Clinicians › Knee
Total Knee Replacement
Total knee arthroplasty for end-stage degeneration, including management of PJI, component malalignment, and aseptic loosening.
For patients: a plain-language version of this topic is available. See the patient guide.
Overview¶
Total knee arthroplasty aims to deliver the best possible outcome for each individual patient, whether by restoring the native knee or creating the optimal prosthetic knee [2, 3]. For the vast majority of patients, a standard conventional procedure with familiar surgical approaches and standard components leads to satisfactory long-term clinical outcomes [15]. There is no single 'best' way to perform the surgery [15]. Indication criteria are based on limited evidence [21], and the Appropriate Use Criteria provide guidance for surgical management of knee osteoarthritis based on patient-specific factors [35]. Patient selection should consider general health, emotional role, and knee function to predict outcomes [217]. While most patients are successfully treated, a certain number remain unhappy, requiring analysis of whether symptoms are surgery-related or patient-related [36]. Nearly 20% of patients are dissatisfied following well-performed arthroplasty with good functional outcomes, often due to unfulfilled expectations [51]. An inventory review highlights the lack of consensus on definitions for poor outcome, emphasizing the need for standardized definitions to improve comparability across studies [5].
Unicompartmental knee arthroplasty offers clinical results and survivability as good as, or better than, total knee arthroplasty when specific patient and anatomic indications are met [8]. Evidence suggests that many originally described contraindications to unicompartmental arthroplasty are no longer applicable in modern practice [19]. Expanded indications, including younger and heavier patients, are associated with comparable clinical outcomes and great short-term survivorship [22, 179]. Patients with pre-existing patellofemoral disease should not be contraindicated from undergoing unicompartmental arthroplasty [18]. Good-to-excellent outcomes can be achieved in patients less than 65 years of age, with both procedures not contraindicated at younger ages [214]. Total knee arthroplasty is considered the last surgical option for unicompartmental osteoarthritis [17]. The procedure can be performed safely in nonagenarians with acceptable perioperative morbidity and mortality [56], and in end-stage renal failure patients with careful selection, specifically excluding those with stroke or peripheral vascular disease [57].
Periprosthetic joint infection is the most common indication for secondary revision within one year after primary total knee arthroplasty [60]. In cases of failed arthroplasty, data did not allow definite treatment recommendations [33]. Megaprosthesis implantation in revision knee arthroplasty is an exceptional indication [31]. In salvage total knee arthroplasty, implant design does not significantly affect overall functional outcome [53]. The diagnosis of a well-fixed mechanically-aligned total knee arthroplasty requiring revision for restoration of joint line obliquity is not a universally accepted indication, and further data on long-term outcomes are required [43].
Anatomy & Pathophysiology¶
Bony Anatomy and Alignment¶
The mechanical limb line, or Mikulicz line, extends from the femoral head center to the ankle center and normally passes within the confines of the knee [11]. The mechanical axis femur (MAF) is defined as the line extending from the femoral head center to the center of the distal femur (intercondylar groove), while the anatomic axis femur (AAF) follows the line of the femoral medullary canal [11]. The mechanical lateral distal femoral angle (mLDFA) is the angle subtended by the MAF and the distal femoral intercondylar line, with a neutral value of 90 degrees [11]. In contrast, the anatomic lateral distal femoral angle (aLDFA) is the angle subtended by the AAF and the distal femoral intercondylar line, usually measuring less than 90 degrees [11]. The mechanical axis tibia (MAT) extends from the ankle center (center of talus) to the center of the proximal tibia [11]. The average mechanical proximal tibial angle (mPTA) is 3 degrees varus [13].
In total knee arthroplasty, the proximal tibia is cut perpendicular to the mechanical axis, which results in a trapezoidal (unbalanced) flexion gap due to the native slight varus of the proximal tibia [13]. To compensate for this trapezoidal flexion gap and create a rectangular (balanced) flexion gap, the femoral component is externally rotated 3 to 5 degrees [13]. Internal rotation of the femoral component results in a relative lateral tilt of the patella and causes the patellar groove to face inward [13]. A trapezoidal flexion gap leads to a loose lateral compartment (instability) or a tight medial compartment (stiffness) [13]. For mechanical alignment, the distal femoral bone cut is made perpendicular to the MAF, resulting in an mLDFA of 90 degrees, and the proximal tibial bone cut is made perpendicular to the MAT, resulting in an mPTA of 90 degrees [172]. Kinematic alignment maintains native limb alignment by making the distal femoral cut at the native mLDFA and the proximal tibial cut at the native mPTA [172].
Ligamentous Anatomy and Biomechanics¶
The knee is a hinge joint that incorporates both gliding and rolling, which are essential to its kinematics [85]. The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [85]. As the knee flexes, the center of joint rotation moves posteriorly, causing rolling and gliding at the articular surfaces [183]. Ligaments anterior to the flexion axis stretch as the joint flexes, while ligaments posterior to the axis shorten [183].
The anterior cruciate ligament (ACL) has two bundles: the anteromedial bundle is tight in flexion and primarily an anterior restraint, while the posterolateral bundle is tight in extension and primarily a rotatory restraint [85]. The ACL length is 30 mm and its diameter is 11 mm [85]. Its composition is 90% type I collagen and 10% type III collagen [85]. The posterior cruciate ligament (PCL) resists posterior tibial translation at all degrees of knee flexion [85].
The medial collateral ligament complex includes the superficial medial collateral ligament (sMCL) and the deep medial collateral ligament. The sMCL proximal division resists valgus tibial translation and tibial external rotation, while the sMCL distal division resists tibial external rotation in knee extension and tibial internal rotation [85]. The deep medial collateral ligament resists valgus translation and tibial internal and external rotation [85]. The posterior oblique ligament resists tibial internal rotation, especially in knee extension [85].
The lateral structures include the lateral collateral ligament, which resists varus tibial translation and tibial external rotation, especially at 30 degrees of knee flexion [85]. The popliteus tendon resists tibial external rotation, especially in knee flexion [85]. The popliteofibular ligament resists tibial external rotation, especially in knee flexion, and posterior tibial displacement [85]. The oblique popliteal ligament resists knee hyperextension and varus tibial translation [85].
Tensile strength values for these structures are as follows: * ACL: Approximately 2200 N, up to 2500 N in young individuals [183]. * PCL: Approximately 2500 to 3000 N [183]. * sMCL: Approximately 550 N [183]. * dMCL: Approximately 100 N [183]. * POL: Approximately 250 N [183]. * LCL: Approximately 750 N [183].
Meniscal Anatomy and Biomechanics¶
The menisci transmit 50% to 75% of axial loads across the knee in full extension and 85% of axial loads in 90 degrees of knee flexion [183]. The medial meniscus bears 30% to 40% of the tibiofemoral load, while the lateral meniscus bears 70% of the tibiofemoral load [183]. Menisci decrease peak contact stresses at the articular surface by 100% to 200% [183]. Resection of 75% of the radial meniscal width results in an increase in peak contact stresses equivalent to that after a segmental or total meniscectomy [183]. The posterior and peripheral zones of the meniscus are the most important in decreasing contact stresses [183]. The lateral meniscus has twice the excursion of the medial meniscus during knee flexion [183].
ACL deficiency may result in abnormal meniscal strain, particularly in the posterior horn of the medial meniscus [183]. The posterior horn of the medial meniscus is a major secondary stabilizer against anterior tibial translation in an ACL-deficient knee [183]. Meniscal root tears completely disrupt the circumferential fibers of the meniscus, leading to meniscal extrusion [183]. Meniscal root tears are more commonly associated with the medial meniscus due to the pull of the capsule and MCL [183]. Biomechanical studies show similar load patterns in posterior root tears and complete meniscectomy [183]. A meniscal root tear is functionally equivalent to a total meniscectomy [199]. Lateral meniscal root tears are associated with ACL tears, while medial meniscal root tears are associated with chondral injuries [199].
Patellar Anatomy and Tracking¶
The Q angle increase in total knee arthroplasty increases the resultant lateral subluxation force on the patella [13]. The dome shape of the resurfaced patella is less able to resist the lateral pull effect compared to other designs, increasing the risk for patellar subluxation [13]. The femoral component should never be internally rotated to optimize patellar tracking [13]. Externally rotating the femoral component and lateralizing the femoral or tibial component are maneuvers to improve patellar maltracking [13]. Medializing the patellar component is an additional rule for managing patellar tracking issues when needed [13]. Total patellar height must be measured to avoid overstuffing [13].
The Schottle point for the femoral attachment of the medial patellofemoral ligament (MPFL) is located 1 mm anterior to the posterior cortex extension line and 2.5 mm distal to the posterior origin of the medial femoral condyle [40]. The normal TT–TG distance is between 9 and 13 mm [40]. A TT–TG distance over 20 mm is highly associated with patellar instability [40]. In complete patellar dislocation, a bone bruise pattern involving the lateral femoral condyle and medial patella is often observed on MRI [40]. The MPFL is often disrupted at its patellar insertion in complete dislocations [40]. Articular cartilage on the medial facet of the patella is the most common donor site for injury during reduction of the patella [40].
Patellar thickness affects patellofemoral kinematics after total knee arthroplasty [132]. Kinematic alignment restores native patellar tracking patterns more closely than mechanical alignment [141]. Kinematically aligned total knee arthroplasty better restores patellar kinematics and patellofemoral contact pressure distribution to the native condition than mechanically aligned total knee arthroplasty during deep knee flexion [133]. None of the analyzed surgical patellar interventions could restore natural patellar kinematics after total knee arthroplasty [161].
Pathophysiology of Pain and Failure¶
Hip pathology is a common cause of referred pain to the anterior-medial knee region, mediated by the distal branch of the obturator nerve [59]. Spinal pathology, typically involving L3 and L4 nerve roots, can cause referred pain to the knee [59]. Gait analysis and dedicated examinations of the ipsilateral hip and spine are performed because radiating or referred pain may be experienced in the anterior thigh or knee [1].
Infection is the number one reason for revision total knee arthroplasty and the number one reason for revision within 2 years of index primary total knee arthroplasty [59]. Aseptic mechanical implant loosening is the number two reason for revision total knee arthroplasty [59]. Early aseptic loosening can result from failure of osteointegration into cementless implants or debonding of the implant from PMMA cement [59]. Late aseptic loosening can result from PMMA fatigue, bone resorption away from cement, or osteolysis with bone resorption from cement [59]. Smooth radiolucent lines around cement mantles and metallic implants suggest aseptic loosening [59]. Stem tilt to the side of the medullary canal with an outer cortical periosteal reaction suggests aseptic loosening [59].
Implant malposition or malalignment typically presents with knee stiffness and activity-related pain [59]. The posterior condylar axis of the metallic femoral condyles should be parallel or slightly externally rotated in relation to the epicondylar axis on CT [59]. Internal rotation of the femoral implant is a known cause of flexion gap imbalance [59]. A tibial implant axis lying medial to the tibial tubercle indicates malalignment and a relative increase of tibial tubercle external rotation [59]. Instability results in abnormal excessive limb subluxation or angulation with weight-bearing stress [59].
Early polyethylene wear presents with a warm knee and effusion due to PE debris deposits creating reactive synovitis [59]. Late polyethylene wear presents with osteolysis and retroprosthetic bone resorption creating excess bone strain and pain [59]. Hypersensitivity to implant materials typically presents with constant global pain, normal serum biomarkers, and negative aspiration studies [59]. An intraarticular lidocaine challenge test where relief of ≥90% of pain constitutes a positive result indicates that pain emanates primarily from within the knee joint [59].
Patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis have higher revision rates than patients with osteoarthritis due to immune inhibitors and altered bone metabolism [59]. Revision of a painful total knee arthroplasty without an identified specific cause of pain is likely to have a poor outcome [59].
Different pain characteristics help distinguish causes: * Immediate-onset pain: Associated with acute postoperative infection, periprosthetic fracture, severe implant malpositioning, polyethylene liner dislocation, venous thromboembolism, and ligamentous injury [1]. * Delayed-onset pain: Associated with hematogenous or chronic infection, implant malpositioning or loosening, knee instability, extensor mechanism disorders, arthrofibrosis, and rare causes [1]. * Pain different from preoperative pain: Associated with infection, implant malpositioning or loosening, knee instability, extensor mechanism disorders, arthrofibrosis, and rare causes [1]. * Pain same as preoperative pain: Associated with hip pathology, spine pathology, vascular pathology, tendinitis and bursitis, minimal preoperative knee osteoarthritis, and rare causes [1].
Osteolysis occurs late in the implant lifecycle at 13 to 15 years [205]. Osteolysis is caused by submicron shedding of microparticulate PE debris which invades bone surrounding the knee [205]. Macrophages stimulated by phagocytosis of submicron-sized PE wear particles release TNFα, IL-1β, and IL-6 [205]. Up-regulation of RANKL production by osteophytes leads to RANK on osteoclast progenitors mediating osteoclast differentiation and increased number, resulting in bone resorption [205]. The most common site for osteolytic lesions is behind the posterior femur [205]. Femoral osteolysis can be more difficult to detect on an AP radiograph because lesions are typically located in the posterior condyles and obscured by the femoral implant [202]. Tibial osteolytic lesions are usually more readily visible on radiographs than femoral lesions [202]. PMMA cement debris can contribute to osteolysis when caused by motion between the implant and cement due to loosening or debonding [202]. Smaller wear particles (<10 mm) are more readily absorbed by macrophages, which then release cytokines that signal osteoclasts to resorb bone [202].
Catastrophic polyethylene failure generally occurs in the intermediate lifecycle of the implant [69]. If untreated, areas of broken polyethylene allow metal-to-metal contact, creating metallosis [69]. To keep knee bearing contact stress below the yield strength of UHMWPE (12–20 mPA), the polyethylene must be at least 6 to 8 mm thick for traditional non-highly cross-linked PE [69]. Many second-generation knee systems had polyethylene inserts with a thickness of 4 to 5 mm in the thinnest region [69]. Current designs ensure that polyethylene thickness in the thinnest areas of the insert is at least 6 mm [69]. Flat polyethylene designs should be avoided because knee loads exceed the yield strength of UHMWPE due to a thin line of joint contact during loading [69]. Goals of current tibial articular designs are to maximize contact area and minimize contact loads [69]. Sliding movements are least pronounced in a posterior stabilized or asymmetric knee design with a congruent polyethylene insert [69]. Sliding wear across the tibia in laboratory testing created surface and subsurface cracking with high wear [69].
Arthrofibrosis is the process by which pathologic scar tissue forms after total knee arthroplasty and restricts functional range of motion [202]. Arthrofibrosis may develop in patients who have normal intraoperative range of motion [202]. Arthrofibrotic scar contains dense fibrous tissue with abundant fibroblasts and frequently includes heterotopic bone [202]. Surgical technique factors that can contribute to arthrofibrosis include oversizing the femoral implant, overstuffing the patella, or rotational malalignment [202].
Mediolateral instability caused by loss of collateral ligament support may result from intraoperative collateral ligament laceration, postsurgical trauma, or gradual attenuation over time [202]. Loss of collateral ligament support requires an implant constrained to varus and valgus stress [202]. Flexion instability can develop after surgery despite appropriate mediolateral and flexion-extension gap balancing [202]. Both posterior cruciate-retaining and posterior cruciate-substituting total knee arthroplasties require sacrifice of the anterior cruciate ligament, which can result in flexion instability [202]. Radiographs of patients with symptomatic flexion instability typically demonstrate "paradoxical motion," or anterior subluxation of the femur on the tibia in flexion, rather than roll back [202].
Extensor mechanism dysfunction is the most frequent complication and the most commonly cited reason for secondary surgery after total knee arthroplasty [72]. The incidence of extensor mechanism complications has decreased from approximately 12% to 1.5% over the past three decades [72]. Patellofemoral instability is the most commonly reported extensor mechanism complication [273]. Patellar fracture or rupture of either the quadriceps or patellar tendon can cause catastrophic disruption of the extensor mechanism [273]. The minimum patellar bone thickness required to prevent fracture is 13 mm [200]. Transection of the lateral superior genicular artery during lateral retinacular release increases the risk for osteonecrosis of the patella [200].
Classification¶
Outcome and Satisfaction Definitions¶
Classifications of good versus poor outcome following knee arthroplasty should not rely on arbitrary cutoff scores, as this homogeneity impedes scientific progress [182]. Instead, non-biased statistical model-based approaches are proposed for classifying outcomes [182]. The WOMAC score can be reliably used to classify patient satisfaction after total knee arthroplasty [164]. One study defined a post-operative classification of excellent, good, fair, and poor for the components and total WOMAC scores [164].
Indication and Appropriateness¶
Validated total knee replacement appropriateness criteria include 16 mutually exclusive combinations of five elements: age, symptomatology, radiographic knee osteoarthritis severity, number of knee compartments involved, and knee stability [25]. Based on these criteria, patients are classified into three categories: appropriate, inconclusive, and inappropriate [25]. Patients classified as "appropriate" and "inconclusive" are combined into a group defined as "potentially appropriate" for total knee replacement because they have been shown to have the same 2-year postoperative trajectories of pain and functional improvement [25]. Patients classified as "inappropriate" are defined as "likely inappropriate" for total knee replacement [25].
Anatomical and Phenotypic 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 [46]. Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all total knee arthroplasty systems fit these phenotypes well [196]. The concept of 'Functional Knee Phenotypes' goes beyond utilizing implants manufactured based on individual 3D-data and may help to structure and categorize individual morphology and alignment to identify the optimal total knee arthroplasty strategy [215]. With arthroplasty registry adoption of patient-reported outcome measures, precise anatomical categorisation of knee osteoarthritis is supported in outcome studies [220]. The anatomical site of radiographic degeneration is an independent variable influencing the outcome of total knee arthroplasty [220].
Radiographic and Implant Classification¶
Knee Society Radiographic Evaluation and Scoring System: A modern system developed for total knee arthroplasty, focusing on radiographic evaluation, classification, and radiolucency [39].
Generic Implant Classification: Enables comparison across implant designs, with a complete implant library containing characteristics of 32,500 orthopaedic implants covering about 85 different hip and 85 different knee implants [242].
Modified Joint Line Obliquity Classification: When applied, postoperative joint line obliquity was associated with high survival rates following total knee arthroplasty at a mean follow-up of 12.7 years [206].
Anderson Orthopaedic Research Institute: Used to classify preoperative tibial and femoral bone loss in revision total knee arthroplasty [307].
Ahlback Classification: Used to grade the presence of osteoarthritic changes in the nonreplaced compartment in unicompartmental knee replacement studies [321].
Complication and Fracture Classification¶
Periprosthetic Femur Fracture Classification: A new system that considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations [150].
Unified Classification System: Proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures [224].
Brooker Classification: A four-stage system that has been implemented widely and is the only validated grading system for hip heterotopic ossification [316]. Maloney et al. modified the Brooker classification to reflect functional limitation resulting from heterotopic ossification by subdividing classes III and IV into A and B based on difficulty with sitting, ascending stairs, or putting on shoes and socks [316]. The absence of a single, standardized classification system for heterotopic ossification precludes the comparisons of HO severity between studies following primary total knee arthroplasty [54].
Revision and Failure Classification¶
Revision Knee Complexity Classification (RKCC): A guide for surgeons to support regional clinical networking in revision knee surgery [41].
Baldini Classification: A modified grading system was developed and validated to improve the reliability of the Baldini Classification for revision total knee arthroplasty [216].
ICD-9-CM Procedure Codes: International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes are used to identify patients undergoing revision total knee arthroplasty and to identify the indication for each procedure [301].
Diagnosis-Related Group Systems: Several countries' Diagnosis-Related Group systems might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities [124].
Intraoperative Component Loosening: A Delphi study established a consensus among knee revision surgeons on the definition of intraoperatively determined component loosening, with visible fluid motion on manipulation serving as the new threshold [234].
Clinical Presentation¶
Assessment of Painful Total Knee Arthroplasty¶
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 [23]. The workup for a painful total knee arthroplasty should include evaluation for infection, neurogenic pain, referred pain from the hip or back, and mechanical sources of pain [281]. This evaluation requires a thorough history and physical examination, laboratory studies, and plain radiographs [281]. Additional nuclear medicine studies or specialized imaging may be necessary for the evaluation of a painful total knee arthroplasty [281].
History and Pain Characterization: A history of pain that develops immediately after surgery and persists without a pain-free interval, along with pain at rest and with weight bearing, suggests an inflammatory and/or neurogenic source of pain [281]. Pain during weight-bearing activity or knee motion is consistent with a mechanical source of pain [281]. Infection is a common source of pain after total knee arthroplasty and must be ruled out first in all patients [281]. Infection is usually associated with an elevated erythrocyte sedimentation rate and C-reactive protein level and can be detected by aspiration with cell count, differential, and culture [281]. False-negative and false-positive results can occur in the laboratory evaluation for infection, and additional imaging studies may be necessary [281]. 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 [281]. Pain described as burning or numbness that is nonfocal on examination supports the diagnosis of neurogenic pain [281]. Neurogenic pain may improve with analgesic medications, medications for neuropathic pain such as gabapentin, pregabalin, or tricyclic antidepressants, and with local trigger point or epidural injections [281].
Mechanical Causes: Mechanical causes of early pain after total knee arthroplasty include patellar maltracking, patellar clunk or crepitus, tibiofemoral instability, periprosthetic fracture, or occult implant loosening [281]. Patellar problems are usually evident on physical examination because the location of pain is restricted to the patellofemoral joint [281]. Patients with patellar problems may present with reduced knee range of motion and flexion [281]. Patellar clunk is a complication of posterior-stabilized total knee arthroplasty that occurs when a fibrous nodule at the inferior pole of the patella catches in the trochlear groove during knee extension [281]. Patellar clunk was a problem with older implant designs but is rarely described with newer ones [281]. Patellar crepitus is more common with current posterior-stabilized designs and may cause anterior knee pain [281]. Symptoms of patellar clunk or crepitus are relieved by open or arthroscopic excision of the fibrous nodules and synovium [281]. Patellar maltracking and subluxation may result from dehiscence of the medial retinacular arthrotomy, femoral or tibial component internal rotation, or patellar component malpositioning [281]. Rotational orientation of the femoral implant may be assessed on an axial view of the patella but is better quantitated using CT with metal artifact reduction [281]. Symptomatic patellar subluxation or maltracking resulting from internal rotation of the femoral or tibial components requires revision of the malaligned components [281].
Instability and Late Failures: A history of pain and effusion that occurs after activity and is relieved with rest is consistent with flexion instability [281]. Flexion instability caused by intact but attenuated soft-tissue constraints can be detected on physical examination by varus and valgus stress testing [281]. Laxity in flexion instability is typically more evident in flexion than in full extension as the posterior capsule and hamstrings contribute to stability in extension [281]. Flexion instability is more common with constrained rotation total knee arthroplasties than with posterior-stabilized total knee arthroplasties [281]. Flexion instability is associated with paradoxic motion or rolling forward of the femoral implant, which can be seen on flexion lateral radiographs as anterior subluxation of the distal femur on the tibia [281]. 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 [281]. Complete dislocation of a posterior-stabilized knee is more common when excessive posterior slope occurs with the tibial cut and with some posterior-stabilized-designed total knee arthroplasties [281]. Pain that develops late after total knee arthroplasty is more often associated with loosening or ultra-high-molecular-weight polyethylene wear [281]. Late hematogenous infection can occur and should be included in the differential diagnosis for late-onset pain after total knee arthroplasty [281]. Wear can be seen radiographically as asymmetric height of the tibial plateaus [281]. Rotation and flexion of the knee can alter the projected height of the joint space, making radiographic measurements of wear inaccurate [281]. Loosening occurs when subsidence or displacement of the component or a complete or progressive radiolucency at the implant and bone interface occurs [281].
Physical Examination and Differential Diagnosis: Crepitus and patellar clunk syndrome may be carefully assessed during the physical examination of a painful total knee arthroplasty [1]. Motor strength, sensory, and vascular examination of the lower extremity complete the assessment of a painful total knee arthroplasty [1]. The differential diagnosis for pain after total knee arthroplasty varies by onset and character relative to preoperative symptoms. Infection is listed as a cause for different pain versus preoperative, immediate-onset pain, and delayed-onset pain [1]. Hip pathology, spine pathology, vascular pathology, tendinitis and bursitis, and minimal preoperative knee osteoarthritis are listed as causes for different pain versus preoperative [1]. Periprosthetic fracture, severe implant malpositioning, polyethylene liner dislocation, venous thromboembolism, and ligamentous injury are listed as causes for immediate-onset pain [1]. Implant malpositioning, loosening, and catastrophic failure are listed as causes for same pain versus preoperative and delayed-onset pain [1]. Knee instability, extensor mechanism disorders, arthrofibrosis, and rare causes are listed as causes for different pain versus preoperative and delayed-onset pain [1].
Diagnostic Algorithms and Imaging¶
A practical 10-step diagnostic algorithm is described for failure analysis in the painful total knee arthroplasty [137]. The evaluation of a painful total knee arthroplasty includes an extended history, analysis of the type of pain, psychological exploration, thorough clinical examination including spine, hip and ankle, laboratory tests, joint aspiration and test infiltration, radiographic analysis and special imaging techniques [137]. It is important to enquire about the length and type of conservative therapy when evaluating a painful total knee arthroplasty [137]. 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 [34]. Weight-bearing pain and implant migration, progressive radiolucencies, radiolucency more than 2 mm and subsidence on radiographs and CT are generally accepted criteria for knee arthroplasty loosening [30]. Amongst specialized knee revision surgeons, there is high variability in clinical and radiological criteria that are seen as important contributing factors to diagnosis of knee implant loosening [30].
Preoperative Evaluation for Revision¶
Preoperative evaluation of a patient requiring revision total knee arthroplasty involves obtaining a thorough history and performing a clinical examination in addition to laboratory assessment and a critical review of radiographs [126]. The goals of the history in revision total knee arthroplasty are to determine if the patient’s symptomatology is consistent with a failed total knee arthroplasty and to rule out conditions in which revision may be contraindicated such as infection, Charcot arthropathy, neuromuscular disease, or adverse medical conditions [126]. Analysis of previous surgical procedures, including review of previous operative reports, is necessary to assess the previous surgical approach used, the soft-tissue releases performed, and the size and type of the present prosthetic components [126]. Clinical examination for revision total knee arthroplasty includes assessment of range of motion, ligamentous stability, lower-limb alignment, and patellofemoral tracking [126]. The skin is carefully inspected to determine previous skin incisions, mobility of the anterior soft tissues, and presence of any preexisting ulcerations that would require treatment before proceeding with revision total knee arthroplasty [126]. A neurologic examination is performed to ensure the patient has adequate motor control of the operative lower extremity [126]. If diminished pulses are present, noninvasive arterial studies are obtained and a preoperative vascular surgery consultation is considered [126]. Signs of venous insufficiency are evaluated with duplex color ultrasonography [126]. The examination must confirm that the patient’s symptoms are truly secondary to a failed total knee arthroplasty by ruling out referred pain from adjacent areas, such as a diseased hip joint, or radicular pain from spinal nerve root impingement [126]. Revision total knee arthroplasty is a challenging procedure requiring a correct diagnosis of the original cause of failure and a detailed plan [32].
Periprosthetic Joint Infection Evaluation¶
Periprosthetic joint infection remains one of the most common failure modes following total hip and total knee arthroplasty [134]. A systematic and cost-effective approach to the evaluation and work-up of a patient with a suspected periprosthetic joint infection should be undertaken in every patient with a painful total joint [134]. A history and physical remain the most important diagnostic tools for periprosthetic joint infection [134]. Many current laboratory tests are indirect measures of infection, lack specificity for diagnosis of infection, but serve as sensitive and cost-effective screening tools [134]. Biomarkers hold the promise of improved specificity and are becoming increasingly popular as a diagnostic tool for periprosthetic joint infection [134]. Periprosthetic joint infection is the leading cause of revision for failed total knee arthroplasty, accounting for 16.8% of all knee revisions [134]. Periprosthetic joint infection is the third leading cause of failure of total hip arthroplasty, accounting for 14.8% of all hip revisions [134]. The economic impact of treating a patient with an infection after total joint replacement is associated with higher costs in the range of $60,000 to $100,000 per treatment, longer hospital stays and higher complication rates [134]. It is imperative that the diagnosis of infection be ruled out or defined because the treatment of a patient with periprosthetic joint infection is drastically different from those without an infection [134]. Joint aspiration was encouraged as a primary diagnostic procedure but not always performed in a retrospective analysis of revision surgery for periprosthetic joint infection [140]. Ordering X-ray examination and routine inflammatory markers (leukocyte count in peripheral blood and plasma C-reactive protein) were standardized laboratory-confirmed in a retrospective analysis of revision surgery for periprosthetic joint infection [140].
Patient Factors and Outcomes¶
About 20% of patients after total knee arthroplasty are not satisfied with their outcomes [137]. A painful total knee arthroplasty causes medical, social, and sometimes legal problems [137]. A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis [47]. Almost a third of the patients continued to have residual knee pain at 2 years post-total knee arthroplasty [143]. 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 after total knee arthroplasty [143]. More than half the patients presenting for total knee arthroplasty had mild-to-severe contralateral knee pain [145]. Patients with contralateral knee pain were significantly less likely to be satisfied with their total knee arthroplasty despite having a clinically meaningful improvement [145]. Improvement in knee pain after total knee arthroplasty is associated with a reduction in pain in other bodily regions, suggesting a potential physiological link [159]. Persistent pain remains common after total knee arthroplasty and improvement does not equate to cure [159]. Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes [26]. 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 [160]. Pain symptoms of moderate or severe pain are unequivocal when considering a total knee arthroplasty [166]. Surgical timing preferences for knee replacement vary between patients older than 65 years, who prefer immediate surgery only when pain is intense, and younger patients, who prefer immediate surgery no matter the amount of pain [178]. ED visits following elective major joint replacement were numerous and most commonly for pain-related diagnoses [175]. Long-term patient-reported outcome measures for total knee and hip arthroplasty beyond one or two years are often incomplete and lose sensitivity [49]. Good early outcomes, as measured by the Oxford Knee Score and EQ-5D, can be anticipated following knee replacement regardless of the patient's age, although younger patients gain greater improvement [44]. Patients aged 68 years or older experience deterioration in functional outcomes and quality of life from 2 to 10 years after total knee arthroplasty [176]. The estimated lifetime risk of revision knee arthroplasty varied depending on patient sex, age, and underlying diagnosis [171]. Total knee arthroplasty done in young and presumed active patients less than 65 years have excellent survivorship [6]. The optimal surgical treatment of knee osteoarthritis in the young and active patient is still insufficiently defined, requiring a compromise between pain relief, functional restoration, and treatment durability [48]. 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 [165]. Clinically, elderly patients undergoing hip or knee replacement surgery should perform well in terms of preoperative and perioperative management [168]. Functional knee phenotypes of osteoarthritis patients undergoing total knee arthroplasty are significantly more varus or valgus than in a non-osteoarthritic control group [46]. 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 [123]. The use of knee arthroplasty should be thoroughly monitored with more emphasis on standardization in the decision-making process and preventive measures [28]. 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 [5]. The AAOS Appropriate Use Criteria for Surgical Management of Osteoarthritis of the Knee categorize treatments as Appropriate, May Be Appropriate, or Rarely App
Investigations¶
Clinical Assessment and History¶
A correct diagnosis of the original cause of failure and a detailed plan are prerequisites for revision total knee arthroplasty [32]. The assessment of a painful total knee arthroplasty includes evaluating crepitus, patellar clunk syndrome, motor strength, sensory function, vascular examination, gait analysis, and dedicated examinations of the ipsilateral hip and spine [1]. Radiating or referred pain from the hip or spine may be experienced in the anterior thigh or knee [1]. Differentiating pain onset is critical for diagnosis; immediate-onset pain is associated with infection, periprosthetic fracture, severe implant malpositioning, polyethylene liner dislocation, venous thromboembolism, and ligamentous injury [1].
Radiographic Imaging¶
Plain radiography: Standard images for initial evaluation include weight-bearing AP and lateral views, a weight-bearing knee flexed at 45-degree angle imaged posterior to anterior, sunrise view, extension and flexion lateral views, and a standing full-length AP radiograph [38]. The standing full-length AP radiograph evaluates limb alignment, knee deformity, and identifies femoral or tibial bone deformity [38]. The Kellgren-Lawrence (KL) rating grades the extent of osteoarthritis based on review of the AP knee radiograph [38]. Primary features used for KL rating include osteophytes, joint space narrowing, subchondral sclerosis with or without cysts, and altered shape of periarticular bones [38]. KL Grade 0 indicates normal knee features with no osteoarthritis [38]. KL Grade 1 indicates osteoarthritis possibly present [38]. KL Grade 2 indicates minimal severity osteoarthritis [38]. KL Grade 3 indicates moderate severity osteoarthritis [38]. KL Grade 4 indicates severe osteoarthritis [38]. Knee arthroplasty is recommended when Grade 4 findings are present [38].
Routine radiographic surveillance did not detect any true abnormalities during the first year after primary total joint arthroplasty [327]. Weight-bearing pain, implant migration, progressive radiolucencies, radiolucency more than 2 mm, and subsidence on radiographs and CT are generally accepted criteria for knee arthroplasty loosening [30]. Amongst specialized knee revision surgeons, there is high variability in clinical and radiological criteria that are seen as important contributing factors to the diagnosis of knee implant loosening [30]. Novel radiographic findings of anterior heterotopic bone formation and cysts develop in patients who have aseptic loosening following primary total knee arthroplasty [369]. Simultaneous biplane radiography can accurately assess the motion of total joint replacements in vivo and may detect early changes before clinical or radiographic evidence of loosening is apparent [364]. Utilization of an axial weight-bearing view to evaluate total knee arthroplasty may provide additional information over standard radiographic views [363]. A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy [333]. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease, should be part of the pre-operative assessment for patellofemoral joint replacement, especially for the non-dysplastic knee [291].
Advanced Imaging (MRI, CT, SPECT/CT)¶
MRI: MRI is not indicated if the joint space is significantly narrowed on radiograph [38]. MRI is used when osteonecrosis is suspected [38]. MRI has a noteworthy value of distinguishing suspected periprosthetic joint infection in patients with total knee arthroplasty, but the definition of specific MRI features related to diagnosis lacks consensus and standardization [292]. 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 demonstrated [34]. 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 in double-layered patella management [324]. Routine screening for osteonecrosis is not necessary, but patients with persistent hip or knee pain should be assessed with MRI [314]. Assessment of medial cartilage thickness loss using MRI provides additional utility over standard radiographs in preoperative assessments of medial unicompartmental knee arthroplasty patients [374]. To prevent malalignment, MRI should be the imaging modality of choice when performing total knee arthroplasty surgery with patient-specific instrumentation [382].
CT: Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [38].
Bone scan: 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 [246]. The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven [303]. 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 implants [341]. Bone SPECT/CT has excellent sensitivity and specificity for the diagnosis of loosening and patellofemoral problems after total knee arthroplasty [343]. The SPECT/CT algorithm presented is both reliable and useful in the management of patients with painful total knee arthroplasty [397].
Tomosynthesis: Tomosynthesis is superior to fluoroscopically guided plain radiography, CT, and MRI for the early detection of small periprosthetic bone defects after total knee arthroplasty in terms of sensitivity, specificity, radiation dose, and cost [326].
Preoperative Planning and Alignment¶
Other Considerations: 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 [328]. Improving long-term outcomes after total knee arthroplasty requires moving beyond the static concept of 'correct alignment option' to integrate static images with dynamic and kinetic insights [385]. 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 [286].
Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis [278]. Mild radiographic knee osteoarthritis is the main predicting factor for dissatisfaction after total knee arthroplasty in patients aged 65 years or less [377]. A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively [339]. Severe arthritis predicts greater improvements in function following total knee arthroplasty [330]. Radiographic severity of arthritic changes can predict knee-specific functional improvement, but the extent of global functional improvement cannot be predicted by radiographic severity alone [330]. In patients with an unsatisfactory response to their first knee replacement, the level of radiographic osteoarthritis in the contralateral knee is the best predictor of achieving a satisfactory response to the second replacement [376]. Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect [249]. Radiographic findings including joint space narrowing and MRI-detected bone marrow lesions, synovitis, and effusion are significantly associated with the long-term risk of total knee arthroplasty in persons with knee osteoarthritis [296]. Patients undergoing total knee replacement exhibit significantly worse baseline clinical outcomes, particularly in WOMAC scores, despite having similar radiographic severity to those receiving conservative treatment [392]. Functional and symptomatic measures may be more valuable than radiographic findings in determining surgical intervention for knee osteoarthritis [392].
Treatment¶
Non-Operative¶
Conservative management remains the prerequisite for surgical intervention. Strong recommendations for non-arthroplasty management of knee osteoarthritis include patient education programs, exercise, self-management programs, topical NSAIDs, oral NSAIDs, and oral acetaminophen [11]. Moderate recommendations include canes, brace treatment, neuromuscular training combined with traditional exercise, sustained weight loss, intraarticular corticosteroids for short-term relief, and arthroscopic partial meniscectomy for meniscal tears in patients with concomitant mild to moderate osteoarthritis [11]. Oral narcotics, including Tramadol, and lateral wedge insoles are not recommended [11]. Similarly, hyaluronic acid intraarticular injections and arthroscopy with lavage and/or débridement are not recommended [11]. High tibial osteotomy may improve pain and function in properly indicated patients with unicompartmental knee osteoarthritis [11]. Free-floating interpositional devices, such as unispacers, are not recommended [11]. A stepwise approach with graduated interventional treatment is advised as pain and functional disability progress [11]. Total knee replacement combined with a 12-week nonsurgical treatment program proved more effective than nonsurgical treatment alone for knee osteoarthritis, though it was associated with more serious adverse events [204].
Operative¶
Indications: The primary indication for total knee arthroplasty is to relieve pain caused by severe arthritis, with or without significant deformity [50]. Radiographic findings must correlate with a clear clinical impression of knee arthritis before surgery is considered [50]. Conservative treatment measures, including physical therapy, antiinflammatory medications, intraarticular injections, activity modifications, and the use of a cane, should be exhausted before surgery is considered [50]. Patients who do not have complete cartilage space loss before surgery tend to be less satisfied with their clinical result after total knee arthroplasty [50]. Total knee arthroplasty is generally indicated in older patients with more sedentary lifestyles due to the finite expected survival of the implant being adversely affected by activity level [50]. It is clearly indicated in younger patients who have significant functional impairment from osteoarthritis, systemic arthritis, or osteonecrosis with subchondral collapse of a femoral condyle [50]. Severe pain from chondrocalcinosis and pseudogout in an elderly patient is an occasional indication for arthroplasty in the absence of complete cartilage space loss [50]. Severe patellofemoral arthritis in an elderly patient may justify total knee arthroplasty because the expected outcome is better than that of patellectomy or patellofemoral replacement [50]. Deformity can become the principal indication for arthroplasty when progression threatens the expected outcome, such as a flexion contracture progressing beyond 20 degrees [50]. Severe varus or valgus laxity may necessitate a constrained condylar prosthesis to prevent subsequent coronal plane instability [50]. Intervening before severe varus or valgus laxity is present allows the use of a prosthesis that lacks coronal plane constraint and has a more favorable expected survivorship [50]. Total knee arthroplasty should be considered as the last surgical option for unicompartmental osteoarthritis [17]. Nonagenarians undergoing primary total knee arthroplasty had low mortality rates at 90 days (0%) and 1 year (2%) with substantial functional improvements [268]. When total knee arthroplasty is used for appropriate indications, high body mass index should not be considered as a contraindication [104]. Obese patients have less improvement in outcomes with total knee arthroplasty [12].
Contraindications: Absolute contraindications to total knee arthroplasty include recent or current knee sepsis, a remote source of ongoing infection, extensor mechanism discontinuity or severe dysfunction, recurvatum deformity secondary to neuromuscular weakness, and the presence of a painless, well-functioning knee arthrodesis [50]. Relative contraindications include medical conditions that compromise the patient’s ability to withstand anesthesia, immunodeficiency, and the significant rehabilitation necessary to ensure a favorable functional outcome [50]. Other relative contraindications include significant atherosclerotic disease of the operative leg, skin conditions such as psoriasis within the operative field, venous stasis disease with recurrent cellulitis, neuropathic arthropathy, superobesity (BMI ≥ 45), recurrent urinary tract infections, and a history of infections in the proximity of the knee [50]. A severely osteoarthritic ipsilateral hip joint should be considered for arthroplasty before the symptomatic osteoarthritic knee because rehabilitation is easier with a total hip arthroplasty and an osteoarthritic knee than with a total knee arthroplasty and an osteoarthritic hip joint [50].
Preoperative Optimization: Patient optimization is key to ensuring the best chance of a good long-term outcome in total knee arthroplasty [50]. Modifiable risk factors to consider before elective total knee arthroplasty include low vitamin D levels, metabolic syndrome, low albumin, neutropenia, superobesity, and a BMI less than 20 [50]. Delaying primary total knee arthroplasty for up to 8 months while a patient works to improve a modifiable risk factor does not appear to worsen the outcome [50]. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline provides 16 recommendations and seven options based on a systematic review of over 1,500 full-text articles to assist surgeons in the surgical management of osteoarthritis of the knee [27].
Surgical Approach / Technique: 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 [3]. 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 [15]. Specifically, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes [116]. Minimally invasive techniques for total knee arthroplasty are encouraged by meta-analysis evidence [16]. However, 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 in total knee arthroplasty [64]. There are relatively few prospective, randomized studies comparing minimally invasive and conventional exposures for knee arthroplasty, and those that exist fail to substantiate any significant clinical benefit of the smaller incision [315]. Combining several procedures in a single setting for the treatment of severe knee osteoarthritis accompanied by extra-articular deformity may eliminate the need for multiple surgeries [112]. The total knee arthroplasty should be performed before surgical reconstruction of the foot is undertaken in patients with a planovalgus foot [115].
Implant Selection: Cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty techniques both provide good results with no difference in surgical complications, range of motion, patient-reported outcome scores, or implant survivorship [64]. No difference in outcomes or complications exists between posterior stabilized and posterior cruciate retaining designs in total knee arthroplasty [12]. Bicruciate retaining (BCR) 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 [64]. Studies have not demonstrated improved survivorship in mobile bearing total knee arthroplasty compared to fixed bearing designs [64]. There is no evidence in support that mobile bearing implants promote greater outcomes compared to fixed bearing implants in primary total knee arthroplasty [272]. All-polyethylene or metal-backed monoblock tibial components have shown good long-term outcomes and are reasonable options for implant choice in total knee arthroplasty [64]. No difference in outcomes exists with use of all polyethylene or modular tibial components in knee arthroplasty [12]. Outcome studies of modern noncemented total knee arthroplasty implants show survivorship and functional outcomes equivalent to cemented prostheses [64]. There is no evidence to support that fixation techniques alone affect the durability of a total knee arthroplasty when design-related failure was excluded [211]. 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 [245]. Cementless fixation did not decrease the rate of revision after total knee arthroplasty compared with the cemented fixation, while the long-term functional recovery was significantly better in the cementless group [270]. In a large cohort of primary total knee arthroplasties, patients with cemented fixation reported early incremental benefit in KOOS-Jr. over those with cementless total knee arthroplasty [279]. 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 [261]. Similar functional outcomes and complication rates exist in tibial component fixation that is cemented or cementless [12]. No difference in pain or function exists with or without patellar resurfacing in total knee arthroplasty [12].
Alignment / Balancing Strategy: Limb alignment remains an area of controversy in total knee arthroplasty, with studies advocating for both mechanical and kinematic alignment [64]. A recent randomized controlled trial showed no significant difference in functional outcomes at 2 years when comparing mechanical and kinematic alignment techniques in total knee arthroplasty [64]. The balancing goal in total knee arthroplasty is full extension and full flexion of the knee [9]. Unbalanced gaps in total knee arthroplasty cause pain from tightness or instability [9]. The flexion gap in total knee arthroplasty is controlled by the posterior cut of the femur, the tibial cut, and the posterior cruciate ligament [9]. The extension gap in total knee arthroplasty is controlled by the distal cut of the femur, the tibial cut, and the posterior capsule [9]. Posterior capsule recession technique in total knee arthroplasty is performed with the knee flexed (≥90 degrees) because the popliteal artery relaxes posteriorly in flexion, making it safer to work posteriorly [9]. For symmetrical gap problems in total knee arthroplasty, the tibia is addressed first; for asymmetrical gap problems, the femur is addressed first [9]. The femoral component in total knee arthroplasty should never be internally rotated [13]. Internal rotation of the femoral component in total knee arthroplasty results in relative lateral tilt of the patella and the patellar groove facing inward [13]. The technique goal for femoral component rotation in total knee arthroplasty is slight external rotation to center the patellar groove under the patella and create a rectangular flexion gap [13]. The native proximal tibia is often in slight varus, with an average mechanical proximal tibial angle of 3 degrees varus [13]. During total knee arthroplasty, the proximal tibia is cut perpendicular to the mechanical axis, which results in a trapezoidal flexion gap if the femur is not externally rotated [13]. A trapezoidal flexion gap in total knee arthroplasty results in relative lateral tilt of the patella, loose lateral compartment instability, or tight medial compartment stiffness [13]. A rectangular flexion gap in total knee arthroplasty results in central patella tracking, a balanced flexion gap, and stability without stiffness [13]. Five established techniques to determine proper femoral component rotation in total knee arthroplasty include the AP axis method, epicondylar axis method, posterior condylar axis method, tibial alignment axis method, and gap balance axis method [13]. In the posterior condylar axis method for total knee arthroplasty, the femoral rotation line is mechanically chosen along a line that is 3 degrees externally rotated to the posterior condylar axis, with an acceptable range of 3–5 degrees of external rotation [13]. Conventional surgical technique allows a precise joint line reconstruction in primary total knee arthroplasty [114].
Patellar Management: Patellar resurfacing versus nonresurfacing remains controversial in total knee arthroplasty [288]. The absolute indication for patellar resurfacing in total knee arthroplasty is inflammatory arthritis [288]. Indications for patellar resurfacing include inflammatory arthritis, patellar bone deformity, and when the primary reason for total knee arthroplasty is patellofemoral joint arthritis with anterior knee pain [288]. Requirements for patellar nonresurfacing include noninflammatory disease, no dysplasia or maltracking, no baja, lower activity level, and an anatomic V-shaped trochlea to match native patella shape [288]. Overall, the risk of reoperation of the patella is lower when the patella is resurfaced compared with nonresurfacing in total knee arthroplasty [288]. Surgeons who selectively resurface the patella have four times higher risk of patellar revision compared to surgeons who routinely resurface [288]. The 10-year all-cause revision is higher when the patella is nonresurfaced compared to resurfacing in total knee arthroplasty [288]. All-cause revision after secondary patellar resurfacing is 4.6 times higher when compared to knees where the patella is initially resurfaced [288]. Anterior knee pain incidence increases over time in nonresurfaced patellae due to articular cartilage wear resulting in point loading of patellar bone in flexion [288]. Problems associated with patellar resurfacing in total knee arthroplasty include patellar implant loosening, patellar bone fracture, patella clunk and crunch, and avascular necrosis with patellar fragmentation [288]. The minimum thickness for the patellar bone cut in total knee arthroplasty should be 13 mm to prevent fracture [288]. An increased Q angle in total knee arthroplasty increases the resultant lateral subluxation force and the risk for patellar subluxation [13]. Maneuvers to improve patellar maltracking in total knee arthroplasty include externally rotating the femoral component, externally rotating the tibial component, lateralizing the femoral component, and lateralizing the tibial component [13]. Maneuvers to avoid in total knee arthroplasty to prevent patellar maltracking include internally rotating the femoral component, internally rotating the tibial component, medializing the femoral component, and medializing the tibial component [13]. The patellar component should be medialized when needed in total knee arthroplasty [13]. Total patellar height should be measured and not overstuffed in total knee arthroplasty [13]. The patellar component should be superiorized when needed for baja and inferior patellar bone trimmed in total knee arthroplasty [13]. Excess valgus limb alignment should always be corrected in total knee arthroplasty [13].
Pain Management: With no known contraindications, treatment with tranexamic acid decreases postoperative blood loss and reduces the need for postoperative transfusions in total knee arthroplasty [12]. Tranexamic acid is a lysine analog that reversibly binds to four to five lysine receptors on plasminogen, blocking conversion to plasmin [12].
Adjuncts: Evidence supports not using intraoperative navigation because there is no difference in pain or complications in total knee arthroplasty [12]. Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points [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 [12]. Evidence supports not using a drain with total knee arthroplasty because there is no difference in complications or outcomes [12].
Complications¶
Infection (PJI): Periprosthetic joint infection is the most common indication for secondary TKA revision and the primary reason for revision within two years of index primary TKA [59, 60]. The incidence of PJI after primary total knee replacement is reported as 0.4% to 2% [312, 358]. Patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis have higher revision rates due to immune inhibitors and altered host cytokine production [59], while rheumatoid arthritis specifically carries a significantly higher rate of deep periprosthetic infections than osteoarthritis [404]. Risk factors include a history of treated PJI [359], aseptic reoperation within one year [361], acute traumatic wound dehiscence (6.5-fold increased risk) [424], and resolved prior bone or joint sepsis (9.7% infection rate) [353]. Over 20% of patients with multiple arthroplasties and a single PJI develop subsequent PJI in another arthroplasty [415]. Revisions for infection are four times more likely to fail than revisions for aseptic loosening [318, 378], and repeat two-stage revision for recurrent knee PJI yields low infection control rates with a 23% amputation rate [398]. PJI is also associated with an increased risk of venous thromboembolism following revision TKA [389].
Aseptic Loosening and Mechanical Failure: Aseptic loosening is the second most common reason for revision TKA and the primary cause of late revision, whereas infection is the primary cause of early revision [59, 391]. In contemporary practice, aseptic loosening is less common compared with national registry data [293]. Cementless fixation is an independent risk factor for aseptic loosening requiring revision within two years [399], and high-viscosity cement is associated with higher odds of revision for aseptic loosening [354]. The proportion of revisions for osteolysis and polyethylene wear was higher for primary TKAs performed prior to 2000 [322]. Early modular bearing exchange for premature bearing failure (5 to 8 years) has a failure rate of 30% to 40% if the cause of excessive wear is not corrected [302]. Revision arthroplasty is associated with lower outcomes and higher infection rates compared to primary replacements [370], and re-revision carries a high risk of early failure [383]. Patients under 55 years undergoing revision TKA have a 5-year revision-free survival of 80% [402]. Survivorship of aseptic conversion TKA was similar to primary TKA for up to 10 years and significantly better than first-time revision TKA [336]. Isolated and full component revision TKA for aseptic loosening does not differ regarding prosthesis failures, complications, or clinical results at 5 years [337].
Patellar / Extensor-Mechanism: Internal rotation of the femoral component results in relative lateral tilt of the patella and causes the patellar groove to face inward [13]. A trapezoidal flexion gap results in relative lateral tilt of the patella, a loose lateral compartment (instability), or a tight medial compartment (stiffness) [13]. Patellar resurfaced TKA has demonstrated superior overall performance with a lower rate of postoperative anterior knee pain and reoperation [419], although no difference in pain or function was found with or without patellar resurfacing in other analyses [12]. Patellar fracture occurred in 4% of knees (8 knees) one to sixty-six months postoperatively in a survivorship analysis of total condylar knee arthroplasty [89].
Stiffness / Arthrofibrosis: Post-operative stiffness continues to be the most common reason for re-operation [293]. Malposition and/or malalignment of implants typically presents with knee stiffness and activity-related pain [59]. The type of anticoagulant used after total knee arthroplasty affects the rate of knee manipulation for postoperative stiffness [388]. In a series of TKA performed after high tibial osteotomy, 9.1% of knees required manipulation under anesthesia for stiffness [252].
Instability: Instability results in abnormal excessive limb subluxation or angulation with weight-bearing stress [59]. Revisions for instability were higher for primary TKAs performed after 2000 compared to those performed prior to 2000 [322]. The cumulative incidence of subsequent revision for aseptic loosening and instability was very low at five years with a fixed-bearing varus-valgus constraint implant in revision TKAs [350].
Periprosthetic Fracture: Periprosthetic fracture is a less common but troublesome source of dysfunction after total knee arthroplasty [72]. Supracondylar fracture occurred in 2% of knees (3 knees) eight to 100 months postoperatively in a survivorship analysis of total condylar knee arthroplasty [89]. Revision TKA secondary to periprosthetic fracture has become less common with the advent of improved internal fixation devices such as locked plates [7]. Bony defects secondary to comminution, multiple previous procedures, broken hardware, and deformity may present technical challenges to a successful outcome [7]. In elderly patients with massive bony defects from distal femoral fractures, distal femoral replacement “megaprostheses” are often required [7]. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events compared to primary knee arthroplasty and revision arthroplasty for elective indications [411].
Thromboembolism: Venous thromboembolism (VTE) after elective total joint arthroplasty continues to occur despite prophylaxis strategies and should not be considered a 'never event' [384]. Elective total knee arthroplasty is associated with a higher incidence and odds of inpatient pulmonary embolism than total hip arthroplasty [373], and multiple procedures pose the highest risk for pulmonary embolism and associated mortality [373]. Prior VTE significantly increased the risk of 90-day DVT, PE, and 2-year PJI after TKA [356]. DVT is common in patients over 60 years of age after TKA [367]. Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE compared with rivaroxaban [375]. In 3512 primary TJA patients treated with aspirin, the cumulative incidence of VTE was <1% at 90 days [365]. No differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis [371]. The use of a tourniquet in primary TKA does not increase the risk of VTE within 90 days [387]. Patients with a prior VTE episode receiving aspirin thromboprophylaxis had comparable odds of developing DVT and lower odds of experiencing PE relative to patients receiving other types of anticoagulation [381]. Staged bilateral TKA during a single period of hospitalization does not increase the incidence of DVT [380]. A significant association exists between alcohol use disorder and the development of VTE after primary TKA [372]. 1% of patients undergoing primary total joint arthroplasty accessed the emergency department for concern for DVT, with only a small portion testing positive [298].
Wound Complications: Compromised wound healing is a less common but troublesome source of dysfunction after total knee arthroplasty [72]. Great care should be taken to prevent narrow, acutely angled skin bridges between connecting incisions and to develop full-thickness flaps during dissection [7]. The anterior knee blood supply originates predominantly from the medial side of the distal thigh and knee [302]. Dissecting and lifting the skin without incorporating the fascial layer can result in skin flap necrosis [302]. If a second incision is required, the minimum distance needed is 7 cm between incisions to avoid skin bridge necrosis [302]. Prior transverse knee incisions should cross at no less than 60 degrees to avoid skin tip necrosis at acute angles [302]. Outpatient TKA led to an increased number of complications although there were no differences in the number of readmissions [434].
Other Considerations: Thromboembolic disease, neurovascular problems, and stiffness are less common but troublesome sources of dysfunction after total knee arthroplasty [72]. Simultaneous bilateral total knee arthroplasty is associated with significantly higher odds of in-hospital complications compared with unilateral arthroplasty: OR 1.51 for minor complication, OR 1.30 for major complication, and OR 2.51 for mortality [84]. The in-hospital mortality rate was 0.15% for simultaneous bilateral TKA compared with 0.07% for unilateral TKA [84]. Fat embolism syndrome prevalence was found to be 12% with simultaneous bilateral TKA in one study, while other authors found no differences in clinically significant fat embolism between simultaneous and staged groups [299]. An increased risk of cardiovascular and neurologic complications has been noted in patients older than 70 years undergoing simultaneous bilateral TKA [299]. Most major medical complications requiring additional physician interventions occur greater than 24 hours following primary THA/TKA [386]. Hospital-acquired conditions (HACs) were the strongest predictor for early readmission after arthroplasty [102]. Urinary tract infections accounted for 33.8% of all HACs, followed by surgical site infections (26.9%), VTE (23.5%), and pneumonia (15.8%) [102]. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exists for patients with cerebrovascular accident sequelae [357]. TKA in Charcot joint is associated with high complication rates, most frequently instability, aseptic loosening, periprosthetic fracture, and PJI [313]. Prior knee surgery is a clinical condition predisposed to a higher postoperative complication rate in primary TKA compared to the no prior surgery group [340]. A high percentage of patients undergoing early revision arthroplasty had at least 1 modifiable risk factor for a primary joint arthroplasty [400]. The rates of perioperative complications, including problems with primary wound-healing, were similar in obese and non-obese groups in one study [295]. Blacks and individuals with low income undergo total knee replacement less frequently and generally have higher rates of adverse outcomes following primary knee replacement [67]. The 10-year mortality rate was 15.2% in a cohort of patients undergoing primary TKA for idiopathic osteoarthritis [78]. Patients undergoing primary and revision knee arthroplasty had lower mortality rates than their age- and sex-matched peers from the general population [437]. 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 [408]. Heterotopic ossification after primary TKA has a relatively low overall rate, but the absence of a single, standardized classification system precludes comparisons of HO severity between studies [54]. A relatively high complication rate was encountered in TKA performed after high tibial osteotomy, including stiffness, superficial wound infection, common peroneal nerve palsy, and intraoperative patellar tendon avulsion [252]. Ten-year survivorship free from aseptic loosening was 95% for TKA after distal femoral osteotomy, though there was a high complication rate secondary to problems with balancing the knee [368]. Complications associated with failure of the primary knee arthroplasty prior to arthrodesis included infection in 65%, mechanical problems in 9%, wound-healing problems in 7%, and extensor mechanism disruption in 5% [284]. Post-operative complications occurred in 46.5% of cases following knee arthrodesis for failed total knee arthroplasty [297]. Eight knees (32%) had a complication after above-the-knee amputation performed after total knee replacement, including five deep infections, one superficial infection, one case of skin necrosis, and one perioperative death [73]. The prevalence of above-the-knee amputation after total knee replacement was 0.14% in one registry study and 0.18% in another series [73].
Recovery¶
Light activity (weeks): Patients undergoing primary total knee arthroplasty (TKA) return to driving considerably earlier than previously reported [80]. Return to driving a car after a primary TKA is highly variable, most commonly occurring around 4 weeks but ranging between 2 and 8 weeks [152]. Driving may be resumed 4 weeks after a right knee replacement, provided the patient drives at low or moderate speed; the best predictor of safe driving is step counts [135]. Advice regarding return to driving following hip or knee arthroplasty should be individualized for each patient, as the patient must feel safe to drive while acknowledging the legal responsibility to remain in control of the vehicle at all times [181]. These results may serve as guidelines for orthopaedic surgeons when advising patients when to resume driving, though advice should be individualised [269].
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 [407]. The findings may serve as a basis for answering patient questions on timing and giving recommendations for returning to sports following standard primary TKA [259]. Return to physical activity is achievable after revision TKA in the same proportion as after primary TKA, but it occurs later [420]. 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 [248]. One third of working patients never returned to work after TKA [274]. Eighty-six percent of patients return to duty following total joint arthroplasty [209].
Complete recovery / outcome plateau (months): Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty [251]. The maximum Oxford knee score is achieved at two years post-operatively, followed by a gradual decline over ten years [433]. 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 [409].
Rehabilitation protocol: The group recommends, by consensus opinion, early mobilization for patients following elective hip and knee arthroplasty [213]. Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized [231]. Future rehabilitation protocols should consider the replaced knee and also the non-replaced knee and surrounding joints [52]. There seems to be an additional need for postoperative rehabilitation after fast-track total knee arthroplasty and unicompartmental knee arthroplasty regarding early functional outcome [236]. Clinically relevant is that the training programme could be considered an alternative to continuous passive motion after total knee arthroplasty [227]. Many observed changes in the knee outcome measures exceeded the MDC thresholds, indicating clinically meaningful benefits from later-stage exercise interventions post-TKA [233]. 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 [193]. 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 [207]. In the rehabilitation period and at the short and mid-term follow-up, no relevant clinical and radiographic differences were found between the MMV and the conventional approach for total knee arthroplasty, making the advantage of MMV total knee arthroplasty cosmetic [223].
Functional milestones: Good early outcomes, as measured by the OKS and EQ-5D, can be anticipated following knee replacement regardless of the patient's age, although younger patients gain greater improvement [44]. The functional status of a large cohort of patients significantly improved after hip and knee replacement based on routine data collection [417]. Patients who have undergone total knee replacement demonstrate a response shift in the measurement of their outcome at six months postoperatively [192]. Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA [185]. The ability to kneel was important to patients and significantly influenced knee-specific PROMs, but was poorly restored by TKA with equal chances of improvement or decline [421]. Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors [210].
Other Considerations: Primary TKAs in patients with AS resulted in significant improvement in clinical outcomes with excellent 10-year implant survivorship [74]. Simultaneous bilateral total knee replacement was associated with a similar reduction of pain intensity and recovery of function compared to unilateral total knee replacement, suggesting the use of simultaneous bilateral total knee replacement in patients with bilateral knee osteoarthritis since its costs and rehabilitation process could be reduced compared to staged bilateral total knee replacement [226]. Same-day total joint arthroplasty is expected to become an everyday procedure for most patients, driven by equivalent or improved patient-reported outcomes and financial incentives, provided appropriate patient selection, optimization, and clinical pathways are followed [275]. Revision total knee arthroplasty results in a similar QALY gain as primary total knee arthroplasty [70].
Key Evidence¶
- [L4] [1] (10.5435/jaaos-d-18-00083)
- [L2] The main objective of total knee arthroplasty is to ensure the best possible outcome for the patient. [2] (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. [3] (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)
- [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. [5] (10.1186/s12891-020-03406-y)
- [L4] Total knee arthroplasty done in young and presumed active patients less than 65 years have excellent survivorship. [6] (10.5435/jaaosglobal-d-22-00116)
- [L4] With careful attention to specific patient and anatomic indications, unicompartmental knee arthroplasty offers clinical results and survivability that are as good, or better, than total knee arthroplasty. [8] (10.1016/j.csm.2013.06.005)
- [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. [15] (10.1016/j.arth.2020.04.031)
- [L1] The present meta-analysis encourages the use of minimally invasive techniques for total knee arthroplasty. [16] (10.1007/s00167-020-06306-9)
- [L5] Total knee arthroplasty should be considered as the last surgical option. [17] (10.1007/s00167-017-4466-1)
- [L3] These patients should not be contraindicated from undergoing unicompartmental knee arthroplasty. [18] (10.1007/s00167-018-5169-y)
- [L5] In recent years, evidence suggests that many of the originally described contraindications to unicompartmental knee arthroplasty (UKA) are no longer applicable in modern clinical practice. [19] (10.1016/j.arth.2024.10.043)
- [L2] The indication criteria for THA/TKA are based on limited evidence. [21] (10.1186/s12891-016-1325-z)
- [L3] Expanded indications for unicompartmental knee arthroplasty were associated with comparable clinical outcomes and great short-term, albeit limited, survivorship. [22] (10.1016/j.arth.2025.08.005)
- [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. [23] (10.2106/00004623-200300001-00006)
- [L1] Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. [24] (10.2106/00004623-200708000-00031)
- [L3] [25] (10.2106/jbjs.19.00432)
- [L5] Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes. [26] (10.2106/jbjs.20.02260)
- [L1] The guideline provides 16 recommendations and seven options based on a systematic review of over 1,500 full-text articles to assist surgeons in the surgical management of osteoarthritis of the knee. [27] (10.5435/jaaos-d-23-00338)
- [L4] The use of knee arthroplasty should be thoroughly monitored with more emphasis on standardization in the decision-making process and preventive measures. [28] (10.1186/s12891-019-2766-y)
- [L5] Amongst specialized knee revision surgeons, there is high variability in clinical and radiological criteria that are seen as important contributing factors to diagnosis of knee implant loosening. [30] (10.1002/ksa.12419)
- [L4] Megaprosthesis implantation in revision knee arthroplasty is an exceptional indication. [31] (10.1007/s00167-012-1945-2)
- [L5] Revision total knee arthroplasty is a challenging procedure requiring a correct diagnosis of the original cause of failure and a detailed plan. [32] (10.1302/2058-5241.6.210018)
- [L3] In case of failed arthroplasty after total knee arthroplasty, data did not allow definite treatment recommendations. [33] (10.1016/j.arth.2020.04.078)
- [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. [34] (10.1016/j.arth.2010.01.004)
- [L5] The Appropriate Use Criteria provide guidance for the surgical management of osteoarthritis of the knee, helping clinicians determine the appropriateness of various surgical options based on patient-specific factors. [35] (10.2106/jbjs.16.01484)
- [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. [36] (10.1007/s00167-011-1545-6)
- [L5] [39] (10.1016/j.arth.2015.05.049)
- [L5] [41] (10.1007/s00167-019-05462-x)
- [L5] The authors acknowledge that this diagnosis is not a universally accepted indication for revision total knee surgery and that further data must be collected regarding long-term outcomes. [43] (10.5435/jaaosglobal-d-24-00399)
- [L3] Good early outcomes, as measured by the OKS and EQ-5D, can be anticipated following knee replacement regardless of the patient's age, although younger patients gain greater improvement. [44] (10.1302/0301-620x.95b1.28061)
- [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. [46] (10.1007/s00167-021-06687-5)
- [L3] A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. [47] (10.1186/s12891-022-05800-0)
- [L5] The optimal surgical treatment of knee osteoarthritis in the young and active patient is still insufficiently defined, requiring a compromise between pain relief, functional restoration, and treatment durability. [48] (10.1007/s00167-006-0195-6)
- [L1] Long-term patient-reported outcome measures for total knee and hip arthroplasty beyond one or two years are often incomplete and lose sensitivity. [49] (10.1302/0301-620x.107b3.bjj-2024-0910.r1)
- [L5] Nearly 20% of patients are dissatisfied following well-performed total knee arthroplasty with good functional outcomes, often due to unfulfilled expectations. [51] (10.5435/jaaos-d-14-00049)
- [L3] Future rehabilitation protocols should consider the replaced knee and also the non-replaced knee and surrounding joints. [52] (10.1016/j.arth.2015.06.052)
- [L3] In salvage total knee arthroplasty the implant design does not significantly affect the overall functional outcome. [53] (10.1007/s00167-003-0401-8)
- [L1] Although studies reported a relatively low overall rate of HO after a primary TKA, the absence of a single, standardized classification system precludes the comparisons of HO severity between studies. [54] (10.5435/jaaosglobal-d-21-00096)
- [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. [56] (10.1016/j.arth.2014.09.017)
- [L4] Total knee arthroplasty can be performed safely with low infection rates and good functional outcomes in end-stage renal failure patients provided careful patient selection is in place, specifically excluding those with stroke or peripheral vascular disease. [57] (10.1016/j.arth.2015.07.019)
- [L4] PJI is the most common indication for secondary TKA revision and within one year after primary TKA. [60] (10.1186/s12891-018-2314-1)
- [L2] In the United States, blacks and individuals with low income undergo total knee replacement less frequently and generally have higher rates of adverse outcomes following primary knee replacement. [67] (10.2106/jbjs.d.02546)
- [L2] Revision total knee arthroplasty results in a similar QALY gain as primary total knee arthroplasty. [70] (10.1002/ksa.12343)
- [L4] [72] (10.5435/00124635-199909000-00004)
- [L3] [73] (10.2106/00004623-200306000-00003)
- [L4] Primary TKAs in patients with AS resulted in significant improvement in clinical outcomes with excellent 10-year implant survivorship. [74] (10.1016/j.arth.2020.06.033)
- [L4] [78] (10.1007/s00167-015-3502-2)
- [L2] Overall, patients undergoing primary TKA returned to driving considerably earlier than previously reported. [80] (10.2106/jbjs.24.01177)
- [L3] [84] (10.2106/jbjs.m.00065)
- [L4] [89] (10.2106/00004623-199274030-00009)
- [L3] [102] (10.1016/j.arth.2015.02.024)
- [L3] When TKA was used for appropriate indications, high BMI should not be considered as a contraindication. [104] (10.1186/s12891-022-05634-w)
- [L4] Combining several procedures in a single setting for the treatment of severe knee osteoarthritis accompanied by extra-articular deformity may eliminate the need for multiple surgeries. [112] (10.1007/s00167-018-4920-8)
- [L3] Conventional surgical technique allows a precise joint line reconstruction in primary TKA. [114] (10.1007/s00167-013-2580-2)
- [L4] The total knee arthroplasty should be performed before surgical reconstruction of the foot is undertaken. [115] (10.2106/jbjs.e.00484)
- [L1] For the vast majority of patients, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes. [116] (10.1016/j.arth.2020.01.065)
- [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. [123] (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. [124] (10.1007/s00167-013-2374-6)
- [L5] [126] (10.1016/j.arth.2007.01.001)
- [L4] Patellar thickness affects patellofemoral kinematics after TKA. [132] (10.1007/s00167-012-2312-z)
- [L5] Kinematically aligned TKA better restores patellar kinematics and PF contact pressure distribution to the native condition than mechanically aligned TKA during deep knee flexion. [133] (10.1007/s00167-018-5270-2)
- [L5] [134] (10.1016/j.arth.2015.03.042)
- [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. [135] (10.1186/1471-2474-15-198)
- [L4] [137] (10.1007/s00167-011-1634-6)
- [L4] [140] (10.1186/s12891-024-08071-z)
- [L1] Kinematic alignment restored native patellar tracking patterns more closely compared to mechanical alignment. [141] (10.1002/ksa.12335)
- [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. [143] (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. [145] (10.1302/0301-620x.102b1.bjj-2019-0328.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. [150] (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. [152] (10.1155/2020/8921892)
- [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. [159] (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. [160] (10.2106/jbjs.e.00147)
- [L5] None of the analysed surgical patellar interventions could restore natural patellar kinematics after TKA. [161] (10.1016/j.arth.2014.07.008)
- [L3] This study has defined a post-operative classification of excellent, good, fair and poor for the components and total WOMAC scores after TKA. [164] (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. [165] (10.1007/s00167-006-0196-5)
- [L3] Pain symptoms of moderate or severe pain are unequivocal when considering a TKA. [166] (10.1007/s00167-015-3961-5)
- [L3] Clinically, elderly patients undergoing hip or knee replacement surgery should perform well in terms of preoperative and perioperative management. [168] (10.1186/s12891-025-08742-5)
- [L3] The estimated lifetime risk of revision knee arthroplasty varied depending on patient sex, age, and underlying diagnosis. [171] (10.1302/0301-620x.104b12.bjj-2021-1631.r3)
- [L4] ED visits following elective major joint replacement were numerous and most commonly for pain-related diagnoses. [175] (10.2106/jbjs.16.00692)
- [L3] Patients aged 68 years or older experience deterioration in functional outcomes and quality of life from 2 to 10 years after total knee arthroplasty. [176] (10.1007/s00167-020-06200-4)
- [L3] Surgical timing preferences for knee replacement vary between patients older than 65 years (immediate surgery only when pain is intense) and younger patients (immediate surgery no matter the amount of pain). [178] (10.1007/s00167-021-06611-x)
- [L5] Recent reports have demonstrated success in expanding the classic indications of unicompartmental knee arthroplasty to younger and heavier patients. [179] (10.5435/jaaos-d-24-00380)
- [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. [181] (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. [182] (10.1186/s12891-020-03583-w)
- [L1] Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA. [185] (10.1007/s00167-012-2349-z)
- [L1] Patients who have undergone total knee replacement demonstrate a response shift in the measurement of their outcome at six months postoperatively. [192] (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. [193] (10.1007/s00167-016-4256-1)
- [L3] Absolute and relative differences in knee dimensions exist between Asian and Caucasian knees, and not all TKA systems fit these phenotypes well. [196] (10.1007/s00167-020-05914-9)
- [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. [204] (10.2106/jbjs.16.00208)
- [L3] When applying the modified joint line obliquity classification, postoperative joint line obliquity was associated with high survival rates following total knee arthroplasty at a mean follow-up of 12.7 years. [206] (10.1016/j.arth.2025.10.114)
- [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. [207] (10.1016/j.arth.2024.12.021)
- [L3] Eighty-six percent of patients return to duty following total joint arthroplasty. [209] (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. [210] (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. [211] (10.1007/s00167-013-2806-3)
- [L4] Good-to-excellent outcomes can be achieved following UKA and TKA in patients less than 65 years of age, with both procedures not contraindicated at younger age. [214] (10.1007/s00167-017-4817-y)
- [L5] Personalised medicine in orthopaedics, specifically the concept of 'Functional Knee Phenotypes', goes beyond utilizing implants manufactured based on individual 3D-data and may help to structure and categorize individual morphology and alignment to identify the optimal TKA strategy. [215] (10.1007/s00167-019-05428-z)
- [L4] [216] (10.1016/j.arth.2026.06.061)
- [L2] The indication for TKA should consider the general health, emotional role and knee function of the patients as well in order to predict patient's outcome. [217] (10.1007/s00167-011-1621-y)
- [L3] With arthroplasty registry adoption of patient-reported outcome measures (PROMs), this study supports precise anatomical categorisation of knee OA in outcome studies. [220] (10.1016/j.jisako.2024.01.002)
- [L1] In the rehabilitation period and at the short and mid-term follow-up, no relevant clinical and radiographic differences were found between the MMV and the conventional approach for total knee arthroplasty, making the advantage of MMV total knee arthroplasty cosmetic. [223] (10.2106/jbjs.15.00654)
- [L5] The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures. [224] (10.1302/0301-620x.96b6.34040)
- [L3] Simultaneous bilateral total knee replacement was associated with a similar reduction of pain intensity and recovery of function compared to unilateral total knee replacement, suggesting the use of simultaneous bilateral total knee replacement in patients with bilateral knee osteoarthritis since its costs and rehabilitation process could be reduced compared to staged bilateral total knee replacement. [226] (10.1186/s12891-020-03269-3)
- [L2] Clinically relevant is that the training programme could be considered an alternative to continuous passive motion after total knee arthroplasty. [227] (10.1007/s00167-018-4918-2)
- [L5] Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized. [231] (10.1016/j.arth.2024.10.105)
- [L1] Many observed changes in the knee outcome measures exceeded the MDC thresholds, indicating clinically meaningful benefits from later-stage exercise interventions post-TKA. [233] (10.1186/s13018-025-06430-7)
- [L5] This study successfully established a consensus among knee revision surgeons on the definition of intraoperatively determined component loosening. [234] (10.1002/ksa.12357)
- [L2] There seems to be an additional need for postoperative rehabilitation after fast-track total knee arthroplasty and unicompartmental knee arthroplasty regarding early functional outcome. [236] (10.1007/s00167-012-1919-4)
- [L4] A complete implant library containing characteristics of 32,500 orthopaedic implants was developed, covering about 85 different hip and 85 different knee implants. [242] (10.1302/2058-5241.4.180063)
- [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. [245] (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. [246] (10.1002/ksa.12206)
- [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. [248] (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. [249] (10.2106/jbjs.17.01657)
- [L4] Recovery in knee range of motion reaches a plateau by 12 months after total knee arthroplasty. [251] (10.1007/s00167-014-3212-1)
- [L4] [252] (10.1186/s13018-023-04199-1)
- [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. [259] (10.1007/s00167-020-06400-y)
- [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. [261] (10.1007/s00167-020-06028-y)
- [L4] Nonagenarians undergoing primary TKA had low mortality rates at 90 days (0%) and 1 year (2%) with substantial functional improvements. [268] (10.1016/j.arth.2021.05.015)
- [L1] These results may serve as guidelines for orthopaedic surgeons when advising patients when to resume driving, though advice should be individualised. [269] (10.1302/0301-620x.99b5.bjj-2016-1064.r1)
- [L1] Cementless fixation did not decrease the rate of revision after the total knee arthroplasty compared with the cemented fixation, while the long-term functional recovery was significantly better in the cementless group. [270] (10.1186/s13018-021-02299-4)
- [L1] There is no evidence in support that mobile bearing implants promote greater outcomes compared to fixed bearing implants in primary total knee arthroplasty. [272] (10.1007/s00167-022-07065-5)
- [L5] [273] (10.5435/00124635-200307000-00003)
- [L4] One third of working patients never returned to work after TKA. [274] (10.1016/j.arth.2014.01.004)
- [L5] Same-day total joint arthroplasty is expected to become an everyday procedure for most patients, driven by equivalent or improved patient-reported outcomes and financial incentives, provided appropriate patient selection, optimization, and clinical pathways are followed. [275] (10.1016/j.arth.2023.11.018)
- [L1] Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. [278] (10.1007/s00167-021-06487-x)
- [L3] In a large cohort of primary TKAs, patients with cemented fixation reported early incremental benefit in KOOS-Jr. over those with cementless TKA. [279] (10.1186/s12891-022-05899-1)
- [L3] [284] (10.2106/jbjs.15.01363)
- [L4] The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for THA, but not for TKA. [286] (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. [291] (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. [292] (10.1186/s12891-023-06926-5)
- [L3] [293] (10.1302/0301-620x.99b5.bjj-2016-0617.r3)
- [L2] [295] (10.2106/00004623-200408000-00002)
- [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. [296] (10.1186/s12891-017-1871-z)
- [L3] [297] (10.1016/j.arth.2013.09.054)
- [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. [298] (10.5435/jaaos-d-20-00878)
- [L4] [301] (10.1016/j.arth.2020.02.030)
- [L3] The diagnostic benefits of SPECT/CT in patients after total knee arthroplasty have been proven. [303] (10.1177/2325967116s00051)
- [L3] [307] (10.1016/j.arth.2007.03.025)
- [L3] [312] (10.1016/j.arth.2014.03.012)
- [L4] [313] (10.1016/j.arth.2020.08.008)
- [L3] Routine screening is not necessary, but patients with persistent hip or knee pain should be assessed with MRI. [314] (10.1016/j.arth.2007.01.006)
- [L4] [315] (10.1016/j.arth.2006.12.055)
- [L5] [316] (10.5435/00124635-200211000-00005)
- [L3] [318] (10.1016/j.arth.2008.04.020)
- [L1] A longer interval between infection and total joint arthroplasty reduced the risk of PJI, and two-stage arthroplasty was associated with a higher rate of PJI. [320] (10.1016/j.arth.2026.06.056)
- [L4] [321] (10.1007/s00167-007-0397-6)
- [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. [322] (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. [324] (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. [326] (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. [327] (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. [328] (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. [330] (10.1007/s00167-015-3806-2)
- [L4] A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy. [333] (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. [336] (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. [337] (10.1016/j.arth.2022.09.006)
- [L3] A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively. [339] (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. [340] (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. [341] (10.1186/1471-2474-12-36)
- [L2] The diagnostic benefits of SPECT/CT in patients with pain after primary TKA have been proven, with excellent sensitivity and specificity for detection of tibial or femoral component loosening and patellofemoral OA surgically confirmed. [343] (10.1007/s00167-019-05609-w)
- [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. [350] (10.1302/0301-620x.102b4.bjj-2019-0719.r2)
- [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. [353] (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. [354] (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. [356] (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. [357] (10.1016/j.arth.2022.06.026)
- [L3] A history of PJI predisposes patients to subsequent PJI in primary THA or TKA. [359] (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. [361] (10.1016/j.arth.2020.06.054)
- [L1] Utilization of this axial weight-bearing view to evaluate total knee arthroplasty may provide additional information over standard radiographic views. [363] (10.2106/jbjs.e.00432)
- [L4] Simultaneous biplane radiography can accurately assess the motion of total joint replacements in vivo and may become an important adjunct in postoperative management to detect early changes before clinical or radiographic evidence of loosening is apparent. [364] (10.2106/00004623-198466040-00028)
- [L3] In 3512 primary TJA patients treated with ASA, we found a cumulative incidence of VTE <1% at 90 days. [365] (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. [366] (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. [367] (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. [368] (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
- [L4] In this study, we describe novel radiographic findings of anterior heterotopic bone formation and cysts that develop in patients who have aseptic loosening following primary total knee arthroplasty. [369] (10.1016/j.arth.2023.01.031)
- [L3] Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements. [370] (10.1155/2018/8987104)
- [L3] No differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis. [371] (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. [372] (10.5435/jaaos-d-20-00466)
- [L4] Elective total knee arthroplasty is associated with a higher incidence and odds of inpatient pulmonary embolism than is total hip arthroplasty; multiple procedures pose the highest risk for pulmonary embolism and associated mortality. [373] (10.2106/jbjs.l.00466)
- [L3] Assessment of medial cartilage thickness loss using MRI provides additional utility over standard radiographs in preoperative assessments of medial UKA patients. [374] (10.1002/ksa.12611)
- [L2] Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE following primary TKA surgery compared with treatment with rivaroxaban. [375] (10.1302/0301-620x.103b10.bjj-2021-0023.r1)
- [L4] In a patient who has an unsatisfactory response to their first knee replacement, the best predictor of achieving a satisfactory response to their contralateral knee replacement is the level of radiographic osteoarthritis in that knee. [376] (10.1007/s00167-021-06465-3)
- [L3] Mild radiographic knee OA was the main predicting factor for dissatisfaction after TKA, suggesting that performing TKA for such patients should be carefully considered. [377] (10.1186/s12891-021-04543-8)
- [L3] Mechanisms of failure for revision total knee arthroplasties are different than for primary total knee arthroplasty, with revisions for infection being 4 times more likely to fail than revisions for aseptic loosening. [378] (10.1016/j.arth.2008.01.228)
- [L3] Routine preoperative DVT evaluation is probably not necessary, and staged bilateral TKA during a single period of hospitalization does not increase the incidence of DVT. [380] (10.1186/s12891-018-2166-8)
- [L3] Patients with a prior VTE episode receiving aspirin thromboprophylaxis following primary TJA had comparable odds of developing DVT and lower odds of experiencing PE relative to patients receiving other types of anticoagulation. [381] (10.1016/j.arth.2025.10.069)
- [L1] To prevent for malalignment, MRI should be the imaging modality of choice when performing TKA surgery with PSI. [382] (10.1007/s00167-017-4637-0)
- [L3] Re-revision knee arthroplasty carried a high risk of early failure. [383] (10.1016/j.arth.2023.01.030)
- [L5] Venous thromboembolism (VTE) after elective total joint arthroplasty continues to occur despite various strategies in prophylaxis and should not be considered a 'never event.' [384] (10.2106/jbjs.21.01529)
- [L5] Improving long-term outcomes after total knee arthroplasty requires moving beyond the static concept of 'correct alignment option' to integrate static images with dynamic and kinetic insights. [385] (10.1002/ksa.70010)
- [L3] Most major medical complications requiring additional physician interventions occur greater than 24 hours following primary THA/TKA. [386] (10.1016/j.arth.2015.01.056)
- [L2] In contemporary TKAs the rate of VTE within 90 days is low and not significantly altered by tourniquet-use. [387] (10.1007/s00167-022-06965-w)
- [L3] Surgeons should consider these data when selecting thromboprophylaxis for patients after total knee replacement. [388] (10.2106/jbjs.17.01110)
- [L3] The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis. [389] (10.2106/jbjs.20.01486)
- [L3] Aseptic loosening and infection are the most common causes of failure in contemporary total knee arthroplasty, with infection being the primary cause of early revision and loosening the primary cause of late revision. [391] (10.1016/j.arth.2013.07.024)
- [L3] Patients undergoing TKR exhibited significantly worse baseline clinical outcomes, particularly in WOMAC scores, despite having similar radiographic severity to those receiving conservative treatment, suggesting that functional and symptomatic measures may be more valuable than radiographic findings in determining surgical intervention. [392] (10.1186/s13018-025-05552-2)
- [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. [393] (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. [396] (10.1016/j.arth.2026.01.042)
- [L4] The SPECT/CT algorithm presented is both reliable and useful in the management of patients with painful TKA. [397] (10.1007/s00167-010-1070-z)
- [L3] Repeat two-stage revision for recurrent knee PJI yields low infection control rates and major morbidity, including a 23% amputation rate. [398] (10.1016/j.arth.2026.01.057)
- [L3] In this large national database, cementless fixation was found to be an independent risk factor for aseptic loosening requiring revision and any reoperation within 2 years after primary TKA. [399] (10.1016/j.arth.2023.02.058)
- [L3] A high percentage of patients undergoing early revision arthroplasty had at least 1 modifiable risk factor for a primary joint arthroplasty. [400] (10.1016/j.arth.2017.07.005)
- [L3] Survival rates decreased with time, particularly more than 10 years post-surgery, for both primary and revision TKAs. [401] (10.1016/j.otsr.2017.10.003)
- [L3] Patients less than 55 years undergoing revision TKA have a modest 5-year revision-free survival of 80%. [402] (10.1016/j.arth.2020.12.008)
- [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. [404] (10.1007/s00167-016-4306-8)
- [L4] Most patients can expect to resume physical activity or sports within a short timeframe after knee arthroplasty, particularly to low-impact activities. [407] (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. [408] (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. [409] (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. [411] (10.1302/0301-620x.103b10.bjj-2020-2590.r1)
- [L3] Extended antibiotic prophylaxis in TKA was not associated with reduced PJI rates in both normal and high-risk patients at two years. [414] (10.1016/j.arth.2025.10.017)
- [L4] Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% occurring in another arthroplasty. [415] (10.1016/j.arth.2023.03.014)
- [L4] The functional status of a large cohort of patients significantly improved after hip and knee replacement based on routine data collection. [417] (10.1186/s12891-017-1455-y)
- [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. [419] (10.1007/s00402-019-03246-z)
- [L3] Return to physical activity is achievable after revision TKA in the same proportion as after primary TKA, but it occurs later. [420] (10.1002/ksa.12638)
- [L2] The ability to kneel was important to patients and significantly influenced knee-specific PROMs, but was poorly restored by TKA with equal chances of improvement or decline. [421] (10.1302/0301-620x.103b9.bjj-2020-2129.r2)
- [L3] Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. [422] (10.1016/j.arth.2021.02.037)
- [L3] Future randomized prospective clinical trials are needed to validate the efficacy of regional prophylactic antibiotics in reducing the PJI risk in primary TKA. [423] (10.1097/corr.0000000000001919)
- [L3] Acute, traumatic wound dehiscence following primary TKA is a rare event associated with a 6.5-fold increased risk of PJI. [424] (10.1302/0301-620x.103b6.bjj-2020-2425.r1)
- [L3] The maximum Oxford knee score is achieved at two years post-operatively, followed by a gradual decline over ten years. [433] (10.1302/0301-620x.95b1.28573)
- [L1] This meta-analysis documented that outpatient TKA led to an increased number of complications although there were no differences in the number of readmissions. [434] (10.1186/s13018-020-01925-x)
- [L3] Patients undergoing primary and revision knee arthroplasty had lower mortality rates than their age- and sex-matched peers from the general population. [437] (10.1302/0301-620x.104b1.bjj-2021-0753.r1)
- [L3] Our data suggest that the implant survival and clinical outcomes were inferior to primary TKA. [440] (10.1302/0301-620x.107b12.bjj-2025-0184.r2)
See Also¶
- Knee osteoarthritis
- Meniscal root tear
- Patellofemoral instability
- Unicompartmental knee replacement
- Knee arthroscopy
- Partial meniscectomy
- High tibial osteotomy
- Distal femoral osteotomy
References¶
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