Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Total knee arthroplasty

Gregory M Martin, MD
Marianna Crowley, MD
Section Editor
Daniel E Furst, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH


Total knee arthroplasty, also known as total knee replacement, is one of the most commonly performed orthopedic procedures. As of 2010, over 600,000 total knee replacements were being performed annually in the United States and were increasingly common [1]. Among older patients in the United States, the per capita number of primary total knee replacements doubled from 1991 to 2010 (from 31 to 62 per 10,000 Medicare enrollees annually) [2]. The number of total knee replacements performed annually in the United States is expected to grow by 673 percent to 3.48 million procedures by 2030 [3]. A variety of pathologic conditions affecting the knee can be treated with total knee replacement, leading to pain relief, to restoration of function, and to mobility.

The normal knee joint functions as a complex hinge, primarily allowing flexion and extension but also allowing rotation and gliding. The knee joint is made up of three compartments: lateral, medial, and patellofemoral. Damage to the cartilage of one or more compartments may be the result of osteoarthritis (idiopathic or posttraumatic), inflammatory arthritis (rheumatoid, psoriatic, etc), avascular necrosis, tumors, or congenital deformities. Over 95 percent of total knee replacements in the United States are performed for osteoarthritis [1,4].

The introduction of the "total condylar prosthesis" by Insall and colleagues in 1972 is generally considered to mark the era of "modern" knee replacement [5]. This prosthesis was the first to replace all three compartments of the knee. There are variations of the original design, and there is increasing interest in partial (unicompartmental) knee replacements. (See 'Choice of prosthesis and fixation technique' below and 'Alternatives to total knee arthroplasty' below.)

Modern total knee arthroplasty consists of resection of the diseased articular surfaces of the knee, followed by resurfacing with metal and polyethylene prosthetic components. For the properly selected patient, the procedure results in significant pain relief, as well as improved function and quality of life [6].

Despite the potential benefits of total knee arthroplasty, it is an elective procedure and should only be considered after extensive discussion of the risks, benefits, and alternatives. This topic reviews aspects of total knee arthroplasty including preoperative, operative, and postoperative considerations.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 16, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. HCPUnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. http://hcupnet.ahrq.gov (Accessed on December 20, 2012).
  2. Cram P, Lu X, Kates SL, et al. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012; 308:1227.
  3. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780.
  4. Mahomed NN, Barrett J, Katz JN, et al. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am 2005; 87:1222.
  5. Insall JN. Historical development, classification, and characteristics of knee prostheses. In: Surgery of the Knee, 2nd, Insall JN (Ed), Churchill Livingstone, New York 1993.
  6. Lavernia CJ, Guzman JF, Gachupin-Garcia A. Cost effectiveness and quality of life in knee arthroplasty. Clin Orthop Relat Res 1997; :134.
  7. Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am 2003; 85-A:259.
  8. Bayliss LE, Culliford D, Monk AP, et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet 2017; 389:1424.
  9. Meehan JP, Danielsen B, Kim SH, et al. Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Joint Surg Am 2014; 96:529.
  10. Kerkhoffs GM, Servien E, Dunn W, et al. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am 2012; 94:1839.
  11. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arthritis Rheum 2005; 52:3143.
  12. Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 2003; 85-A:27.
  13. Robinson CM, Christie J, Malcolm-Smith N. Nonsteroidal antiinflammatory drugs, perioperative blood loss, and transfusion requirements in elective hip arthroplasty. J Arthroplasty 1993; 8:607.
  14. Connelly CS, Panush RS. Should nonsteroidal anti-inflammatory drugs be stopped before elective surgery? Arch Intern Med 1991; 151:1963.
  15. Stoner SC, Lea JW, Dubisar BM, Farrar C. Possible international normalized ratio elevation associated with celecoxib and warfarin in an elderly psychiatric patient. J Am Geriatr Soc 2003; 51:728.
  16. Stading JA, Skrabal MZ, Faulkner MA. Seven cases of interaction between warfarin and cyclooxygenase-2 inhibitors. Am J Health Syst Pharm 2001; 58:2076.
  17. Mersfelder TL, Stewart LR. Warfarin and celecoxib interaction. Ann Pharmacother 2000; 34:325.
  18. Schwartz JI, Bugianesi KJ, Ebel DL, et al. The effect of rofecoxib on the pharmacodynamics and pharmcokinetics of warfarin. Clin Pharmacol Ther 2000; 68:626.
  19. Herrlin S, Hållander M, Wange P, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc 2007; 15:393.
  20. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013; 368:1675.
  21. Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 2003; 85-A:4.
  22. Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007; 89:1220.
  23. Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain 2011; 152:566.
  24. Lingard EA, Katz JN, Wright EA, et al. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am 2004; 86-A:2179.
  25. Gill GS, Joshi AB. Long-term results of cemented, posterior cruciate ligament-retaining total knee arthroplasty in osteoarthritis. Am J Knee Surg 2001; 14:209.
  26. Ritter MA, Stringer EA. Predictive range of motion after total knee replacement. Clin Orthop Relat Res 1979; :115.
  27. Whiteside LA, Mihalko WM. Surgical procedure for flexion contracture and recurvatum in total knee arthroplasty. Clin Orthop Relat Res 2002; :189.
  28. Skou ST, Rasmussen S, Laursen MB, et al. The efficacy of 12 weeks non-surgical treatment for patients not eligible for total knee replacement: a randomized controlled trial with 1-year follow-up. Osteoarthritis Cartilage 2015; 23:1465.
  29. Skou ST, Roos EM, Laursen MB, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med 2015; 373:1597.
  30. Coventry MB. Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report. 1965. Clin Orthop Relat Res 1989; :4.
  31. Coventry MB. Osteotomy about the knee for degenerative and rheumatoid arthritis. J Bone Joint Surg Am 1973; 55:23.
  32. Phillips MJ, Krackow KA. High tibial osteotomy and distal femoral osteotomy for valgus or varus deformity around the knee. Instr Course Lect 1998; 47:429.
  33. Brouwer RW, Jakma TS, Bierma-Zeinstra SM, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev 2005; :CD004019.
  34. Rinonapoli E, Mancini GB, Corvaglia A, Musiello S. Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop Relat Res 1998; :185.
  35. Takai S, Yoshino N, Hirasawa Y. Revision total knee arthroplasty after failed high tibial osteotomy. Bull Hosp Jt Dis 1997; 56:245.
  36. Meding JB, Keating EM, Ritter MA, Faris PM. Total knee arthroplasty after high tibial osteotomy. A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000; 82:1252.
  37. Stähelin T, Hardegger F, Ward JC. Supracondylar osteotomy of the femur with use of compression. Osteosynthesis with a malleable implant. J Bone Joint Surg Am 2000; 82:712.
  38. Cameron HU, Botsford DJ, Park YS. Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997; 40:114.
  39. McKeever DC. The classic: Patellar prosthesis.1955. Clin Orthop Relat Res 2005; 440:13.
  40. McKeever DC. The classic: Tibial plateau prosthesis.1960. Clin Orthop Relat Res 2005; 440:4.
  41. Schai PA, Suh JT, Thornhill TS, Scott RD. Unicompartmental knee arthroplasty in middle-aged patients: a 2- to 6-year follow-up evaluation. J Arthroplasty 1998; 13:365.
  42. Newman JH, Ackroyd CE, Shah NA. Unicompartmental or total knee replacement? Five-year results of a prospective, randomised trial of 102 osteoarthritic knees with unicompartmental arthritis. J Bone Joint Surg Br 1998; 80:862.
  43. Smith AM, Peckett WR, Butler-Manuel PA, et al. Treatment of patello-femoral arthritis using the Lubinus patello-femoral arthroplasty: a retrospective review. Knee 2002; 9:27.
  44. Merchant AC. Early results with a total patellofemoral joint replacement arthroplasty prosthesis. J Arthroplasty 2004; 19:829.
  45. Cartier P, Sanouiller JL, Grelsamer RP. Unicompartmental knee arthroplasty surgery. 10-year minimum follow-up period. J Arthroplasty 1996; 11:782.
  46. Tabor OB Jr, Tabor OB. Unicompartmental arthroplasty: a long-term follow-up study. J Arthroplasty 1998; 13:373.
  47. Levine WN, Ozuna RM, Scott RD, Thornhill TS. Conversion of failed modern unicompartmental arthroplasty to total knee arthroplasty. J Arthroplasty 1996; 11:797.
  48. Chakrabarty G, Newman JH, Ackroyd CE. Revision of unicompartmental arthroplasty of the knee. Clinical and technical considerations. J Arthroplasty 1998; 13:191.
  49. Leopold SS. Minimally invasive total knee arthroplasty for osteoarthritis. N Engl J Med 2009; 360:1749.
  50. Campbell's Operative Orthopaedics, 9th, Mosby, 1999.
  51. Archibeck MJ, Berger RA, Garvin KL, et al. Orthopaedic Knowledge Update 7, Koval KJ (Ed), AAOS, 2002. p.517.
  52. Ansari S, Ackroyd CE, Newman JH. Kinematic posterior cruciate ligament-retaining total knee replacements. A 10-year survivorship study of 445 arthroplasties. Am J Knee Surg 1998; 11:9.
  53. Hanyu T, Murasawa A, Tojo T. Survivorship analysis of total knee arthroplasty with the kinematic prosthesis in patients who have rheumatoid arthritis. J Arthroplasty 1997; 12:913.
  54. Malkani AL, Rand JA, Bryan RS, Wallrichs SL. Total knee arthroplasty with the kinematic condylar prosthesis. A ten-year follow-up study. J Bone Joint Surg Am 1995; 77:423.
  55. Emmerson KP, Moran CG, Pinder IM. Survivorship analysis of the Kinematic Stabilizer total knee replacement: a 10- to 14-year follow-up. J Bone Joint Surg Br 1996; 78:441.
  56. Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res 1997; :79.
  57. Colizza WA, Insall JN, Scuderi GR. The posterior stabilized total knee prosthesis. Assessment of polyethylene damage and osteolysis after a ten-year-minimum follow-up. J Bone Joint Surg Am 1995; 77:1713.
  58. Verra WC, van den Boom LG, Jacobs W, et al. Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis. Cochrane Database Syst Rev 2013; :CD004803.
  59. Buechel FF. Cementless meniscal bearing knee arthroplasty: 7- to 12-year outcome analysis. Orthopedics 1994; 17:833.
  60. Armstrong RA, Whiteside LA. Results of cementless total knee arthroplasty in an older rheumatoid arthritis population. J Arthroplasty 1991; 6:357.
  61. Thienpont E, Schwab PE, Fennema P. Efficacy of Patient-Specific Instruments in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2017; 99:521.
  62. Keeney JA. Innovations in Total Knee Arthroplasty: Improved Technical Precision, But Unclear Clinical Benefits. Orthopedics 2016; 39:217.
  63. Johnson RL, Kopp SL, Burkle CM, et al. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 2016; 116:163.
  64. Biboulet P, Morau D, Aubas P, et al. Postoperative analgesia after total-hip arthroplasty: Comparison of intravenous patient-controlled analgesia with morphine and single injection of femoral nerve or psoas compartment block. a prospective, randomized, double-blind study. Reg Anesth Pain Med 2004; 29:102.
  65. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 2008; 108:703.
  66. Siddiqui ZI, Cepeda MS, Denman W, et al. Continuous lumbar plexus block provides improved analgesia with fewer side effects compared with systemic opioids after hip arthroplasty: a randomized controlled trial. Reg Anesth Pain Med 2007; 32:393.
  67. Jaeger P, Nielsen ZJ, Henningsen MH, et al. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 2013; 118:409.
  68. Zhao XQ, Jiang N, Yuan FF, et al. The comparison of adductor canal block with femoral nerve block following total knee arthroplasty: a systematic review with meta-analysis. J Anesth 2016; 30:745.
  69. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008; 79:174.
  70. Parvataneni HK, Shah VP, Howard H, et al. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty 2007; 22:33.
  71. Amundson AW, Johnson RL, Abdel MP, et al. A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty. Anesthesiology 2017; 126:1139.
  72. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007; 335:812.
  73. Buhagiar MA, Naylor JM, Harris IA, et al. Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial. JAMA 2017; 317:1037.
  74. He ML, Xiao ZM, Lei M, et al. Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty. Cochrane Database Syst Rev 2014; :CD008207.
  75. Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev 2014; :CD004260.
  76. Jones DL, Cauley JA, Kriska AM, et al. Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study. J Rheumatol 2004; 31:1384.