Total Knee Arthroplasty- A Review of Emerging Trends in Patient Management and Surgical Practices
Asian Journal of Orthopaedic Research,
Background: Osteoarthritis is a chronic, multifactorial, degenerative disorder commonly seen in elderly with predominance for females above the age of 45yrs with largely unknown etiology. With the rising demand for TKA in the foreseeable future, our aim is to assess the emerging trends in patient management and surgical practices for TKA.
Material and Methods: A narrative review of current literature analyzing the patient characteristics, current practices in peri-operative management, methods to control blow loss, pain management and recent advances in TKA.
Results: Literature describes that the prevalence of osteoarthritis of knee along with average BMI and associated comorbidities are on the rise. Emphasis is being laid on blood preservation, including iron therapy, erythropoietin tranexamic acid, low pressure tourniquet, acute normovolemic hemodilution. Multimodal analgesia including pre-emptive analgesia, peri articular injections, peripheral nerve blocks play a major role in pain management. The use of artificial intelligence, Robotics, 3D printing and Computer assisted navigation in TKA in recent years shows a promising future.
Conclusion: Favorable outcomes have been observed with various blood preservation and pain management techniques. TKA remains the forefront of evolution of scientific innovation that have a great potential for refining the TKA alignment and biomechanical outcome to subsequently reduce the incidence of TKA revision and improve patient’s satisfaction. However, further Level 1 studies are required to assess the long-term outcomes.
- tranexamic acid
- normovolemlic haemodilution
- multimodal analgesia;
How to Cite
Singh JA. Epidemiology of Knee and Hip Arthroplasty: A Systematic Review§. Open Orthop J. 2011;5:80–5.
Kumar H, Pal CP, Sharma YK, Kumar S, Uppal A. Epidemiology of knee osteoarthritis using Kellgren and Lawrence scale in Indian population. J Clin Orthop Trauma. 2020;11:S125–9.
Heckmann N, Ihn H, Stefl M, Etkin CD, Springer BD, Berry DJ, et al. Early results from the American joint replacement registry: A comparison with other national registries. J Arthroplasty. Elsevier; 2019;34:S125-S134.e1.
Goudie EB, Robinson C, Walmsley P, Brenkel I. Changing trends in total knee replacement. Eur J Orthop Surg Traumatol. 2017;27:539–44.
Liu J, Wilson L, Poeran J, Fiasconaro M, Kim DH, Yang E, et al. Trends in total knee and hip arthroplasty recipients: a retrospective cohort study. Reg Anesth Pain Med. 2019;44:854–9.
Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. JBJS. 2014;96:272–278.
Muñoz M, Acheson AG, Auerbach M, Besser M, Habler O, Kehlet H, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia. 2017;72:233–47.
Baron DM, Hochrieser H, Posch M, Metnitz B, Rhodes A, Moreno RP, et al. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth. 2014;113:416–23.
Petis SM, Lanting BA, Vasarhelyi EM, Naudie DDR, Ralley FE, Howard JL. Is there a role for preoperative iron supplementation in patients preparing for a total hip or total knee arthroplasty? J Arthroplasty. 2017;32:2688–93.
Alsaleh K, Alotaibi GS, Almodaimegh HS, Aleem AA, Kouroukis CT. The use of preoperative erythropoiesis-stimulating agents (ESAs) in patients who underwent knee or hip arthroplasty: a meta-analysis of randomized clinical trials. J Arthroplasty. 2013;28:1463–72.
Lin DM, Lin ES, Tran M-H. Efficacy and safety of erythropoietin and intravenous iron in perioperative blood management: A systematic review. Transfus Med Rev. 2013;27:221–34.
Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: A systematic review and meta-analysis. J Bone Joint Surg Br. 2011;93:1577–85.
Chen Y, Chen Z, Cui S, Li Z, Yuan Z. Topical versus systemic tranexamic acid after total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2016;95:e4656.
Nielsen CS, Jans Ø, Ørsnes T, Foss NB, Troelsen A, Husted H. Combined Intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2016;98:835–41.
Lei Y-T, Xie J-W, Huang Q, Huang W, Pei F-X. The antifibrinolytic and anti-inflammatory effects of a high initial-dose tranexamic acid in total knee arthroplasty: A randomized controlled trial. Int Orthop. 2020;44:477–86.
Zhang S, Xie J, Cao G, Lei Y, Huang Q, Pei F. Six-Dose Intravenous tranexamic acid regimen further inhibits postoperative fibrinolysis and reduces hidden blood loss following total knee arthroplasty. J Knee Surg. 2019;s-0039-1694768.
Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: A meta-analysis. J Orthop Surg. 2019;14:348.
Yasin S, Sood C, Dubey CR, Manzoor N, kompani A. Blood loss and tourniquet in total knee replacement surgery: A randomised control study. J Arthrosc Jt Surg. 2020;7:122–6.
Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg. 2014;9:13.
Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 1999;81:30–3.
Ayik O, Demirel M, Birisik F, Ersen A, Balci HI, Sahinkaya T, et al. The effects of tourniquet application in total knee arthroplasty on the recovery of thigh muscle strength and clinical outcomes. J Knee Surg. 2020;s-0040-1701454.
Goel R, Rondon AJ, Sydnor K, Blevins K, O’Malley M, Purtill JJ, et al. Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. J Bone Jt Surg. 2019;101:1821–8.
Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F. The effect of tourniquet usage on cement penetration in total knee arthroplasty: A prospective randomized study of 3 methods. Medicine (Baltimore). 2018;97:e9668.
Touzopoulos P, Ververidis A, Mpogiatzis C, Chatzigiannakis A, Drosos GI. The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty. Eur J Orthop Surg Traumatol. 2019;29:869–75.
Chen X, Yang W, Wang X. Is bipolar sealer superior than standard electrocautery for blood loss control after primary total knee arthroplasty. Medicine (Baltimore) [Internet]; 2019.
[cited 2020 Sep 21];98.
Kapadia BH, Torre BB, Ullman N, Yang A, Harb MA, Grieco PW, et al. Reducing perioperative blood loss with antifibrinolytics and antifibrinolytic-like agents for patients undergoing total hip and total knee arthroplasty. J Orthop. 2019;16:513–6.
Pasqualotto S, Demey G, Michelet A, Nover L, Saffarini M, Dejour D. Bipolar sealers do not improve blood loss or functional outcomes of primary total knee arthroplasty. J Knee Surg. Thieme Medical Publishers; 2020;33:62–6.
Rai S, Verma S, Yadav PK, Ahmad J, Yadav HK. Utility of acute normovolemic hemodilution in major surgeries in rural area: A prospective comparative study from north india. Anesth Essays Res. 2017;11:909–12.
Bansal N, Kaur G, Garg S, Gombar S. Acute normovolemic hemodilution in major orthopedic surgery. J Clin Orthop Trauma. 2020;11:S844–8.
Krishnan BH, S R, Agrawal A, Kawale A, Kanade S. Role of drain in early clinical outcomes following primary total knee arthroplasty. J Arthrosc Jt Surg. 2018;5:167–70.
Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty: a meta-analysis. JBJS. 2004;86:1146–1152.
Cheung KW, Chiu KH. Effect of drain pressure in total knee arthroplasty: J Orthop Surg [Internet]. SAGE PublicationsSage UK: London, England; 2016.
[cited 2020 Sep 24]
Drinkwater CJ, Neil MJ. Optimal timing of wound drain removal following total joint arthroplasty. J Arthroplasty. 1995;10:185–9.
Agarwala S, Jhaveri M, Menon A. Advantages of clamping and drainage over continuous drainage in a total knee arthroplasty. J Clin Orthop Trauma. 2020;11:133–5.
Kakadiya G, Soni Y, Gandbhir V, Shakya A. Study of the role of surgical drain on outcome of total knee replacement surgery. Int J Orthop Sci. 2019;5:824–7.
Wu Y, Zeng Y, Li C, Zhong J, Hu Q, Pei F, et al. The effect of post-operative limb positioning on blood loss and early outcomes after primary total knee arthroplasty: a randomized controlled trial. Int Orthop. 2019;43:2083–91.
Cao L, Yang H, Sun K, Wang H, Fan H, Cheng W. The role of knee position in blood loss and enhancement of recovery after total knee arthroplasty. J Knee Surg [Internet]. Thieme Medical Publishers; 2020.
[cited 2020 Sep 24]
Lamplot JD, Wagner ER, Manning DW. Multimodal pain management in total knee arthroplasty. J Arthroplasty. 2014;29:329–34.
Kissin I, Weiskopf RB. Preemptive Analgesia. Anesthesiology. American Society of Anesthesiologists; 2000;93:1138–43.
Ong CK-S, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: A meta-analysis. Anesth Analg. 2005;100:757–773.
Lubis AMT, Rawung RBV, Tantri AR. Preemptive analgesia in total knee arthroplasty: comparing the effects of single dose combining celecoxib with pregabalin and repetition dose combining celecoxib with pregabalin: Double-blind controlled clinical trial [Internet]. Pain Res. Treat. Hindawi. 2018; e3807217.
[cited 2020 Sep 24].
Sadigursky D, Simões DP, Albuquerque RA de, Silva MZ, Fernandes RJC, Colavolpe PO, et al. Local periarticular analgesia In total knee arthroplasty. Acta Ortopédica Bras. Sociedade Brasileira de Ortopedia e Traumatologia. 2017;25:81–4.
Seangleulur A, Vanasbodeekul P, Prapaitrakool S, Worathongchai S, Anothaisintawee T, Mc Evoy M, et al. The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: A systematic review and meta-analysis. Eur J Anaesthesiol EJA. 2016;33:816–831.
Li J, Ma Y, Xiao L. Postoperative pain management in total knee arthroplasty. Orthop Surg. 2019;11:755–61.
Youm YS, Cho SD, Cho HY, Hwang CH, Jung SH, Kim KH. Preemptive femoral nerve block could reduce the rebound pain after periarticular injection in total knee arthroplasty. J Arthroplasty. 2016;31:1722–6.
Tsukada S, Wakui M, Hoshino A. Postoperative Epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: A randomized controlled trial. JBJS. 2014;96:1433–1438.
Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for total knee arthroplasty. JAAOS - J Am Acad Orthop Surg. 2016;24:60–73.
Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (ERAS®) society recommendations. Acta Orthop. Taylor & Francis. 2020;91:3–19.
Keny S, Bagaria V, Chaudhary K, Dhawale A. Emergency and urgent orthopaedic surgeries in non-covid patients during the COVID 19 pandemic: Perspective from India. J Orthop. 2020;20:275–9.
Eichler S, Salzwedel A, Rabe S, Mueller S, Mayer F, Wochatz M, et al. The effectiveness of telerehabilitation as a supplement to rehabilitation in patients after total knee or hip replacement: Randomized controlled trial. JMIR Rehabil Assist Technol. 2019;6:e14236.
Blasco JM, Igual-Camacho C, Blasco MC, Antón-Antón V, Ortiz-Llueca Á, Roig-Casasús S. The efficacy of virtual reality tools for total knee replacement rehabilitation: A systematic review. Physiother Theory Pract. Taylor & Francis. 2019;0:1–11.
Bini SA, Schilling PL, Patel SP, Kalore NV, Ast MP, Maratt JD, et al. Digital orthopaedics: A glimpse into the future in the midst of a pandemic. J Arthroplasty. 2020;35:S68–73.
Huang YP, Liu YY, Hsu WH, Lai LJ, Lee MS. Monitoring and assessment of rehabilitation progress on range of motion after total knee replacement by sensor-based system. Sensors. Multidisciplinary Digital Publishing Institute. 2020;20:1703.
Abdelaal MS, Restrepo C, Sharkey PF. Global perspectives on arthroplasty of hip and knee joints. Orthop Clin North Am. 2020;51:169–76.
Berger RA, Nedeff DD, Barden RM, Sheinkop MM, Jacobs JJ, Rosenberg AG, et al. Unicompartmental knee arthroplasty: Clinical experience at 6− to 10-year followup. Clin Orthop Relat Res. 1999;367:50–60.
Romanowski MR, Repicci JA. Minimally invasive unicondylar arthroplasty: Eight-year follow-up. J Knee Surg. 2002;15:17–22.
Kulshrestha V, Datta B, Kumar S, Mittal G. Outcome of unicondylar knee arthroplasty vs total knee arthroplasty for early medial compartment arthritis: A randomized study. J Arthroplasty. 2017;32:1460–9.
Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson WF, et al. Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis. BMJ [Internet]. British Medical Journal Publishing Group. 2019;364.
[cited 2020 Sep 18]
Cm H, Er B, Tr T, Dr H, Cd B. Randomized trial of computer-assisted knee arthroplasty: Impact on clinical and radiographic outcomes. J Arthroplasty. 2011;26:1259–64.
Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;22:1097–106.
Cheng T, Zhao S, Peng X, Zhang X. Does computer-assisted surgery improve postoperative leg alignment and implant positioning following total knee arthroplasty? A meta-analysis of randomized controlled trials? Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2012;20:1307–22.
Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK. Meta-analysis of navigation vs conventional total knee arthroplasty. J Arthroplasty. 2012;27:1177–82.
Selvanayagam R, Kumar V, Malhotra R, Srivastava DN, Digge VK. A prospective randomized study comparing navigation versus conventional total knee arthroplasty. J Orthop Surg. SAGE Publications Ltd STM. 2019;27:2309499019848079.
Ayekoloye C, Nwangwu O, Alonge T. Computer navigation-assisted knee replacement demonstrates improved outcome compared with conventional knee replacement at mid-term follow-up: a systematic review and meta-analysis. Indian J Orthop; 2020 [Internet].
[cited 2020 Sep 25]
Song EK, Agrawal PR, Kim SK, Seo HY, Seon JK. A randomized controlled clinical and radiological trial about outcomes of navigation-assisted TKA compared to conventional TKA: Long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2016;24:3381–6.
McGrory BJ, Weber KL, Jevsevar DS, Sevarino K. Surgical management of osteoarthritis of the knee: Evidence-based guideline. J Am Acad Orthop Surg. 2016;24:e87-93.
Gharaibeh MA, Solayar GN, Harris IA, Chen DB, MacDessi SJ. Accelerometer-based, portable navigation (KneeAlign) vs conventional instrumentation for total knee arthroplasty: A prospective randomized comparative trial. J Arthroplasty. 2017; 32:777–82.
Goh GSH, Liow MHL, Tay DKJ, Lo NN, Yeo SJ, Tan MH. Accelerometer-based and computer-assisted navigation in total knee arthroplasty: A reduction in mechanical axis outliers does not lead to improvement in functional outcomes or quality of life when compared to conventional total knee arthroplasty. J Arthroplasty. 2018;33:379–85.
Nam D, Weeks KD, Reinhardt KR, Nawabi DH, Cross MB, Mayman DJ. Accelerometer-based, portable navigation vs imageless, large-console computer-assisted navigation in total knee arthroplasty: a comparison of radiographic results. J Arthroplasty. 2013;28:255–61.
Sun H, Li S, Wang K, Wu G, Zhou J, Sun X. Efficacy of portable accelerometer-based navigation devices versus conventional guides in total knee arthroplasty: A meta-analysis. J Knee Surg Thieme Medical Publishers. 2020;33:691–703.
Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop. 2002;7–13.
Roche M, Elson L, Anderson C. Dynamic soft tissue balancing in total knee arthroplasty. Orthop Clin North Am. 2014;45:157–65.
Gustke K. Use of smart trials for soft-tissue balancing in total knee replacement surgery. J Bone Joint Surg Br. 2012;94-B:147–50.
MacDessi S, Gharaibeh M. Accuracy of manual surgeon-defined assessment of soft tissue balance in TKA in comparison to sensor-guided measures and its effect on final balance. Orthop J Sports Med. SAGE Publications Inc. 2017;5:2325967117S00161.
Gustke KA, Golladay GJ, Roche MW, Elson LC, Anderson CR. A targeted approach to ligament balancing using kinetic sensors. J Arthroplasty. 2017;32:2127–32.
Gustke KA, Golladay GJ, Roche MW, Jerry GJ, Elson LC, Anderson CR. Increased satisfaction after total knee replacement using sensor-guided technology. Bone Jt J. 2014;96-B:1333–8.
Lakra A, Sarpong NO, Jennings EL, Grosso MJ, Cooper HJ, Shah RP, et al. The learning curve by operative time for soft tissue balancing in total knee arthroplasty using electronic sensor technology. J Arthroplasty. 2019;34:483–7.
Luna IE, Kehlet H, Peterson B, Wede HR, Hoevsgaard SJ, Aasvang EK. Early patient-reported outcomes versus objective function after total hip and knee arthroplasty: A prospective cohort study. Bone Jt J. 2017;99-B:1167–75.
Tayton ER, Frampton C, Hooper GJ, Young SW. The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty. Bone Jt J. The British Editorial Society of Bone & Joint Surgery. 2016;98-B:334–40.
Petrie JR, Haidukewych GJ. Instability in total knee arthroplasty. Bone Jt J. The British Editorial Society of Bone & Joint Surgery. 2016;98-B:116–9.
Hsu RW-W, Hsu W-H, Shen W-J, Hsu W-B, Chang S-H. Comparison of computer-assisted navigation and conventional instrumentation for bilateral total knee arthroplasty. Medicine (Baltimore); 2019. [Internet]
[cited 2020 Sep 25];98.
Kayani B, Haddad FS. Robotic total knee arthroplasty. Bone Jt Res. The British Editorial Society of Bone & Joint Surgery. 2019;8:438–42.
Khlopas A, Chughtai M, Hampp EL, Scholl LY, Prieto M, Chang TC, et al. Robotic-arm assisted total knee arthroplasty demonstrated soft tissue protection. Surg Technol Int. 2017;30:441–6.
Marchand RC, Sodhi N, Khlopas A, Sultan AA, Harwin SF, Malkani AL, et al. Patient satisfaction outcomes after robotic arm-assisted total knee arthroplasty: A short-term evaluation. J Knee Surg. 2017;30:849–53.
Ren Y, Cao S, Wu J, Weng X, Feng B. Efficacy and reliability of active robotic-assisted total knee arthroplasty compared with conventional total knee arthroplasty: A systematic review and meta-analysis. Postgrad Med J. The Fellowship of Postgraduate Medicine. 2019;95:125–33.
Liow MHL, Goh GS-H, Wong MK, Chin PL, Tay DK-J, Yeo S-J. Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: A 2-year follow-up of a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc. 2017;25:2942–51.
Cho K-J, Seon J-K, Jang W-Y, Park C-G, Song E-K. Robotic versus conventional primary total knee arthroplasty: clinical and radiological long-term results with a minimum follow-up of ten years. Int Orthop. 2019;43:1345–54.
Kayani B, Konan S, Ayuob A, Onochie E, Al-Jabri T, Haddad FS. Robotic technology in total knee arthroplasty: A systematic review. EFORT Open Rev. 2019;4:611–7.
Vaishya R, Vijay V, Vaish A, Agarwal AK. Computed tomography based 3D printed patient specific blocks for total knee replacement. J Clin Orthop Trauma. 2018;9:254–9.
Predescu V, Prescura C, Olaru R, Savin L, Botez P, Deleanu B. Patient specific instrumentation versus conventional knee arthroplasty: Comparative study. Int Orthop. 2017;41:1361–7.
Nizam I, Batra A. Accuracy of bone resection in total knee arthroplasty using ct-assisted 3d-printed patient-specific cutting guides in 201 total knee arthroplasties. Orthop Proc. The British Editorial Society of Bone & Joint Surgery. 2019;101-B:143–143.
Watters TS, Mather RC, Browne JA, Berend KR, Lombardi AV, Bolognesi MP. Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty. J Surg Orthop Adv. 2011;20:112–6.
Abstract View: 71 times
PDF Download: 39 times