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 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, standard conventional total knee arthroplasty using a familiar surgical approach and standard components yields satisfactory long-term clinical outcomes [7]. However, there is no single 'best' way to perform the procedure [7]. Consequently, total knee arthroplasty should be considered only as the last surgical option [9].

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 kinematic total knee arthroplasty have been maintained after a minimum follow-up duration of ten years [73].

Revision total knee arthroplasty is typically reserved for specific complex scenarios, including fractures around a loose prosthesis, fractures with inadequate bone stock for stable internal fixation, or recalcitrant supracondylar nonunions requiring resection and megaprosthesis implantation [23]. Bony defects, areas of osteolysis, osteopenia, and short periarticular fragments pose significant challenges to successful revision arthroplasty [23].

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 ACL attaches to the posteromedial aspect of the lateral femoral condyle, divided by the bifurcate ridge [34]. Its 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 [34]. The ACL consists of two bundles: * Anteromedial bundle: Originates proximal to the bifurcate ridge, is tight in flexion, and primarily resists anterior tibial translation [34]. * Posterolateral bundle: Originates distal to the bifurcate ridge, is tight in extension, and primarily resists rotatory loads [34]. This bundle measures 30 mm in length and 11 mm in diameter [34].

The ACL is composed of 90% type I collagen and 10% type III collagen [34].

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

Medial Compartment Stabilizers: * Superficial Medial Collateral Ligament (sMCL): The proximal division resists valgus tibial translation [34]. The distal division resists tibial external rotation in knee extension and internal rotation [34]. * Deep MCL: Resists valgus translation and tibial internal and external rotation [34]. * Posterior Oblique Ligament: Resists tibial internal rotation, especially in knee extension [34].

Lateral Compartment Stabilizers: * Lateral Collateral Ligament (LCL): Resists varus tibial translation and external rotation, especially at 30 degrees of knee flexion [34]. * Popliteus Tendon: Resists tibial external rotation, especially in knee flexion, and varus tibial translation [34]. * Popliteofibular Ligament: Resists tibial external rotation, especially in knee flexion, and posterior tibial displacement [34]. * Oblique Popliteal Ligament: Resists knee hyperextension and varus tibial translation [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 is a frequent cause of hemarthrosis [65]. The recurrence rate following a first-time patellar dislocation is between 15% and 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 termed "miserable malalignment syndrome" [65]. 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 classifies trochlear dysplasia [65].

Tibial Tubercle–Trochlear Groove (TT–TG) Distance: This measures the lateralization of the tibial tubercle [65]. * Normal: 9 to 13 mm [65]. * Questionably abnormal: 15 to 20 mm [65]. * Highly associated with patellar instability: Over 20 mm [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 dislocation [65]. The Schottle point is used to identify the femoral attachment of the MPFL, located 1 mm anterior to the posterior cortex extension line and 2.5 mm distal to the posterior origin of the medial femoral condyle [65].

Surgical Management of Patellar Instability: * Proximal realignment: Typically involves MPFL reconstruction using a gracilis or semitendinous tendon [65]. * Distal realignment: Typically involves tibial tubercle anterior medialization and is indicated for patients with an increased Q angle or a TT-TG distance exceeding 20 mm [65]. Proximal arthrosis of the medial patellar facet is a contraindication to distal realignment [65]. * Contraindication: Isolated lateral release should not be performed for patellar instability [65].

Patellofemoral pain syndrome is an extremely common cause of anterior knee pain, particularly in adolescents, and is made worse by activities that increase compressive loads on the patellofemoral joint [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 presentation of knee arthritis [21]. A knee thrust indicates ligament stretch-out on the convex side of the thrust [21].

Gait Thrusts: * Varus thrust: Occurs when the knee pushes outward during the stance phase of gait, overloading the medial compartment and accelerating cartilage degeneration [21]. A varus thrust increases the adductor moment of force (AMoF) [21]. * Valgus thrust: Occurs when the knee pushes inward during the stance phase of gait, overloading the lateral compartment and accelerating cartilage degeneration [21]. A valgus thrust increases the abductor moment of force [21].

Alignment Techniques and Kinematics¶

Alignment Strategies: * Mechanical alignment: Aims to create a neutral mechanical limb line (Mikulicz) to provide symmetrical implant loading and minimize overload [76]. In mechanical alignment, the distal femoral bone cut is made perpendicular to the mechanical axis of the femur (mLDFA = 90 degrees) [76]. The proximal tibial bone cut is made perpendicular to the mechanical axis of the tibia (mPTA = 90 degrees) [76]. * Kinematic alignment: Aims to maintain native limb alignment, leaving the Mikulicz line unchanged [76]. In kinematic alignment, the distal femoral bone cut is made at the native mLDFA and the proximal tibial cut at the native mPTA [76]. Kinematic alignment does not require ligament balancing in the coronal and sagittal planes [76].

Kinematic Outcomes: * Kinematically aligned knees show greater multi-planar mobility, higher sagittal moments, and a more physiological gait pattern compared to mechanically aligned knees [37]. * Kinematically aligned TKAs more closely resemble the knee kinematics of normal healthy controls than mechanically aligned TKAs [53]. * Mechanical alignment results in more balanced load distribution and kinematics more closely resembling the native knee in patients with constitutional varus [33]. * Static native tibial alignment optimizes whole-body gait kinematics, suggesting that subtle modifications to the knee joint line contribute to widespread kinematic adaptations [27].

Implant Design and Kinematics: * Contemporary knee implant designs do not replicate the kinematics of a healthy knee [29]. * The kinematics of posterior-stabilized (PS) and cruciate-retaining (CR) total knee arthroplasties are comparable [39]. * The PS design provides significantly better knee flexion kinematics compared to CR designs, with no statistical differences in other kinematic gait parameters [55]. * Medial pivot (MP) designs provide a more native-like knee kinematic profile than CR designs, with a more pronounced MP motion pattern and reduced quadriceps loading [40]. * Retention of the posterior cruciate ligament alone may not achieve physiological knee joint kinematics after TKA [46]. * The morphology of the medial tibial insert produces a small but noticeable effect on knee kinematics in medial pivot prostheses [42]. * Tibial slope does not contribute significantly to knee kinematics after total knee arthroplasty [54]. * Combined flexion influences knee biomechanics in robotic TKA, but its direct impact on clinical outcomes remains unclear [30]. * Knee kinematics and muscle activation do not appear to change in the first 2 post-operative years after implantation of a highly congruent mobile-bearing prosthesis [35]. * Nearly normal kinematics can be preserved, and shear stresses at the component-cement-bone interface minimized, when non-constrained prostheses are utilized [41]. * Kinematics is not the only or most relevant parameter to predict or explain knee function after TKA [45]. * The considerable difference between TKA design kinematics and healthy knee kinematics is highlighted in systematic reviews [48]. * Anatomy-mimetic design preserves natural kinematics of the knee joint in patient-specific mobile-bearing unicompartmental knee arthroplasty through tibiofemoral conformity [49]. * Native rotational knee kinematics is restored after lateral UKA but not after medial UKA [52].

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: * Flexion gap: Controlled by the posterior cut of the femur, the tibial cut, and the PCL [56]. * Extension gap: Controlled by the distal cut of the femur, the tibial cut, and the posterior capsule [56].

Gap Modification: * The flexion gap can be increased by cutting more posterior femur, cutting more proximal tibia, or removing (recessing) 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].

Correction Principles: * The rule for gap correction is that 2 mm of bone removal equals a 10-degree contracture correction [56]. * The STAF mnemonic guides gap balancing: Symmetrical gap problems are addressed by tinkering with the Tibia first, while Asymmetrical gap problems are addressed by tinkering with the Femur first [56].

Osteolysis and Implant Failure Pathophysiology¶

Osteolysis occurs late in the lifecycle of a TKA implant, typically at 13 to 15 years [104]. Clinical presentation includes a gradual increase in knee effusion, mild to moderate joint warmth, and gradual increase in weight-bearing pain [104]. Evaluation shows normal serum infection biomarkers (CRP and sedimentation rate) and negative aspiration [104]. Radiographs show round lytic lesions behind implants, most commonly behind the posterior femur [104].

Pathogenesis: * The initial cause is submicron shedding of microparticulate polyethylene (PE) debris that invades surrounding bone [104]. * Macrophages are stimulated by phagocytosis of submicron-sized PE wear particles [104]. * Macrophages release TNFα, IL-1β, and IL-6 in response to PE wear particles [104]. * Osteophytes up-regulate RANKL production in response to wear debris [104]. * RANK on osteoclast progenitors mediates osteoclast differentiation and increase in number, leading to bone resorption [104]. * Smaller wear particles (<10 μm) are more readily absorbed by macrophages, which release cytokines signaling osteoclasts to resorb bone [101].

Wear Factors: UHMWPE wear rate is affected by sterilization method, manufacturing method, third-body debris, motion between the tibial insert and metal tray, femoral implant roughness, alignment/stability, and patient activity level [101]. PMMA cement debris can contribute to osteolysis through motion between the implant and cement due to loosening or debonding [101]. Osteolysis can result in expansile bone defects and substantial compromise of femoral condyle and tibial metaphysis bone stock [101]. Femoral osteolysis is often located in the posterior condyles and obscured by the implant on AP radiographs, whereas tibial lesions are more readily visible [101]. Limb malalignment causes asymmetric loading, which can result in early loosening, occurring more frequently with varus malalignment than valgus [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].

Instability Mechanisms: * Flexion instability: Can develop after surgery despite appropriate gap balancing, often due to ACL sacrifice resulting in paradoxical motion or anterior subluxation of the femur on the tibia in flexion [101]. * Mediolateral instability: May result from loss of collateral ligament support due to intraoperative laceration, postsurgical trauma, or gradual attenuation from polyethylene wear [101].

Periprosthetic Fractures¶

Distal Femur Fractures: The incidence of periprosthetic fracture of the distal femur in TKA is 0.3% to 2.5% [117]. The incidence is higher after revision TKA [117]. Risk factors include rheumatoid arthritis, neurologic disorders, chronic steroid therapy, osteopenia/osteoporosis, anterior femoral notching, and osteolysis with bone loss [117]. Anterior femoral notching weakens the anterior femur at the bone-component interface and decreases fracture resistance [117].

Tibial Fractures: The incidence of periprosthetic tibial fracture in primary TKA is 0.7% or less [117]. The incidence in revision TKA is 0.9% or less [117]. Risk factors include insertion of a long-stem component, loose tibial component, periprosthetic osteolysis, malalignment, component removal during revision, and tibial tubercle osteotomy [117].

Classification¶

Morphometry and Phenotypes: 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]. Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all TKA systems fit these phenotypes well [97]. 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].

Periprosthetic Fractures: The 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 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 Definitions: 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]. 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: 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]. 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]. Experts propose using thorough literature reviews using the GRADE system to develop conclusive guidance or consensus statements on controversial issues in joint arthroplasty [96]. 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¶

The primary goal of total knee arthroplasty is to ensure the best possible outcome for the patient [1], whether by restoring the native knee or creating the optimal prosthetic knee [2]. Total knee replacement cannot be viewed as an isolated intervention; it requires a multifaceted approach that recognizes variations in knee morphometry and phenotypes [4, 17]. A well-structured, algorithmic approach is essential for correctly diagnosing patients with painful total knee arthroplasty and optimizing clinical outcomes [11].

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]. The source of pain may be difficult to determine, requiring evaluation for infection, neurogenic pain, referred pain from the hip or back, and mechanical sources [141]. Evaluation should include thorough history and physical examination, laboratory studies, and plain radiographs [141]. Additional nuclear medicine studies or specialized imaging may be necessary [141]. Although the role for MRI in the postarthroplasty knee has yet to be clearly defined, its utility is demonstrated when history, physical examination, and other diagnostic utilities fail to provide answers [20].

Infection: Infection is a common source of pain and must be ruled out first in all patients [141]. It is usually associated with an elevated erythrocyte sedimentation rate and C-reactive protein level [141]. Detection via aspiration includes cell count with differential and culture [141]. False-negative and false-positive results can occur [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 resulting from postsurgical rehabilitation [141]. Late hematogenous infection can occur and should be included in the differential diagnosis for late pain [141].

Neurogenic Pain: A history of pain that develops immediately after surgery and persists without a pain-free interval suggests an inflammatory and/or neurogenic source [141]. Pain with rest as well as weight bearing also suggests an inflammatory and/or neurogenic source [141]. Pain described as burning or numbness that is nonfocal on examination supports the diagnosis of neurogenic pain [141]. Neurogenic pain may improve with analgesic medications or those for neuropathic pain, such as gabapentin, pregabalin, and tricyclic antidepressant medications [141]. It may also improve with local trigger point or epidural injections [141].

Mechanical Pain: Pain during weight-bearing activity or knee motion is consistent with a mechanical source [141]. Mechanical causes of early pain include patellar maltracking, patellar clunk or crepitus, tibiofemoral instability, periprosthetic fracture, or occult implant loosening [141]. Patellar problems are usually evident on physical examination because the location of pain is restricted to the patellofemoral joint [141]. Patients may present with reduced knee range of motion and flexion [141]. Patellar clunk is a complication of posterior-stabilized total knee arthroplasty where a fibrous nodule at the inferior pole of the patella catches in the trochlear groove during knee extension [141]. Patellar crepitus is more common with current posterior-stabilized implant designs and may cause anterior knee pain [141]. Patellar maltracking and 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: A history of pain and effusion that occurs after activity and is relieved with rest is consistent with flexion instability [141]. Flexion instability caused by intact but attenuated soft-tissue constraints can be detected on physical examination by varus and valgus stress testing [141]. Laxity in flexion instability is typically more evident in flexion than full extension as the posterior capsule and hamstrings contribute to stability in extension [141]. Flexion instability is more common with cruciate-retaining total knee arthroplasties than with posterior-stabilized total knee arthroplasties [141]. It 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 [141]. 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 [141]. Complete dislocation is more common when excessive posterior slope occurs with the tibial cut and with some posterior-stabilized-designed total knee arthroplasties [141].

Late Pain and Wear: Pain that develops late after total knee arthroplasty is more often associated with loosening or ultra-high-molecular-weight polyethylene wear [141]. Wear can be seen radiographically as asymmetric height of the tibial plateaus [141]. Rotation and flexion of the knee can alter the projected height of the joint space, making radiographic measurements of wear 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].

Residual pain remains a significant concern; 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]. 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 most had a clinically meaningful improvement in WOMAC score [61]. 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]. Persistent pain remains common after total knee arthroplasty and improvement does not equate to cure [69]. 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].

Patient expectations vary; 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]. 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]. The findings on knee arthroplasty design and kneeling kinematics may allow improved management of patients' functional expectations [63]. Definitions of poor outcome after total knee arthroplasty vary widely, highlighting the lack of consensus and the need for standardized definitions to improve comparability across studies [22].

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]. Revision total knee arthroplasty is a challenging procedure requiring a correct diagnosis of the original cause of failure and a detailed plan [58]. 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¶

Plain radiography¶

Initial Evaluation: Weight-bearing anteroposterior (AP) and lateral radiographs are the standard for initial evaluation of knee pain [21]. A weight-bearing knee flexed at a 45-degree angle, imaged posterior to anterior with the X-ray plate parallel to the tibia, is recommended for initial evaluation [21]. A sunrise view (Merchant view) is included in the standard radiographic evaluation of knee pain [21]. Extension and flexion lateral views are included in the standard radiographic evaluation of knee pain [21] [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]. The standing full-length AP radiograph is used to identify femoral and/or tibial bone deformity, whether developmental or traumatic [21].

Osteoarthritis Grading: The Kellgren-Lawrence (KL) grading system grades the extent of osteoarthritis based on review of an AP knee radiograph [21]. Primary features used for KL rating include osteophytes (periarticular and tibial spine) and joint space narrowing [21]. Additional features used for KL rating include subchondral sclerosis with or without subchondral cysts and altered shape of periarticular bones [21]. Altered shape of periarticular bones includes flattening of condylar bone contours and articular bone loss [21]. 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 severity [21]. Knee arthroplasty is recommended when KL Grade 4 findings are present [21].

Prognostic Value: Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis [140]. Patients with mild radiographic osteoarthritis have increased pain and dissatisfaction following total knee arthroplasty compared with those with severe osteoarthritis [140]. 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 of arthritic changes [156]. A low radiological severity of osteoarthritis is associated with a lower functional level after total knee replacement [161]. A low radiological severity of osteoarthritis is not associated with pain 12 months postoperatively [161]. Baseline radiographic severity grade is only associated with future total knee arthroplasty risk in the absence of a full-thickness cartilage defect [130]. Radiographic findings including joint space narrowing are significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [145].

MRI¶

Indications and Limitations: MRI is grossly overused in the arthritic patient population [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]. Routine screening for osteonecrosis is not necessary, but patients with persistent hip or knee pain should be assessed with MRI [149].

Advanced Assessment: Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease, should be part of the pre-operative assessment for non-dysplastic knees [143]. A thorough preoperative investigation, especially MRI, is required to determine the role of each patellar layer to make the correct decision between fusion, preservation, removal, or resurfacing in total knee arthroplasty for secondary osteoarthritis [152].

Post-Arthroplasty Workup: 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 is demonstrated [20]. There is preliminary evidence that MRI has noteworthy value in distinguishing suspected periprosthetic joint infection in patients with total knee arthroplasty, but the definition of specific MRI features related to periprosthetic joint infection diagnosis lacks consensus and standardization [144]. MRI-detected bone marrow lesions are significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [145]. MRI-detected synovitis is significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [145]. MRI-detected effusion is significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [145].

CT¶

Preoperative 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¶

Loosening Assessment: 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 [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¶

Defect Detection: 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].

Aspiration¶

(No evidence provided in source bullets for this modality.)

Laboratory¶

(No evidence provided in source bullets for this modality.)

Other Considerations¶

Postoperative 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].

Perioperative Management and Outcomes: Obese patients have less improvement in outcomes with total knee arthroplasty [5]. Treatment with tranexamic acid decreases postoperative blood loss and reduces the need for postoperative transfusions in total knee arthroplasty [5]. Intravenous and topical application of tranexamic acid are both effective for reducing blood loss in total knee arthroplasty [5]. Tranexamic acid reduces net blood loss and transfusion in arthroplasty procedures without increasing the risk of venous thromboembolic events in patients with a history of thromboembolic disease [5]. Tranexamic acid does not increase the risk of cardiovascular events, including myocardial infarction, ischemic stroke, and death [5]. Tranexamic acid is safe 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]. Tranexamic acid is contraindicated in patients with known anaphylaxis [5]. Tranexamic acid is contraindicated in patients with seizure disorder because lysine competes with glycine receptors in the brain causing disinhibition [5]. Tranexamic acid is contraindicated in patients with known defective color vision because it can exacerbate the condition [5].

Technology and Instrumentation: Evidence supports not using intraoperative navigation in total knee arthroplasty because there is no difference in pain or complications compared to conventional instrumentation [5]. Evidence supports not using patient-specific instrumentation compared to conventional instrumentation for total knee arthroplasty because there is no difference in pain or functional outcomes [5]. Evidence supports not using a drain with total knee arthroplasty because there is no difference in complications or outcomes [5]. Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points [16]. There is no difference in aseptic loosening or revision rates at midterm follow-up comparing standard total knee arthroplasty instrumentation with patient-specific instrumentation, digitally navigated total knee arthroplasty, or robotic-assisted total knee arthroplasty [5].

Implant and Technique Choices: Use of periarticular local anesthetic infiltration in total knee arthroplasty decreases pain and opioid use [5]. Peripheral nerve blockade for total knee arthroplasty decreases postoperative pain and opioid requirements [5]. Use of a tourniquet increases short-term postoperative pain in total knee arthroplasty [5]. Continuous passive motion after knee arthroplasty does not improve outcomes [5]. Rehabilitation started on the day of total knee arthroplasty reduces the length of hospital stay [5]. There is no difference in outcomes or complications between posterior stabilized and posterior cruciate retaining designs in total knee arthroplasty [5]. There is no difference in outcomes with use of all polyethylene or modular tibial components in knee arthroplasty [5]. There is no difference in pain or function with or without patellar resurfacing in total knee arthroplasty [5]. There are similar functional outcomes and complication rates in tibial component fixation that is cemented or cementless [5].

Phenotype and Morphometry: 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]. Femoral component rotational alignment variations across knee phenotypes in image-based robotic-assisted total knee arthroplasty do not affect clinical outcomes [155].

Treatment¶

Non-Operative¶

Total knee replacement plus nonsurgical treatment is more effective than nonsurgical treatment alone for knee osteoarthritis, though it is associated with more serious adverse events [103]. Total knee replacement plus physical and medical therapy serves as an adjunct to optimize non-surgical treatment in patients with knee osteoarthritis [86]. Indication criteria for total hip or knee arthroplasty in osteoarthritis are based on limited evidence [14].

Operative¶

Indications: Total knee arthroplasty should be considered as the last surgical option for unicompartmental osteoarthritis [9]. High body mass index should not be considered a contraindication for total knee arthroplasty when used for appropriate indications [44]. Total knee arthroplasty among nonagenarians can be performed with acceptable perioperative morbidity and mortality [105]. Obese patients have less improvement in outcomes with total knee arthroplasty [5]. Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes [17].

Surgical Approach / Technique: 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 [7]. There is no single 'best' way to perform total knee arthroplasty [7]. Minimally invasive techniques for total knee arthroplasty are encouraged based on a meta-analysis showing better outcomes compared to the standard invasive medial parapatellar approach [8]. No studies have convincingly shown that minimally invasive techniques or newer technologies, such as patient-specific instrumentation, can lead to improved outcomes or decreased complications [25]. Understanding the basic principles of exposure of the knee is essential for optimal performance of revision knee replacement [13].

Implant Selection: Cruciate retaining and posterior stabilized total knee arthroplasty techniques both provide good results with no difference in surgical complications, range of motion, patient-reported outcome scores, or implant survivorship [25]. There is no difference in outcomes or complications between posterior stabilized and posterior cruciate retaining designs [5]. Bicruciate retaining knee arthroplasty has been proposed to preserve intra-articular proprioception and native joint kinematics, but adoption has been limited due to high early failure rates in some studies [25]. Mobile bearing total knee arthroplasty implants have not demonstrated improved survivorship compared to traditional 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 implant designs [25]. All-polyethylene or metal-backed monoblock tibial components have shown good long-term outcomes and are reasonable options for implant choice [25]. There is no difference in outcomes with use of all polyethylene or modular tibial components in knee arthroplasty [5]. Modern noncemented total knee arthroplasty implants show survivorship and functional outcomes equivalent to cemented prostheses [25]. 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]. There is no evidence to support that fixation techniques alone affect the durability of a total knee arthroplasty when design-related failure was excluded [110]. Debate remains over treatment of the patella, with studies showing good outcomes with and without patellar resurfacing [25]. There is no difference in pain or function with or without patellar resurfacing [5].

Alignment / Balancing Strategy: The technique goal for femoral component rotation is slight external rotation to center the patellar groove under the patella and create a rectangular, balanced flexion gap [124]. External rotation of the femoral component compensates for the native proximal tibia being in slight varus to avoid a trapezoidal, unbalanced flexion gap [124]. Femoral component should never be internally rotated during total knee arthroplasty [124]. Internal rotation of the femoral component results in relative lateral tilt of the patella and the patellar groove facing inward [124]. 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 [124].

Pain Management: Multimodal analgesia has become the standard for perioperative pain management in total knee arthroplasty, integrating various drugs and modalities to minimize opioid consumption and enhance analgesic efficacy [98]. Implementation of multimodal pain management regimens after total knee arthroplasty has increased patient satisfaction, decreased pain scores, and facilitated faster recovery [114]. A 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]. Local infusion analgesia using an intra-articular double lumen catheter after total knee arthroplasty provided clinically significant analgesic effects and rapid recovery [99]. No benefit of adductor canal block compared with anterior local infiltration analgesia was found in primary total knee arthroplasty [121]. Local infiltration analgesia may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia [121]. There is no evidence to support the routine use of gabapentinoids in the management of acute pain following total knee arthroplasty [122]. Use of periarticular local anesthetic infiltration in total knee arthroplasty decreases pain and opioid use [5]. Peripheral nerve blockade for total knee arthroplasty decreases postoperative pain and opioid requirements [5]. Administration of intravenous or oral acetaminophen does not increase risk of complications following primary total joint arthroplasty [6]. An oral nonsteroidal anti-inflammatory drug administered preoperatively and/or in the early postoperative period reduces pain and opioid consumption following primary total joint arthroplasty [6]. Administration of intravenous ketorolac preoperatively, intraoperatively, or within 24 hours postoperatively reduces pain and opioid consumption postoperatively following primary total joint arthroplasty [6].

Adjuncts: Tranexamic acid decreases postoperative blood loss and reduces the need for postoperative transfusions in total knee arthroplasty [5]. Intravenous and topical administration of tranexamic acid are both effective for reducing blood loss [5]. Tranexamic acid has no increased risk in the rate of venous thromboembolic events in patients with a history of thromboembolic disease [4]. Tranexamic acid has no increase in cardiovascular events, including myocardial infarction, ischemic stroke, and death [4]. Tranexamic acid is safe in high-risk populations, including those with a history of myocardial infarction, stroke, coronary artery bypass graft, coronary artery stent, or prothrombotic states [4]. Contraindications for tranexamic acid include known anaphylaxis, seizure disorder, and known defective color vision [4]. Use of a tourniquet increases short term postoperative pain [5]. Evidence supports not using a drain with total knee arthroplasty because there is no difference in complications or outcomes [5]. Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points [16]. Evidence supports not using intraoperative navigation because there is no difference in pain or complications [5]. Patient-specific instrumentation does not improve total knee arthroplasty clinical outcomes at 2 years followup compared to conventional instrumentation [24]. Evidence supports not using patient specific instrumentation compared to conventional instrumentation for total knee arthroplasty because there is no difference in pain or functional outcomes [5]. No studies have convincingly shown that minimally invasive techniques or newer technologies, such as patient-specific instrumentation, can lead to improved outcomes or decreased complications [25]. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty [24]. Robotic-arm assisted total knee arthroplasty demonstrated soft tissue protection [24]. There is no difference in aseptic loosening or revision rates at midterm follow-up comparing standard total knee arthroplasty instrumentation with patient-specific instrumentation, digitally navigated total knee arthroplasty, or robotic-assisted total knee arthroplasty [4]. Continuous passive motion after knee arthroplasty does not improve outcomes [5]. Rehabilitation started on the day of total knee arthroplasty reduces the length of hospital stay [5].

Setting of Care: Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty [24]. Rehabilitation started on the day of total knee arthroplasty reduces the length of hospital stay [5].

Revision: Revision total knee arthroplasty is a challenging procedure requiring a comprehensive understanding of anatomy and surgical techniques to achieve good outcomes [28]. 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]. Appropriate metaphyseal fixation is crucial for stability and implant support in revision total knee arthroplasty [118]. Revision total knee arthroplasty with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation [134]. Modular knee arthroplasties offer the advantage of intraoperative customization and improved fixation, but the trade-off is the potential for failure, especially at the modular junction [133]. Revision arthroplasty is typically chosen for fractures around loose implants and fractures of the distal femur with distal fragments that offer no reasonable opportunity for internal fixation [23]. Stems should be used routinely in revision total knee arthroplasty, and it is recommended that the stem engage the femoral diaphysis both for alignment and fixation reasons [23]. Commercially available metaphyseal sleeves and trabecular metal cones can be useful for managing capacious metaphyseal defects in revision total knee arthroplasty [23]. Implants with increased varus–valgus constraint and hinged implants should be available in revision total knee arthroplasty since ligamentous insufficiency is common in this setting [23]. In cases with insufficient bone to support a traditional revision, a modular megaprosthesis is performed [23]. Conversion of a fused knee to total knee arthroplasty resulted in good long-term fixation and high patient satisfaction [116]. 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 [123]. Simultaneous revision and contralateral primary total knee arthroplasty is a safe and favorable alternative to a staged procedure [43].

Other Considerations: To keep knee bearing contact stress below the yield strength of ultra-high molecular weight polyethylene, the polyethylene must be at least 6 to 8 mm thick in traditional designs [137]. Flat polyethylene 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 the material [137]. Goals of current tibial articular designs are to maximize contact area and minimize contact loads [137]. Sliding movements are least pronounced in a posterior stabilized or anterior stabilized knee design with a congruent polyethylene insert [137]. Sliding wear across the tibia created surface and subsurface cracking with high wear in laboratory testing [137]. After a minimum follow-up of 15 years, hybrid fixation of primary total knee arthroplasty for osteoarthritis provides significantly higher clinical benefits compared with cemented fixation, although the differences were not clinically relevant [136]. At 24 months after revision total knee arthroplasties, 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 implant revision knee surgery indicated for mechanical complications [119]. 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]. Nonoperative management led to clinical improvement in only a third of patients with flexion instability after primary total knee arthroplasty [115]. 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 joint arthroplasty [135].

Complications¶

Infection (PJI): Periprosthetic joint infection (PJI) remains a serious complication, with incidence rates of 0.4% to 2% after primary total knee replacement [172]. PJI rates are increasing, driven by higher volumes of primary arthroplasties and a rise in infections occurring within 90 days [185]. Risk factors include prior venous thromboembolism, which significantly increases the risk of 2-year PJI [170], and aseptic reoperation within 1 year of primary arthroplasty, which is associated with a notably increased risk of subsequent PJI [174]. Patients with resolved prior bone or joint sepsis face a 9.7% infection rate [168], while rheumatoid arthritis patients have significantly higher deep infection rates than osteoarthritis patients, though superficial rates are similar [189]. A history of treated PJI predisposes patients to subsequent infection in primary arthroplasty [173]. Perioperative vancomycin prophylaxis appears effective in decreasing PJI rates and may result in infections with less virulent organisms [184]. In developing countries, PJI incidence is not statistically significantly higher than in high-income countries [191]. Management of recurrent PJI via repeat two-stage revision yields low infection control rates and major morbidity, including a 23% amputation rate [186].

Aseptic loosening: Revision arthroplasty is associated with lower outcomes and higher infection rates compared to primary replacements [180]. Revisions performed within the first 24 months after primary arthroplasty have a higher rate of any-cause failure [150]. High-viscosity cement use in primary total knee arthroplasty is associated with higher odds of revision for aseptic loosening [169]. Isolated and full component revision for aseptic loosening do not differ regarding prosthesis failures, complications, or clinical results at 5 years [160]. Survivorship of aseptic conversion total knee arthroplasty is similar to primary arthroplasty for up to 10 years and significantly better than first-time revision arthroplasty [159]. Ten-year survivorship free from aseptic loosening after total knee arthroplasty following distal femoral osteotomy was 95% [177].

Instability: Varus-valgus constraint implants in primary total knee arthroplasty raise concerns for significant revision risk with extended follow-up, especially beyond 5 years [200]. However, in revision total knee arthroplasties, these implants provide reliable reconstruction with low subsequent revision rates for aseptic loosening and instability at early to mid-term review (5 years) [165]. Revisions for instability were higher for primary total knee arthroplasties performed after 2000 compared to those performed prior to 2000 [151].

Thromboembolism: Deep vein thrombosis (DVT) is common in patients over 60 years of age after total knee arthroplasty, with multivariable influence on its pathogenesis [178]. Prior venous thromboembolism significantly increases the risk of 90-day DVT and pulmonary embolism [170]. Alcohol use disorder is significantly associated with the development of venous thromboembolism, longer lengths of stay, and higher costs of care [182]. 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]. The prospective use of the first-generation American Academy of Orthopaedic Surgeons guidelines resulted in a low incidence of clinically important thromboembolic events [164]. At one institution, 1% of patients accessed the emergency department for concern for DVT at substantial cost, with only a small portion testing positive [146].

Patellar / Extensor-mechanism: Patellar resurfacing in total knee arthroplasty is associated with a lower rate of postoperative anterior knee pain and reoperation [198]. However, no difference in pain or function is observed with or without patellar resurfacing [5].

Other Considerations: Obesity is associated with less improvement in outcomes after total knee arthroplasty [5]. Prior knee surgery predisposes patients to a higher postoperative complication rate in primary total knee arthroplasty compared to patients with no prior surgery [162]. The incidence of early postoperative morbidity after aseptic knee revisions is similar to that reported after primary procedures [157]. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events compared to primary or elective revision arthroplasty [197]. Revision free survivorship and arthroplasty-related complications at two years following revision unicompartmental knee arthroplasty are lower than primary total knee arthroplasty but higher than aseptic revision total knee arthroplasty, whereas medical complications are similar to primary procedures [177]. There is no apparent increase in the risk of cancer following total joint arthroplasty compared with the general population [194]. A 2.5-fold increased risk of death at a mean of 5 years exists for patients with cerebrovascular accident sequelae after primary total hip or knee arthroplasty [171]. The impact of body mass index on the risk of postoperative 90-day infection differs between primary total hip and knee arthroplasty [192].

Recovery¶

The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient [1]. The goal remains delivering the best possible outcome for each individual patient, whether through restoring the native knee or creating the optimal prosthetic knee [2].

Light activity (weeks): Patients undergoing primary TKA returned to driving considerably earlier than previously reported [31]. 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]. 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]. 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].

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]. 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]. Functional recovery after unicompartmental knee replacement continues beyond 6 months and even up to 2 years [183]. 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].

Complete recovery / outcome plateau (months): Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty [132].

Rehabilitation protocol: Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA [85]. 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]. Future rehabilitation protocols should consider the replaced knee and also the non-replaced knee and surrounding joints [93]. 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].

Functional milestones: Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors [109]. Patients who have undergone total knee replacement demonstrate a response shift in the measurement of their outcome at six months postoperatively [92].

Other Considerations: Eighty-six percent of patients return to duty following total joint arthroplasty [108]. 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].

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] 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. (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. (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)
[L5] Understanding the basic principles of exposure of the knee is essential for optimal performance of revision knee replacement. (10.5435/00124635-199801000-00006)
[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] 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)
[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] 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)
[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)
[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)
[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. (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. (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)
[L4] Appropriate metaphyseal fixation is crucial for stability and implant support in revision total knee arthroplasty. (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. (10.5435/jaaos-d-23-01184)
[L1] LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia. (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. (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. (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)
[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] 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)
[L2] PJI remains a serious complication of arthroplasty. (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. (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. (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. (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)
[L1] Based on the main findings of this meta-analysis, patellar resurfaced TKA was demonstrated to have performed superior overall with a lower rate of postoperative anterior knee pain and reoperation. (10.1007/s00402-019-03246-z)
[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)

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