, we found a cumulative incidence of VTE <1% at 90 days. (10.1016/j.arth.2021.02.007)
[L3] Revision free survivorship and arthroplasty related complications at two years following revision UKA are lower than that for primary TKA, but higher than that for aseptic revision TKA, whereas medical complications are similar to those following primary TKA. (10.1016/j.arth.2024.12.026)
[L3] DVT is common in patients over 60 years of age after TKA, and there is a multivariable influence on its pathogenesis. (10.1186/s13018-023-04339-7)
[L3] Ten-year survivorship free from aseptic loosening was 95% with reliable improvement in clinical function, though there was a high complication rate secondary to problems with balancing the knee. (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
[L3] Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements. (10.1155/2018/8987104)
[L3] No differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis. (10.1186/s12891-021-04707-6)
[L3] The present study demonstrated a significant association between alcohol use disorder and the development of venous thromboembolism, longer lengths of stay, and higher costs of care after primary total knee arthroplasty. (10.5435/jaaos-d-20-00466)
[L3] Mechanisms of failure for revision total knee arthroplasties are different than for primary total knee arthroplasty, with revisions for infection being 4 times more likely to fail than revisions for aseptic loosening. (10.1016/j.arth.2008.01.228)
[L3] Functional recovery after unicompartmental knee replacement continues beyond 6 months and even up to 2 years. (10.1007/s00167-007-0351-7)
[L3] The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of PJI and may result, when they occur, in infections with less virulent organisms. (10.1016/j.arth.2012.03.040)
[L3] The PJIs are increasing, both because of an increase in the numbers of primary arthroplasties and due to an increase in PJIs occurring within 90 days. (10.1016/j.arth.2026.01.042)
[L3] Repeat two-stage revision for recurrent knee PJI yields low infection control rates and major morbidity, including a 23% amputation rate. (10.1016/j.arth.2026.01.057)
[L5] The findings may serve as a basis for answering patient questions on timing and giving recommendations for returning to sports following standard primary TKA. (10.1007/s00167-020-06400-y)
[L1] Following primary TKA, RA patients had a significantly higher rate of deep periprosthetic infections than OA patients, but their superficial infection rates were similar. (10.1007/s00167-016-4306-8)
[L4] Most patients can expect to resume physical activity or sports within a short timeframe after knee arthroplasty, particularly to low-impact activities. (10.1002/ksa.70267)
[L2] The pooled data from nine epidemiological studies encompassing more than 140,000 total hip and knee replacements indicate no apparent increase in the risk of cancer following total joint arthroplasty compared with the general population. (10.2106/00004623-200105000-00019)
[L3] These findings demonstrate a trend toward improvement in cardiovascular fitness one year after total knee arthroplasty and a significant improvement two years postoperatively for patients who had been able to resume routine functional activities because of the arthroplasty. (10.2106/00004623-199611000-00009)
[L3] Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. (10.1302/0301-620x.103b10.bjj-2020-2590.r1)
[L4] The majority of patients returned to sports and recreational activity after unicompartmental knee arthroplasty. (10.1177/0363546507303562)
[L3] Estimates of the rates of revision knee replacement after almost seven years ranged from a low of 4.3 percent to a high of 8.0 percent. (10.2106/00004623-199906000-00004)
[L1] Meta-regression estimates raise concerns for significant revision risk with extended follow-up, especially beyond 5 years. (10.1016/j.arth.2019.09.048)
[L2] Revision total knee arthroplasty results in a similar QALY gain as primary total knee arthroplasty. (10.1002/ksa.12343)

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