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Total Knee Replacement

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

173 citationsUpdated Aug 2026

Overview

The primary objective of total knee arthroplasty is to deliver the best possible outcome for each individual patient, whether by restoring the native knee or creating an optimal prosthetic knee [1], [2]. For the vast majority of patients, a standard conventional total knee arthroplasty utilizing a familiar surgical approach and standard components yields satisfactory long-term clinical outcomes [7]. There is no single 'best' way to perform this procedure [7].

Total knee arthroplasty should be considered as the last surgical option [9]. The indication criteria for total hip or knee arthroplasty in osteoarthritis are based on limited evidence [14]. Despite well-performed procedures with good functional outcomes, nearly 20% of patients remain dissatisfied, often due to unfulfilled expectations [83].

The health benefits of total knee arthroplasty are maintained after a minimum duration of follow-up of ten years [73].

Anatomy & Pathophysiology

Knee Joint Kinematics and Ligamentous Anatomy

The knee functions as a hinge joint incorporating gliding and rolling motions [34]. The "screw-home" mechanism involves external rotation of the tibia by 5 degrees in the final 15 degrees of extension [34].

Anterior Cruciate Ligament (ACL): The anteromedial bundle originates proximal to the bifurcate ridge, is tight in flexion, and primarily resists anterior tibial translation in knee flexion [34]. The posterolateral bundle originates distal to the bifurcate ridge, is tight in extension, and primarily resists rotatory loads in knee extension [34].

Posterior Cruciate Ligament (PCL): The PCL resists posterior tibial translation at all degrees of knee flexion [34]. It also resists tibial internal and external rotation beyond 90 degrees of knee flexion [34].

Medial Compartment Stabilizers: The superficial medial collateral ligament (sMCL) proximal division resists valgus tibial translation, while its distal division resists tibial external rotation in knee extension [34]. The deep MCL resists valgus translation and tibial internal and external rotation [34]. The posterior oblique ligament resists tibial internal rotation, especially in knee extension [34].

Lateral Compartment Stabilizers: The lateral collateral ligament resists varus tibial translation [34]. The popliteus tendon and popliteofibular ligament both resist tibial external rotation, especially in knee flexion [34]. The oblique popliteal ligament resists knee hyperextension [34].

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]. Patellar dislocation is typically lateral and a frequent cause of hemarthrosis [65]. The recurrence rate following a first-time patellar dislocation ranges from 15% to 60% [65]. Younger age, female sex, patella alta, and trochlear dysplasia increase the risk for recurrent patellar dislocation [65]. Articular cartilage on the medial facet of the patella is the most commonly injured site during reduction of a patellar dislocation [65].

Symptoms of patellar instability can be exacerbated by femoral anteversion, genu valgum, and pronated feet, a condition referred to as "miserable malalignment syndrome" [65]. Examination may reveal a positive patellar apprehension test result, the presence of the J sign, and three to four quadrants of lateral patellar glide [65].

Imaging and Classification of Trochlear Dysplasia: Trochlear dysplasia can be identified on a lateral radiograph by the presence of a crossing sign or a supratrochlear spur [65]. The crossing sign is present when the trochlear groove line intersects the anterior femoral condyle rather than the anterior femoral cortex [65]. The Dejour system is used to classify trochlear dysplasia [65]. A TT-TG distance over 20 mm is highly associated with patellar instability [65]. In complete patellar dislocation, MRI often reveals a bone bruise pattern involving the lateral femoral condyle and medial patella [65]. The MPFL is most frequently disrupted at its patellar insertion during complete dislocation [65]. The Schottle point for radiographically identifying the femoral attachment of the MPFL occurs 1 mm anterior to the posterior cortex extension line and 2.5 mm distal to the posterior origin of the medial femoral condyle [65].

Patellofemoral pain syndrome is an extremely common cause of anterior knee pain, particularly in adolescents [65].

Osteoarthritis Pathophysiology and Clinical Presentation

Pain with weight bearing, aggravated by stairs, inclines, and transitions from sit to stand, is a clinical presentation of knee arthritis [21]. Bowing deformity and instability are seen later in the clinical presentation of knee arthritis [21].

Gait Kinematics and Deformity: A varus thrust indicates ligament stretch-out on the convex side of the thrust during the stance phase of gait [21]. A varus thrust causes the knee to push outward during stance, overloading the medial compartment and accelerating cartilage degeneration [21]. A varus thrust increases the adductor moment of force (AMoF) [21]. A valgus thrust indicates ligament stretch-out on the convex side of the thrust during the stance phase of gait [21]. A valgus thrust causes the knee to push inward during stance, overloading the lateral compartment and accelerating cartilage degeneration [21]. A valgus thrust increases the abductor moment of force [21].

Imaging and Grading of Knee Arthritis

Radiographic Evaluation: Weight-bearing AP and lateral views are standard initial radiographic evaluations for knee arthritis [21]. A weight-bearing knee flexed at a 45-degree angle imaged posterior to anterior is used to evaluate compartment joint space loss [21]. A standing full-length AP radiograph from hip joint to ankle joint is used to evaluate limb alignment and identify femoral or tibial bone deformity [21].

Kellgren-Lawrence (KL) Grading System: The KL grading system grades the extent of osteoarthritis based on AP knee radiographs [21]. Primary features for KL rating include osteophytes, joint space narrowing, subchondral sclerosis with or without cysts, and altered shape of periarticular bones [21]. * KL Grade 0: Indicates normal knee features with no OA [21]. * KL Grade 1: Indicates OA is possibly present with doubtful small tibial spine osteophytes [21]. * KL Grade 2: Indicates minimal OA with marginal osteophytes and joint space narrowing less than 50% [21]. * KL Grade 3: Indicates moderate OA with significant osteophytes, articular joint space loss over 50%, and subchondral tibial bone sclerosis [21]. * KL Grade 4: Indicates severe OA with prominent osteophytes, absent joint space, subchondral bone sclerosis with cysts, and bone deformity [21].

Knee arthroplasty is recommended when KL Grade 4 findings are present [21]. MRI is not indicated if the joint space is significantly narrowed on radiograph [21]. MRI is used when osteonecrosis is suspected in the arthritic patient population [21]. Three-dimensional CT with remodeling is used for preoperative planning in complex total knee arthroplasty [21].

Alignment Techniques and Gait Kinematics

Mechanical Alignment: Mechanical alignment aims to create a neutral mechanical limb line (Mikulicz) to provide symmetrical implant loading [76]. In mechanical alignment, the distal femoral bone cut is made perpendicular to the mechanical axis of the femur (mLDFA = 90 degrees) [76]. In mechanical alignment, the proximal tibial bone cut is made perpendicular to the mechanical axis of the tibia (mPTA = 90 degrees) [76]. Mechanical alignment results in more balanced load distribution and kinematics more closely resembling the native knee in patients with constitutional varus [33].

Kinematic Alignment: Kinematic alignment aims to maintain native limb alignment without adjusting ligaments and capsule [76]. In kinematic alignment, the distal femoral bone cut is made at the native mLDFA [76]. In kinematic alignment, the proximal tibial bone cut is made at the native mPTA [76]. Kinematic alignment yields a reduced knee adduction moment and better range of motion compared to mechanical alignment [37]. The kinematically aligned knee shows greater multi-planar mobility, higher sagittal moments, and a more physiological gait pattern than the mechanically aligned knee [37]. Kinematically aligned TKAs more closely resemble normal healthy controls in knee kinematics than mechanically aligned TKAs [53].

General Kinematic Principles: Static native tibial alignment optimizes whole-body gait kinematics [27]. Subtle modifications to the knee joint line may contribute to widespread kinematic adaptations [27]. Contemporary knee implant designs do not replicate the kinematics of a healthy knee [29]. The considerable difference between TKA design and the kinematics of a healthy knee is highlighted in systematic reviews [48]. Tibial slope does not contribute significantly to knee kinematics after total knee arthroplasty [54]. Combined flexion influences knee biomechanics, but its direct impact on clinical outcomes remains unclear [30].

Implant Kinematics and Design

The kinematics of cruciate stabilizing (CS) and cruciate retaining (CR) total knee replacements are comparable [39]. The posterior stabilized (PS) design is significantly better on knee flexion compared to CR designs, with no statistical differences in kinematic gait parameters [55]. Retention of the posterior cruciate ligament alone may not achieve physiological knee joint kinematics after TKA [46]. The medial pivot (MP) design provides a more native-like knee kinematic profile than the CR design, with reduced quadriceps loading [40]. The morphology of the medial tibial insert produces a small but noticeable effect on knee kinematics in medial pivot prostheses [42].

Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years with highly congruent mobile-bearing prostheses [35]. Nearly normal kinematics can be preserved, and shear stresses minimized, when non-constrained prostheses are utilized [41]. Anatomy-mimetic design preserves natural kinematics of the knee joint in patient-specific mobile-bearing unicompartmental knee arthroplasty [49]. Tibiofemoral conformity is important for preserving native knee kinematics [49]. Native rotational knee kinematics is restored after lateral UKA but not after medial UKA [52]. Kinematics is not the only or most relevant parameter to predict or explain knee function after TKA [45]. Knee motion kinematic patterns in posterior-stabilized TKA are not similar to normal knee kinematics and derive from the unique design of the prosthesis [36].

Sagittal Plane Balancing and Gaps

Sagittal plane ligament balancing is also known as "balancing the gaps" [56]. The goal of balancing is to achieve full extension and full flexion for functional range, stability, and pain relief [56]. Unbalanced gaps cause pain from tightness or instability [56].

Gap Control: The flexion gap is controlled by the posterior cut of the femur, the tibial cut, and the PCL [56]. The extension gap is controlled by the distal cut of the femur, the tibial cut, and the posterior capsule [56]. The flexion gap can be increased by cutting more posterior femur, cutting more proximal tibia, or removing the PCL [56]. The extension gap can be increased by cutting more distal femur, cutting more proximal tibia, or recessing the posterior capsule [56]. Posterior osteophytes and capsule recession are performed with the knee flexed at 90 degrees or more to allow the popliteal artery to relax posteriorly [56].

Gap Balancing Strategy: The STAF mnemonic guides gap balancing: Symmetrical gap problems are addressed by tinkering with the Tibia first; Asymmetrical gap problems are addressed by tinkering with the Femur first [56]. A rule of thumb for gap correction is that 2 mm of bone removal or addition equals a 10-degree contracture correction [56].

Specific Gap Corrections: * Extension loose and flexion loose symmetrical gaps: Solved by adding to the tibia with a thicker polyethylene insert or metallic augmentation [56]. * Extension tight and flexion tight symmetrical gaps: Solved by cutting more proximal tibia [56]. * Extension normal and flexion loose asymmetrical gaps: Solved by increasing the femoral implant size or translating it posteriorly [56]. * Extension normal and flexion tight asymmetrical gaps: Solved by checking tibial slope, cutting more posterior femoral bone, or recessing the PCL [56]. * Extension loose and flexion normal asymmetrical gaps: Solved by distal femoral augmentation [56]. * Extension tight and flexion normal asymmetrical gaps: Solved by removing posterior osteophytes, recessing the posterior capsule, or removing more distal femur [56].

Complications: Osteolysis and Instability

Osteolysis: Osteolysis occurs late in the lifecycle of a TKA implant, typically at 13 to 15 years [104]. Clinical presentation includes gradual increase in knee effusion, mild to moderate joint warmth, and gradual increase in weight-bearing pain [104]. Evaluation shows normal serum infection biomarkers and negative aspiration [104]. Radiographs show round lytic lesions behind implants, most commonly behind the posterior femur [104]. Osteolysis is caused by submicron shedding of microparticulate polyethylene (PE) debris that invades surrounding bone [104]. Macrophages stimulated by phagocytosis of PE wear particles release TNFα, IL-1β, and IL-6 [104]. Up-regulation of RANKL production by osteophytes mediates osteoclast differentiation and bone resorption in areas containing PE microparticles [104]. If implants are mechanically loose in osteolysis, revision TKA with radical débridement and bone graft or metal augmentation is required [104]. If implants are mechanically stable in osteolysis, they are retained with modular tibial PE bearing exchange and radical débridement [104].

Instability and Loosening: Mediolateral instability may result from intraoperative collateral ligament laceration, postsurgical trauma, or gradual attenuation over time [101]. Flexion instability can develop after surgery despite appropriate gap balancing due to sacrifice of the anterior cruciate ligament [101]. Radiographs of flexion instability may demonstrate "paradoxical motion" or anterior subluxation of the femur on the tibia in flexion [101]. Limb malalignment causes asymmetric loading which can result in early loosening, occurring more frequently with varus malalignment [101]. Tibial loosening typically presents as a change in implant position or alignment associated with varus or valgus subsidence [101].

Arthrofibrosis: Arthrofibrosis is the formation of pathologic scar tissue after TKA that restricts functional range of motion [101]. Arthrofibrotic scar contains dense fibrous tissue with abundant fibroblasts and frequently includes heterotopic bone [101]. Surgical technique factors contributing to arthrofibrosis include oversizing the femoral implant, overstuffing the patella, or rotational malalignment [101].

Revision Indications and Evaluation

Patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis have higher revision rates due to immune inhibitors and altered cytokine production [112]. Referred pain from the hip is the most common missed diagnosis in patients with painful TKA [112]. Hip pain typically refers to the anterior-medial knee region via the distal branch of the obturator nerve [112].

Reasons for Revision: * Infection: The number one reason for TKA revision and the number one reason for revision within 2 years of index surgery [112]. * Mechanical Implant Loosening: The number two reason for TKA revision [112]. Early aseptic loosening results from failure of osteointegration in cementless implants or cement debonding/poor interdigitation [112]. Late aseptic loosening results from PMMA fatigue, bone resorption away from cement, or osteolysis [112]. * Wear Debris Phenomenon: Presents early with warm knee, effusion, and reactive synovitis from PE debris deposits [112]. Late wear presentation involves osteolysis with bone resorption and retroprosthetic bone resorption causing pain [112].

Diagnostic Evaluation: * Intraarticular Lidocaine Challenge: Relief of ≥90% of pain indicates the pain emanates primarily from within the knee joint [112]. * Radiographic Signs of Aseptic Loosening: Smooth radiolucent lines around cement mantle and metallic implants suggest aseptic loosening [112]. Stem tilt to the side of the medullary canal with outer cortical periosteal reaction suggests aseptic loosening [112]. * Alignment Assessment: Internal rotation of the femoral implant is a known cause of flexion gap imbalance [112]. A tibial implant axis lying medial to the tibial tubercle indicates malalignment [112].

Periprosthetic Fractures

The incidence of periprosthetic fracture of the distal femur in TKA is 0.3% to 2.5% [117]. Risk factors for distal femur periprosthetic fracture include rheumatoid arthritis, neurologic disorders, chronic steroid therapy, osteopenia/osteoporosis, anterior femoral notching, and osteolysis [117]. Anterior femoral notching weakens the anterior femur at the bone-component interface and should be avoided [117].

The incidence of periprosthetic tibial fracture in primary TKA is 0.7% or less [117]. Risk factors for tibial periprosthetic fracture include long-stem component insertion, loose tibial component, periprosthetic osteolysis, malalignment, and tibial tubercle osteotomy [117].

Classification

Advancements in total knee arthroplasty require a multifaceted approach that recognizes variations in knee morphometry and phenotypes, as not all knees are the same [4]. 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 [75]. Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all TKA systems fit these phenotypes well [97].

Anderson Orthopaedic Research Institute: A new classification system for periprosthetic femur fractures 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 [64].

Revision Knee Complexity: 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 [67].

Outcome Classification: The WOMAC score can be reliably used to classify patient satisfaction after total knee arthroplasty, with a post-operative classification of excellent, good, fair and poor defined for the components and total WOMAC scores after TKA [71].

Other Considerations: There is 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 [22]. 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 rely on non-biased statistical model-based approaches [82]. Several countries' DRG systems might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities [51]. Experts propose using thorough literature reviews using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty [96].

Evaluation of data from multiple national joint registries demonstrated the revision rate for a contemporary knee system to be comparable to other TKA systems at latest follow-up [84]. A novel hinged knee system is a highly durable option for complex and revision knee arthroplasty [89]. Both the Genesis II and Vanguard prosthesis systems showed good clinical results at 2 years postoperatively regarding the effect of femoral component design on patellar tracking [91]. The authors reviewed current evidence to determine what defines a 'balanced knee replacement' and how this relates to the native knee [95]. Kujala scores for all patellar implant types (inlay, onlay, oval, round) showed improvement with no difference between types, and KOOS showed minimal and likely clinically unimportant differences between implant types [100].

Clinical Presentation

Total knee arthroplasty (TKA) aims to deliver optimal individual outcomes [1, 2] through a multifaceted approach that accounts for variations in knee morphometry and phenotypes [4]. This intervention cannot be viewed in isolation; it requires consideration of broader factors influencing results [17]. With high annual volumes in the United States representing significant healthcare expenditure [3], registries such as FORCE-TJR, MARCQI, Kaiser Permanente, and the American Joint Replacement Registry capture patient-reported outcomes, implant survivorship, and quality metrics [3]. International registries, including the Swedish Hip Arthroplasty Register, Australian Orthopaedic Association National Joint Replacement Registry, and the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man, report survivorship curves, mortality rates, and healthcare utilization [3].

A well-structured, algorithmic approach is essential for diagnosing painful TKA and optimizing outcomes [11]. Definitions of poor outcomes vary widely, highlighting a lack of consensus and the need for standardization [22]. A complete history, physical examination, and radiographic assessment are critical for determining specific diagnoses and treatment plans [38]. Risk factors for knee arthroplasty following arthroscopy in patients aged ≥50 years include diagnosis codes for both knee osteoarthritis and obesity [50]. Revision TKA requires a correct diagnosis of the original failure cause and a detailed plan [58], with texts covering diverse opinions on diagnosis, implant selection, techniques, and complication management [59].

Almost a third of patients experience residual knee pain at 2 years post-TKA [60]. Gender, ischaemic heart disease, and implant type are significantly associated with residual pain and poorer functional scores [60]. More than half of patients have mild-to-severe contralateral knee pain [61]. These patients are significantly less likely to be satisfied with their TKA, though they may still achieve clinically meaningful improvements in WOMAC scores [61]. Most patients are successfully treated, but unhappy patients require analysis of whether symptoms are surgery-related or patient-related [62]. Knee arthroplasty design influences kneeling kinematics, aiding management of functional expectations [63]. The KSPQ is a valid questionnaire for assessing expected outcomes and current function [68]. Pain improvement is associated with reduced pain in other regions, though persistent pain remains common and improvement does not equate to cure [69]. Patient expectations vary by country and are not fully explained by sociodemographic, clinical, or pain/functional factors [70]. Bilateral knee replacement under a single anaesthetic is suitable for carefully selected patients with bilateral symptomatic arthritis [72].

The source of pain after TKA is often difficult to determine and requires evaluation for infection, neurogenic pain, referred pain from the hip or back, and mechanical sources [141]. Evaluation includes thorough history, physical examination, laboratory studies, and plain radiographs, with additional nuclear medicine or specialized imaging as necessary [141].

Acute/Inflammatory vs. Mechanical Patterns: * Inflammatory/Neurogenic: Pain developing immediately after surgery and persisting without a pain-free interval, along with pain at rest and weight bearing, suggests an inflammatory and/or neurogenic source [141]. * Mechanical: Pain during weight-bearing activity or knee motion is consistent with a mechanical source [141].

Infection Evaluation: Infection is a common source of pain and must be ruled out first, usually associated with elevated erythrocyte sedimentation rate and C-reactive protein levels, and detected by aspiration [141]. False-negative and false-positive results can occur, necessitating additional imaging studies [141]. 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 from postsurgical rehabilitation [141].

Neurogenic Pain: Pain described as burning or numbness, nonfocal on examination, or improving with neuropathic analgesics or local injections supports the diagnosis of neurogenic pain [141].

Mechanical Causes of Early Pain: Mechanical causes include patellar maltracking, patellar clunk or crepitus, tibiofemoral instability, periprosthetic fracture, or occult implant loosening [141]. * Patellar Problems: Usually evident on physical examination with pain restricted to the patellofemoral joint, reduced knee range of motion, and flexion issues [141]. * Patellar Clunk: A complication of posterior-stabilized TKA where a fibrous nodule at the inferior pole of the patella catches in the trochlear groove during knee extension [141]. * Patellar Crepitus: More common with current posterior-stabilized designs and may cause anterior knee pain [141]. * Patellar Maltracking/Subluxation: May result from dehiscence of the medial retinacular arthrotomy, femoral or tibial component internal rotation, or patellar component malpositioning [141]. Symptomatic patellar subluxation or maltracking resulting from internal rotation of the femoral or tibial components requires revision of the malaligned components [141].

Instability and Dislocation: * Flexion Instability: A history of pain and effusion that occurs after activity and is relieved with rest is consistent with flexion instability [141]. Caused by intact but attenuated soft-tissue constraints, it is detected on physical examination by varus and valgus stress testing, with laxity typically more evident in flexion than full extension [141]. It is more common with cruciate-retaining TKA than posterior-stabilized designs and is associated with paradoxic motion or rolling forward of the femoral implant [141]. * Complete Dislocation: Presents with gross instability in flexion on physical examination and posterior displacement of the tibia on the femur [141]. It is more common when excessive posterior slope occurs with the tibial cut and with some posterior-stabilized designs [141].

Late Pain: Pain developing late after TKA is more often associated with loosening or ultra-high-molecular-weight polyethylene wear, although late hematogenous infection should be included in the differential diagnosis [141]. Wear can be seen radiographically as asymmetric height of the tibial plateaus, although rotation and flexion of the knee can alter projected height, making radiographic measurements inaccurate [141]. Loosening occurs when subsidence or displacement of the component or a complete or progressive radiolucency at the implant and bone interface occurs [141].

Investigations

Plain radiography

Standard views: Weight-bearing anteroposterior (AP) and lateral views are standard for the initial evaluation of knee pain [21]. The standard radiographic evaluation also includes a weight-bearing knee flexed at a 45-degree angle imaged posterior to anterior with the X-ray plate parallel to the tibia, a sunrise (Merchant) view, and extension and flexion lateral views [21].

Limb alignment: A standing full-length AP radiograph from the hip joint to the ankle joint is used to evaluate limb alignment and knee deformity [21]. This view identifies femoral and/or tibial bone deformity, whether developmental or traumatic [21].

Osteoarthritis grading: The Kellgren-Lawrence (KL) grading system is the most commonly seen grading system for osteoarthritis severity in exam testing [21]. KL grading is based on review of the AP knee radiograph [21]. Primary features include osteophytes (periarticular and tibial spine) and joint space narrowing [21]. Additional features are subchondral sclerosis with or without subchondral cysts, and altered shape of periarticular bones such as flattening of condylar bone contours or articular bone loss [21].

KL grades: KL Grade 0 indicates normal knee features with no osteoarthritis [21]. KL Grade 1 indicates osteoarthritis is possibly present [21]. KL Grade 2 indicates osteoarthritis is present with minimal severity [21]. KL Grade 3 indicates osteoarthritis is present with moderate severity [21]. KL Grade 4 indicates osteoarthritis is present with severe features including prominent osteophytes, absent joint space, subchondral bone sclerosis with cysts, and bone deformity [21].

Prognostic value: Patients with mild radiographic osteoarthritis gain less from total knee arthroplasty compared to those with severe osteoarthritis [140]. Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty compared with severe osteoarthritis [140]. Low grading of the severity of knee osteoarthritis pre-operatively is associated with a lower functional level after total knee replacement [161]. Low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively [161]. Severe arthritis predicts greater improvements in function following total knee arthroplasty [156]. Radiographic severity of arthritic changes can predict knee-specific functional improvement following total knee arthroplasty [156]. The extent of global functional improvement following total knee arthroplasty cannot be predicted by radiographic severity [156]. Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect [130]. Radiographic findings including joint space narrowing were significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [145].

Post-operative surveillance: Routine radiographic surveillance did not detect any true abnormalities during the first year after primary total joint arthroplasty [154]. A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy [158].

MRI

Indications and limitations: MRI is grossly overused in the arthritic patient population [21]. If the joint space is significantly narrowed on radiograph, MRI is not indicated for osteoarthritis evaluation [21]. MRI is used when osteonecrosis is suspected in the knee [21]. Routine screening for osteonecrosis is not necessary, but patients with persistent hip or knee pain should be assessed with MRI [149]. MRI has lower sensitivity and specificity in children than in adults for detecting meniscal tears due to greater meniscal vascularity in children [87]. MRI has been found to underestimate the size of articular cartilage defects in approximately 75% of cases [79].

Periprosthetic evaluation: MRI has utility in working up a painful arthroplasty when history, physical examination, and other diagnostic utilities fail to provide answers [20]. MRI and SPECT/CT demonstrate the highest diagnostic accuracy for aseptic knee arthroplasty loosening, based on low certainty of evidence [127]. There is preliminary evidence that MRI has noteworthy value in distinguishing suspected periprosthetic joint infection in patients with total knee arthroplasty, but specific MRI features lack consensus and standardization [144].

Pre-operative planning: Thorough preoperative investigation, especially MRI, is required to determine the role of each patellar layer to make decisions regarding fusion, preservation, removal, or resurfacing in total knee arthroplasty for secondary osteoarthritis [152]. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease, should be part of the pre-operative assessment for non-dysplastic knees in joint replacement [143].

CT

Pre-operative planning: Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [21].

Bone scan

SPECT/CT: The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven [147]. 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 [163].

Tomosynthesis

Periprosthetic defects: 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 [153].

Other Considerations

Clinical assessment: Patient assessment of knee pain includes a physical examination and diagnostic radiographic modalities [21]. Pain with weight bearing, aggravated by stairs, inclines, and transition from sit to stand, is part of the clinical presentation of knee arthritis [21]. A knee thrust indicates ligament stretch-out on the convex side of the thrust and is seen later in clinical presentation [21]. A varus thrust causes the knee to push outward during the stance phase of gait, overloading the medial compartment and accelerating cartilage degeneration [21]. A valgus thrust causes the knee to push inward during the stance phase of gait, overloading the lateral compartment and accelerating cartilage degeneration [21].

Prognostic and phenotypic factors: Obese patients have less improvement in outcomes with total knee arthroplasty [5]. Advancements in total knee arthroplasty require a multifaceted approach that recognizes variations in knee morphometry and phenotypes [4]. In the setting of 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 [155]. The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for total hip arthroplasty, but not for total knee arthroplasty [142].

Treatment

Non-Operative

Nonoperative management leads to clinical improvement in only a third of patients with flexion instability after primary TKA [115]. For knee osteoarthritis (KOA), total knee replacement plus a 12-week nonsurgical treatment program is more effective than nonsurgical treatment alone, though it is associated with more serious adverse events [103]. Total knee replacement plus physical and medical therapy serves as an adjunct treatment to optimize non-surgical management in patients with KOA [86].

Operative

Indications: Total knee arthroplasty (TKA) is the mainstay of surgical approaches for advanced arthritis and provides substantial improvements in pain, function, and patient satisfaction with excellent survivorship after failure of conservative care [25]. It is highly cost-effective [25]. Indication criteria are based on limited evidence [14]. TKA should be considered the last surgical option for unicompartmental osteoarthritis [9]. High BMI is not a contraindication when TKA is used for appropriate indications [44]. TKA among nonagenarians can be performed safely with acceptable perioperative morbidity and mortality [105].

Surgical Approach / Technique: Minimally invasive techniques are encouraged based on a meta-analysis showing better outcomes compared to the standard invasive medial parapatellar approach [8]. There is no single 'best' way to perform TKA [7]. For the vast majority of patients, standard conventional TKA with familiar approaches and components leads to satisfactory long-term outcomes [7]. The femoral component should never be internally rotated, as this results in relative lateral tilt of the patella and inward-facing patellar groove [125]. The goal is slight external rotation to center the patellar groove under the patella and create a rectangular (balanced) flexion gap [125]. External rotation compensates for native proximal tibia varus (average 3 degrees) to avoid a trapezoidal (unbalanced) flexion gap [125]. A trapezoidal gap causes kinematic conflict, lateral patellar tilt, lateral instability, and medial stiffness [125]. A rectangular gap ensures central patella tracking, stability, and no stiffness [125]. Five techniques determine proper femoral component rotation: AP axis, epicondylar axis, posterior condylar axis, tibial alignment axis, and gap balance axis [125].

Implant Selection: Cruciate-retaining (CR) and posterior-stabilized (PS) TKA techniques provide good results with no difference in complications, range of motion, patient-reported outcome scores, or implant survivorship [25]. There is no difference in outcomes between PS and CR designs [5]. Bicruciate retaining (BCR) arthroplasty preserves proprioception and kinematics but has limited adoption due to high early failure rates in some studies [25]. Mobile bearing implants are viable but do not demonstrate improved survivorship compared to fixed-bearing implants [25]. There are no significant differences in pain, function, quality of life, complication, or revision rates between fixed-bearing and mobile bearing designs [25]. All-polyethylene or metal-backed monoblock tibial components show good long-term outcomes and are reasonable options [25]. There is no difference in outcomes with all-polyethylene or modular tibial components [5]. Debate remains over patellar resurfacing, with studies showing good outcomes with and without it [25]. There is no difference in pain or function with or without patellar resurfacing [5].

Alignment / Balancing Strategy: There is no difference in functional outcomes at 2 years when comparing mechanical and kinematic alignment techniques [25].

Pain Management: Multimodal analgesia is the standard for perioperative pain management, integrating various drugs to minimize opioid consumption and enhance efficacy [98]. Implementation increases patient satisfaction, decreases pain scores, and facilitates faster recovery [114]. A multimodal protocol including local anesthetic infiltration offers improved pain control and minimal side effects [88]. Local infusion analgesia using an intra-articular double lumen catheter provides clinically significant analgesic effects and rapid recovery [99]. Periarticular local anesthetic infiltration decreases pain and opioid use [5]. Peripheral nerve blockade decreases postoperative pain and opioid requirements [5]. There is no benefit of adductor canal block compared with anterior local infiltration analgesia [121]. Local infiltration analgesia may be used as the primary option for multimodal postoperative pain management in patients undergoing primary TKA with spinal anesthesia [121]. Administration of IV or oral acetaminophen does not increase complication risk [6]. Oral NSAIDs administered preoperatively and/or early postoperatively reduce pain and opioid consumption [6]. IV ketorolac administered preoperatively, intraoperatively, or within 24 hours postoperatively reduces pain and opioid consumption within the first 48 hours [6]. There is no evidence to support routine use of gabapentinoids for acute pain management following TKA [122].

Adjuncts: Tranexamic acid decreases postoperative blood loss and reduces transfusion needs [5]. Intravenous and topical administration are both effective [5]. Tranexamic acid has no increased risk of venous thromboembolic events in patients with a history of thromboembolic disease [4]. It has no increase in cardiovascular events, including myocardial infarction, ischemic stroke, and death [4]. It is safe in high-risk populations, including those with history of myocardial infarction, stroke, coronary artery bypass graft, coronary artery stent, or prothrombotic states [4]. Contraindications include known anaphylaxis, seizure disorder, and known defective color vision [4]. Evidence supports not using intraoperative navigation because there is no difference in pain or complications [5]. Evidence supports not using patient-specific instrumentation (PSI) compared to conventional instrumentation because there is no difference in pain or functional outcomes [5]. Evidence supports not using a drain because there is no difference in complications or outcomes [5]. Use of a tourniquet increases short-term postoperative pain [5]. Continuous passive motion does not improve outcomes [5].

Setting of Care: Rehabilitation started on the day of TKA reduces the length of hospital stay [5].

Revision: Revision TKA is challenging, requiring comprehensive understanding of anatomy and techniques to achieve good outcomes [28]. It presents technical challenges requiring careful preoperative planning, meticulous technique to preserve host bone, and attention to gap balancing [32]. Appropriate metaphyseal fixation is crucial for stability and implant support [118]. Revision with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation [134]. Short-term stable fixation with sleeves is helpful as more patients undergo revision with greater bone loss [134]. At 24 months, cemented and hybrid-fixation replacements are equally stable [128]. Modular knee arthroplasties offer intraoperative customization and improved fixation but carry potential for failure (disengagement or fracture) at the modular junction [133]. Revision TKA with intramedullary femoral stems engaging the diaphysis can stabilize fractures [23]. Commercially available metaphyseal sleeves and trabecular metal cones manage capacious metaphyseal defects [23]. Implants with increased varus–valgus constraint and hinged implants should be available due to common ligamentous insufficiency [23]. In cases with insufficient bone support even with diaphyseal stems, a modular megaprosthesis (distal femoral replacement) is performed [23]. Cement fixation is typically used with modular megaprosthesis for massive bony defects [23]. Surgeons should be experienced in arthroplasty and fracture management [23]. Routine preoperative evaluation for revision secondary to periprosthetic fracture includes CBC with differential, sedimentation rate, C-reactive protein, serologies, and knee aspiration to exclude occult infection [23]. The original operative note should be obtained if available [23]. Prior incisions should be used as best as possible [23]. Care must be taken to prevent narrow skin bridges between connecting incisions and to develop full-thickness flaps [23]. The status of the extensor mechanism is important for treatment and prognosis and should be determined during evaluation [23]. Revision of femoral components typically requires metal augmentation due to bone deficiency from component removal [23]. Stems should be used routinely, engaging the femoral diaphysis for alignment and fixation [23]. Simultaneous revision and contralateral primary TKA is a safe and favorable alternative to staged procedures [43].

Other Considerations: Conversion of a fused knee to TKA results in good long-term fixation and high patient satisfaction [116]. When soft-tissue sleeves in a previously fused knee are preserved intraoperatively, they provide adequate stability after TKA with a posterior stabilized prosthesis [123]. This makes a posterior stabilized prosthesis a reasonable alternative to more constrained implants for conversion of a fused knee [123]. A well-structured, algorithmic approach is essential in managing patients with a painful TKA to correctly diagnose and optimize outcomes [11]. Total knee replacement cannot be seen as an isolated intervention without considering other factors contributing to outcomes [17].

Technology and Techniques: No studies have convincingly shown that minimally invasive techniques or newer technologies, such as PSI, lead to improved outcomes or decreased complications [25]. Navigated knee replacement provides few advantages over conventional surgery based on radiographic endpoints [16]. 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 [4]. Custom cutting guides do not improve clinical outcomes at 2 years followup [24].

Fixation: Modern noncemented TKA implants show survivorship and functional outcomes equivalent to cemented prostheses [25]. There is no evidence that fixation techniques alone affect durability when design-related failure is excluded [110]. Uncemented fixation with titanium fiber mesh coating of the femoral component 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 differences were not clinically relevant [136]. Primary knee fixation type (cemented or noncemented) did not influence surgical duration or costs of implant revision surgery for mechanical complications [119]. Similar functional outcomes and complication rates exist in tibial component fixation that is cemented or cementless [5].

Complications

Infection and Reoperation

Infection (PJI): Periprosthetic joint infection (PJI) incidence after primary total knee replacement ranges from 0.4% to 2% [172], with absolute case numbers projected to rise due to increasing arthroplasty volumes [172]. PJI remains a serious complication [190], with rates in developing countries not statistically significantly higher than in high-income nations [191]. Patients with rheumatoid arthritis have significantly higher deep infection rates than osteoarthritis patients, though superficial rates are similar [189]. Primary TKA in patients with resolved prior sepsis carries a 9.7% periprosthetic infection risk [168], and a history of PJI predisposes to subsequent PJI in primary THA or TKA [173]. Aseptic reoperation within 1 year of primary TKA significantly increases subsequent PJI risk [174]. Perioperative vancomycin prophylaxis appears effective in decreasing PJI rates and may result in less virulent organisms if infection occurs [184]. PJIs are increasing, driven by both primary volume and early (<90 days) occurrences [185]. Revision arthroplysis carries higher infection rates than primary replacements [180] and is cost-intensive [180]. Repeat two-stage revision for recurrent knee PJI yields low infection control and major morbidity, including a 23% amputation rate [186]. Prior knee surgery predisposes to higher postoperative complication rates in primary TKA compared to no prior surgery [162].

Venous Thromboembolism (VTE) and Cardiovascular Events

Thromboembolism: At one institution, 1% of primary total joint arthroplasty patients accessed the ED for DVT concern at substantial cost, with few testing positive [146]. Prior VTE significantly increases 90-day DVT, PE, and 2-year PJI risk after TKA [170]. DVT is common in patients >60 years post-TKA, with multivariable influences on pathogenesis [178]. In 3512 primary TJA patients treated with ASA, 90-day VTE cumulative incidence was <1% [176]. No differences in DVT incidence, location, or characteristics were found with or without pharmacological prophylaxis [181]. Prospective use of first-generation AAOS guidelines resulted in low clinically important thromboembolic events [164]. Alcohol use disorder is significantly associated with VTE development, longer stays, and higher costs after primary TKA [182].

Revision Indications and Outcomes

Aseptic loosening: Revisions for osteolysis and polyethylene wear were more common in TKAs performed prior to 2000, while infection and instability revisions were higher post-2000 [151]. Revisions within 24 months of primary arthroplasty have higher any-cause failure rates [150]. Early post-operative morbidity after aseptic knee revisions is similar to primary procedures [157]. Survivorship of aseptic conversion TKA is similar to primary TKA for up to 10 years and better than first-time revision TKA [159]. Isolated and full component revision for aseptic loosening show no difference in prosthesis failures, complications, or clinical results at 5 years [160]. Cum incidence of subsequent revision for aseptic loosening/instability is very low at 5 years with fixed-bearing VVC implants in revision TKAs [165]. No difference in aseptic revision risk exists for index knees comparing patients with prior primary arthroplasty in a different joint versus no arthroplasty history [167]. Revision free survivorship and arthroplasty-related complications at 2 years following revision UKA are lower than primary TKA but higher than aseptic revision TKA; medical complications are similar to primary TKA [177]. Patients undergoing urgent revision (infection/fracture) face higher mortality and serious adverse events than primary or elective revision patients [197]. Revision knee replacement rates after ~7 years range from 4.3% to 8.0% [199]. Revision TKA yields similar QALY gain as primary TKA [204].

Implant-Specific and Technical Complications

Instability: Primary TKA using high-viscosity cement is associated with higher odds of revision for aseptic loosening [169]. Meta-regression raises concerns for significant revision risk with extended follow-up (>5 years) using varus-valgus constraint in primary TKA [200]. Ten-year survivorship free from aseptic loosening was 95% after TKA following distal femoral osteotomy, though complication rates were high due to balancing problems [179]. Bearing spin-out can occur with mobile bearing implants in the presence of a loose flexion gap [25]. Early failure of cementless mobile-bearing TKA is associated with obesity [25]. Problems with cementless TKA have been reported at 11 years followup [25].

Patient-Specific Risk Factors

Polyethylene wear: Obese patients experience less improvement in outcomes with TKA [5]. The impact of BMI on 90-day infection risk differs between primary total hip and knee arthroplasty [192]. Patients with CVA sequelae have a 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA [171]. Pooled data from nine epidemiological studies (>140,000 total hip and knee replacements) indicate no apparent increase in cancer risk following total joint arthroplasty compared to the general population [194].

Other Considerations

Evidence regarding perioperative management complications is not provided in the source data.

Recovery

Light activity (weeks): Patients undergoing primary total knee arthroplasty (TKA) return to driving considerably earlier than previously reported [31]. Return to driving 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, provided the patient drives at low or moderate speed; step counts are the best predictor of safe driving [57]. Advice regarding return to driving should be individualized, with the ultimate determination resting on the patient’s ability to feel safe and maintain legal control of the vehicle [81]. Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery [85].

Full activity (months): Most patients resume physical activity or sports within a short timeframe, particularly low-impact activities [193]. Functional recovery after unicompartmental knee replacement continues beyond 6 months and up to 2 years [183]. For occupational return, 86% of patients return to duty following total joint arthroplasty [108]. If working pre-operatively, patients aged < 50 years invariably return to work, whereas only half of those aged 50 to 60 years return [129]. Second-generation ACI successfully returned 78% of patients with moderate to very heavy occupational demand to work with significantly decreased patient-reported knee pain [120].

Complete recovery / outcome plateau (months): Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty [132]. Patients demonstrate a response shift in the measurement of their outcome at six months postoperatively [92]. Cardiovascular fitness shows a trend toward improvement one year after TKA and significant improvement two years postoperatively for patients resuming routine functional activities [195].

Rehabilitation protocol: Early physical activity parameters for patients following the outpatient surgery pathway are similar to those following the standard enhanced recovery pathway [94]. Future rehabilitation protocols should consider both the replaced knee and the non-replaced knee and surrounding joints [93]. Clinically, functional improvements may be assessed by objectively measuring changes in low-intensity activity behaviors [109]. While prehabilitation has potential to optimize outcomes, further research from diverse populations is essential to establish robust evidence-based clinical guidelines and uncover optimal interventions for at-risk populations [106].

Key Evidence

• [L2] The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient. [1] (10.1016/j.arth.2024.10.056)
• [L5] The goal of total knee arthroplasty remains delivering the best possible outcome for each individual patient, whether through restoring the native knee or creating the optimal prosthetic knee. [2] (10.1002/ksa.70147)
• [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. [4] (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. [7] (10.1016/j.arth.2020.04.031)
• [L1] The present meta-analysis encourages the use of minimally invasive techniques for total knee arthroplasty. [8] (10.1007/s00167-020-06306-9)
• [L5] Total knee arthroplasty should be considered as the last surgical option. [9] (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. [11] (10.5435/jaaos-d-18-00083)
• [L2] The indication criteria for THA/TKA are based on limited evidence. [14] (10.1186/s12891-016-1325-z)
• [L1] Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. [16] (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. [17] (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. [20] (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. [22] (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. [27] (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. [28] (10.1302/2058-5241.1.000024)
• [L5] The knee implant designs investigated did not replicate the kinematics of a healthy knee. [29] (10.2106/jbjs.h.00817)
• [L3] Although combined flexion influences knee biomechanics, its direct impact on clinical outcomes remains unclear. [30] (10.1002/ksa.12660)
• [L2] Overall, patients undergoing primary TKA returned to driving considerably earlier than previously reported. [31] (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. [32] (10.5435/00124635-201106000-00001)
• [L5] Mechanical alignment seems to result in more balanced load distribution and kinematics more closely resembling the native knee. [33] (10.1007/s00167-020-05996-5)
• [L4] Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years. [35] (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. [36] (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. [37] (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. [38] (10.2106/00004623-200300001-00006)
• [L1] The kinematics of CS and CR TKJR are comparable. [39] (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. [40] (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. [41] (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. [42] (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. [43] (10.2106/00004623-200310000-00020)
• [L3] When TKA was used for appropriate indications, high BMI should not be considered as a contraindication. [44] (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. [45] (10.1007/s00167-015-3514-y)
• [L3] The BCS cohort showed expected knee joint kinematics. [46] (10.2106/jbjs.20.00024)
• [L2] Furthermore, the considerable difference between TKA design and the kinematics of healthy knee were highlighted in this study. [48] (10.1186/s42836-023-00165-8)
• [L5] These results confirm the importance of tibiofemoral conformity in preserving native knee kinematics. [49] (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. [50] (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. [51] (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. [52] (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. [53] (10.1007/s00167-018-5174-1)
• [L2] Tibial slope does not contribute significantly to knee kinematics after total knee arthroplasty. [54] (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. [55] (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. [57] (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. [58] (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. [60] (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. [61] (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. [62] (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. [63] (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. [64] (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. [66] (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. [67] (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. [68] (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. [69] (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. [70] (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. [71] (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. [72] (10.1007/s00167-006-0196-5)
• [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. [75] (10.1007/s00167-021-06687-5)
• [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. [81] (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. [82] (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. [83] (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. [84] (10.1016/j.arth.2019.09.018)
• [L1] Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA. [85] (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. [86] (10.1186/1471-2474-13-67)
• [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. [88] (10.2106/jbjs.e.00173)
• [L4] This novel hinged knee system is a highly durable option for complex and revision knee arthroplasty. [89] (10.1016/j.arth.2019.12.024)
• [L3] Both knee systems showed good clinical results at 2 years postoperatively. [91] (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. [92] (10.2106/jbjs.f.00283)
• [L3] Future rehabilitation protocols should consider the replaced knee and also the non-replaced knee and surrounding joints. [93] (10.1016/j.arth.2015.06.052)
• [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. [94] (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. [95] (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. [96] (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. [97] (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. [98] (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. [99] (10.1007/s00167-012-2004-8)
• [L5] The Kujala scores for all implant types showed improvement and no difference between types, and the Knee injury and Osteoarthritis Outcome Score (KOOS) showed minimal and likely clinically unimportant differences between implant types. [100] (10.2106/jbjs.22.01169)
• [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. [103] (10.2106/jbjs.16.00208)
• [L3] Total knee arthroplasty among nonagenarians can be performed more safely than previously reported with a perioperative morbidity and mortality that is acceptable to both patient and surgeon. [105] (10.1016/j.arth.2014.09.017)
• [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. [106] (10.1016/j.arth.2024.12.021)
• [L3] Eighty-six percent of patients return to duty following total joint arthroplasty. [108] (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. [109] (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. [110] (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. [114] (10.2106/jbjs.19.01035)
• [L4] Nonoperative management led to clinical improvement in only a third of patients with flexion instability after primary TKA. [115] (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. [116] (10.2106/jbjs.25.00149)
• [L4] Appropriate metaphyseal fixation is crucial for stability and implant support in revision total knee arthroplasty. [118] (10.2106/jbjs.24.01094)
• [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. [119] (10.5435/jaaos-d-23-01184)
• [L4] Second-generation ACI successfully returned 78% of patients with moderate to very heavy occupational demand to work with significantly decreased patient-reported knee pain. [120] (10.1177/0363546518800713)
• [L1] LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia. [121] (10.2106/jbjs.22.00745)
• [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. [122] (10.2106/jbjs.15.01202)
• [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. [123] (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. [126] (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. [127] (10.1002/ksa.12206)
• [L1] At 24 months after revision TKAs, cemented and hybrid-fixation replacements were equally stable. [128] (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. [129] (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. [130] (10.2106/jbjs.17.01657)
• [L4] Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty. [132] (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. [133] (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. [134] (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. [135] (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. [136] (10.1007/s00167-020-06028-y)
• [L1] Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. [140] (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. [142] (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. [143] (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. [144] (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. [145] (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. [146] (10.5435/jaaos-d-20-00878)
• [L3] The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven. [147] (10.1177/2325967116s00051)
• [L3] Routine screening is not necessary, but patients with persistent hip or knee pain should be assessed with MRI. [149] (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. [150] (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. [151] (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. [152] (10.1016/j.jisako.2022.01.004)
• [L5] 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. [153] (10.1016/j.arth.2014.05.013)
• [L4] Routine radiographic surveillance did not detect any true abnormalities during the first year after primary total joint arthroplasty. [154] (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. [155] (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. [156] (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. [157] (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. [158] (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. [159] (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. [160] (10.1016/j.arth.2022.09.006)
• [L3] A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively. [161] (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. [162] (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. [163] (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. [164] (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. [165] (10.1302/0301-620x.102b4.bjj-2019-0719.r2)
• [L3] No difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history. [167] (10.1016/j.arth.2022.08.007)
• [L3] 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] (10.1016/j.arth.2014.01.013)
• [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. [169] (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. [170] (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. [171] (10.1016/j.arth.2022.06.026)
• [L3] A history of PJI predisposes patients to subsequent PJI in primary THA or TKA. [173] (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. [174] (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. [176] (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. [177] (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. [178] (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. [179] (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. [180] (10.1155/2018/8987104)
• [L3] No differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis. [181] (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. [182] (10.5435/jaaos-d-20-00466)
• [L3] Functional recovery after unicompartmental knee replacement continues beyond 6 months and even up to 2 years. [183] (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. [184] (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. [185] (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. [186] (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. [188] (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. [189] (10.1007/s00167-016-4306-8)
• [L2] PJI remains a serious complication of arthroplasty. [190] (10.1302/0301-620x.101b1.bjj-2018-0233.r1)
• [L2] The incidence of PJI in this setting was not statistically significantly higher than rates reported in high-income countries. [191] (10.1016/j.jisako.2026.101074)
• [L4] The impact of Body Mass Index on the risk of postoperative 90-day infection differs between primary total hip and knee arthroplasty. [192] (10.1016/j.arth.2026.04.078)
• [L4] Most patients can expect to resume physical activity or sports within a short timeframe after knee arthroplasty, particularly to low-impact activities. [193] (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. [194] (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. [195] (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. [197] (10.1302/0301-620x.103b10.bjj-2020-2590.r1)
• [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. [199] (10.2106/00004623-199906000-00004)
• [L1] Meta-regression estimates raise concerns for significant revision risk with extended follow-up, especially beyond 5 years. [200] (10.1016/j.arth.2019.09.048)
• [L2] Revision total knee arthroplasty results in a similar QALY gain as primary total knee arthroplasty. [204] (10.1002/ksa.12343)

See Also

• Anterior Cruciate Ligament
• Biomechanics
• Anatomy

References

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