A Comprehensive Review of Operative Considerations, Surgical Techniques, Outcomes, and Future Perspectives in Total Knee Arthroplasty

Abstract

Total knee arthroplasty (TKA) is still the gold-standard operative procedure for treating end-stage knee osteoarthritis, a disease impacting millions of patients worldwide and a key contributor to disability. As prevalence rates rise, the number of TKA procedures continues to increase. This review covers surgical procedure history, implant choices, perioperative guidelines, and technologies shaping TKA's future. We performed a comprehensive narrative review of published literature on several aspects of TKA. Significant areas of comparison include cemented versus cementless fixation, mobile versus fixed bearing, posterior-stabilized versus ultra-congruent design, and single-radius versus multi-radius femoral design. The review encompasses preoperative optimization, alignment methods, robotic and sensor-aided surgery, postoperative rehabilitation, and outcomes. The data were collected from peer-reviewed journals, randomized controlled trials, clinical trials, and systematic reviews. Cemented TKA remains the norm, but a cementless approach has equivalent outcomes in younger patients. Subtle functional benefits may exist with mobile-bearing designs, and newer designs, such as medial pivot implants, aim at optimizing kinematics. Robotic and sensor systems enhance implant accuracy and soft-tissue balance, providing short-term benefits such as improved function, reduced errors, and decreased blood loss. However, long-term outcomes, including implant durability and sustained function, remain uncertain. Optimizing the preoperative state and providing patient education have a significant impact on the postoperative state, and an early functional advantage is often associated with minimally invasive approaches. Several upcoming advancements, like AI-assisted surgery, outpatient arthroplasty, and 3D patient-specific printed implants, could positively influence the planning and execution of TKA. Nonetheless, their broad adoption is hindered by high costs, limited accessibility, and the requirement for additional validation via extensive, long-term studies. These evidence gaps need to be filled before such technologies can be seamlessly incorporated into standard clinical routines. However, the aforementioned technologies and approaches require further studies to confirm their efficacy and safety. While TKA outcomes remain excellent, the continuous improvement of techniques, devices, and patient selection remains crucial to achieving optimal long-term outcomes with fewer complications.