Personalized Rehabilitation Following Total Knee Arthroplasty: Integrating Clinical and Imaging Perspectives

Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic procedures worldwide, offering substantial improvements in pain relief and mobility for patients with advanced knee osteoarthritis. Despite advancements in implant design and surgical technique, superficial wound complications remain a significant concern. These include delayed healing, wound dehiscence, infection, and excessive scar formation, potentially prolonging hospital stay, and reducing patient satisfaction. While deep tissue closure and joint mechanics have been extensively studied in orthopaedics, the influence of superficial skin closure techniques on wound outcomes has received less attention. The anterior knee incision traverses a high-tension, mobile area susceptible to healing complications and scar contracture. As such, the technique of skin closure may play a more critical role in postoperative recovery than traditionally recognized. This review examines current literature evaluating the relationship between different superficial skin closure techniques—including subcuticular sutures, staples, and tissue adhesives—and their impact on wound healing outcomes, scar quality, and early postoperative function following TKA. Evidence suggests certain closure techniques, particularly continuous subcuticular sutures, may promote better wound approximation and tissue perfusion, reduce skin tension, and yield more favorable scar profiles compared to traditional interrupted sutures or staples. Some studies also report reduced rates of wound complications and improved patient-reported outcomes with subcuticular methods. However, the majority of research has focused on cosmetic or patient satisfaction outcomes, with fewer studies linking closure technique to orthopaedic recovery metrics, such as early range of motion, infection risk, or revision surgery. The superficial closure technique may have meaningful implications for wound healing, rehabilitation, and overall success in TKA. There is a need for more focused research integrating objective scar assessment tools and correlating them with functional and surgical outcomes. Clarifying these associations could support standardized closure protocols that enhance both short-term and long-term recovery in TKA patients.

What's New in Adult Reconstructive Knee Surgery.

Foot pressure pattern, hindfoot deformities, and their associations with foot pain in individuals with advanced medial knee osteoarthritis

This study aimed to analyze the risk factors that predict recurrent flexion contracture (FC) after total knee arthroplasty (TKA) in osteoarthritic knees with FC ≥ 15°. Data from a consecutive cohort comprising 237 TKAs in 187 patients with degenerative osteoarthritis, preoperative FC ≥ 15°, and a minimum follow-up period of 2 years were retrospectively reviewed. Preoperative FC was corrected intraoperatively from 0° to 5°. The incidence of recurrent FC (FC ≥ 10°) at 2 years postoperatively was investigated. Potential risk factors predicting recurrent FC including age, sex, body mass index, unilateral TKA, severity of preoperative FC, 3-month postoperative residual FC, γ angle, change in posterior femoral offset ratio, and lumbar degenerative kyphosis (LDK) were analyzed using logistic regression analysis. The post-hoc powers for the identified factors were then determined. Forty-one knees (17.3%) with recurrent FC were identified. Risk factors with sufficient power for recurrent FC were unilateral TKA, severity of preoperative FC, residual FC at 3 months postoperatively, and LDK (odds ratios of 3.579, 1.115, 1.274, and 3.096, respectively; p < 0.05; power ≥ 86.1). Recurrent FC can occur in TKAs with the risk factors including unilateral TKA, severe preoperative FC, residual FC at 3 months postoperative, and LDK despite appropriate intraoperative correction. Surgical strategies and rehabilitation protocols used in managing FC should be applied in TKA cases with risk factors for recurrent FC.

Persistent Racial Disparities in Joint Replacement Use: Commentary on an article by Caroline P. Thirukumaran, MBBS, MHA, PhD, et al.: "Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017".

Managing Expectations: The Bigger They Are, the Harder They Fall: Commentary on an article by Danielle Y. Ponzio, MD, et al.: "An Analysis of the Influence of Physical Activity Level on Total Knee Arthroplasty Expectations, Satisfaction, and Outcomes. Increased Revision in Active Patients at Five to Ten Years".

Introduction: Knee osteoarthritis (OA) is a leading cause of disability. In advanced knee OA, the preferred treatment is total knee arthroplasty (TKA) when conservative therapies fail. Although TKA reduces pain, achieving full functional recovery is challenging.Objectives: The aim of this study is to examine the impact of a high-intensity (HI) rehabilitation protocol on quality of life (QoL) and functional outcomes in post-TKA patients.Materials and Methods: This prospective, single-centre cohort study included 41 patients undergoing unilateral TKA in a hospital unit. Patients participated in an HI rehabilitation programme involving supervised exercises during hospitalisation and outpatient follow-ups over 12 weeks. Assessments of QoL and function were conducted preoperatively and at 4, 12, and 24 weeks postoperatively using the Western Ontario McMaster Osteoarthritis Index (WOMAC), 12-Item Short Form Health Survey (SF-12) and Barthel Index.Results: Significant improvements were observed in pain, stiffness, physical function, and overall QoL at all post-intervention time points (p&lt;0.05). Regarding the percentage of change, the median in total WOMAC was 96 (80.92-98.48), in total SF 12, it reached 167.65 (79.57-295.65), and in total Barthel index, the value was 25 (17.65-42.86). QoL gains were consistent regardless of demographic factors such as age, body mass index (BMI) or prior TKA history; however, mental health composite scores correlated positively with age and inversely with BMI. No correlation was found between preoperative measures and patient variables such as age, duration of illness or BMI (p≥0.05).Conclusion: HI rehabilitation post-TKA effectively enhances QoL and functional outcomes, supporting its role in postoperative care. Given the observed benefits, implementing structured rehabilitation protocols can optimise recovery for TKA patients. Future research should focus on identifying optimal rehabilitation strategies for certain subgroups, exploring how adjustments to protocol parameters (e.g., exercise type, intensity, progression) based on individual patient characteristics to optimize recovery

The reported rate of peroneal nerve palsy (PNP) after total knee arthroplasty (TKA) ranges from 0.16% to 2.2%. Risk factors associated with PNP after TKA are preoperative valgus deformity ≥10°, total tourniquet time >120 min, diagnosis of a preexisting neuropathy, post-operative pathological complications and rheumatoid arthritis. Factors not associated with PNP after TKA are flexion contracture and the use of postoperative epidural analgesia. PNP is diagnosed by clinical tests (foot drop) and electrodiagnostic and diagnostic imaging procedures. It is important to differentiate between neurapraxia, axonotmesis and neurotmesis. The most important electrodiagnostic methods for evaluating peripheral nerve lesions are needle electromyography and nerve conduction studies. There is a general consensus that in nerve lesions belonging to the categories of neurapraxia and axonotmesis, early surgical exploration is not indicated due to the possibility of spontaneous recovery helped by rehabilitation and an anti-foot-drop orthesis. Neurapraxia and axonotmesis should be monitored for 6–12 months before recommending surgical exploration. In cases of neurotmesis, the repair time is more urgent (from 3 days to 3 weeks). Currently, the most common surgical techniques for the repair of nerve injuries are external and internal neurolysis, end-to-end suture and nerve grafting.

This study aimed to systematically review the literature and identify the surgical management strategy for fixed flexion contracture in primary total knee arthroplasty (TKA) surgery, pre-, intra-, and post-operatively. Secondary endpoints were etiologies and factors favoring flexion contracture. Searches were carried out in November 2023 in several databases (Pubmed, Scopus, Cochrane, and Google Scholar) using the following keywords: "flexion contracture AND TKA", "fixed flexion deformity AND TKA", "posterior capsular release AND TKA", "posterior capsulotomy in TKA", "distal femoral resection AND TKA". Study quality was assessed using the STROBE checklist and the Downs and Black score. Data concerning factors or strategies leading to the development or prevention of flexion contracture after TKA were extracted from the text, figures, and tables of the included references. The effect of each predictive factor on flexion contracture after TKA was recorded. Thirty-one studies were identified to meet the inclusion and exclusion criteria. These studies described a variety of preoperative and intraoperative factors that contribute to the development or correction of postoperative flexion contracture. The only clearly identified predictor of postoperative flexion contracture was preoperative flexion contracture. Intraoperative steps described to correct flexion contracture were: soft-tissue balancing (in posterior and medial compartments), distal femoral resection, flexion of the femoral component, and posterior condylar resection. However, no study has investigated these factors in a global model. This review identified various pre-, intra-, and post-operative factors predictive of post-operative flexion contracture. In practice, these factors are likely to interact, and it is therefore crucial to further investigate them in a comprehensive model to develop an algorithm for the management of flexion contracture. IV.

Early results with robotic-arm-assisted total knee arthroplasty (TKA) are encouraging; nevertheless, literature might be unrepresentative, as it comes mostly from American, European, and Asian countries. There is limited experience and no comparative clinical reports in Latin America, a region of mainly low- and middle-income countries with limited access to these promising technologies. This study aims to compare the early postoperative results of the first Latin American experience with robotic-arm-assisted TKA versus conventional TKA. A cohort study was performed, including 181 consecutive patients (195 knees) with advanced symptomatic knee osteoarthritis (OA) undergoing primary TKA between March 2016 and October 2019. The cohort included 111 consecutive patients (123 knees) undergoing conventional TKA, followed by 70 consecutive patients (72 knees) undergoing robotic-arm-assisted TKA. The same surgical team (surgeon 1 and surgeon 2) performed all procedures. Patients with previous osteotomy, posttraumatic OA, and revision components were not considered. The same anesthetic and rehabilitation protocol was followed. The investigated clinical outcomes (for the first 60 postoperative days) were: surgical tourniquet time, time to home discharge, time to ambulation, postoperative daily pain (Visual Analog Scale), opioid use, range of motion, blood loss, complications, and postoperative mechanical axis. The early clinical postoperative results of this first Latin American comparative experience of robotic-arm-assisted TKA versus conventional technique showed lower opioids requirements and faster functional recovery of ambulation in those patients operated with the robotic system; nevertheless, surgical times were higher, without differences in total postoperative complications and other clinical outcomes.

A critical review of weight loss recommendations before total knee arthroplasty.

Daily Walking and the Risk of Knee Replacement Over 5 Years Among Adults With Advanced Knee Osteoarthritis in the United States

This review article aims to explore the role of virtual rehabilitation in total knee arthroplasty in terms of functional outcomes and cost-effectiveness. Total knee arthroplasty (TKA) is a widely performed surgery for end-stage knee osteoarthritis, requiring supervised rehabilitation for rapid recovery and pain relief. Virtual rehabilitation has been evolving as an alternative to the traditional rehabilitation program in the recent years especially during the predicament of COVID-19 pandemic. Virtual rehabilitation leverages virtual reality (VR) technology to provide innovative, engaging, and measurable rehabilitation services that can complement or replace traditional therapy approaches. Virtual reality and telerehabilitation represent evolving fields in TKA rehabilitation, offering advantages over traditional therapy in terms of cost-effectiveness, improved outcomes, enhanced exercise adherence, and reduced barriers to accessing postoperative therapy. Despite the need for more research and standardized protocols, VR-based rehabilitation holds significant potential for optimizing the recovery process for patients undergoing TKA. The research indicates that VR-based rehabilitation programs for TKA patients have utilized a variety of interactive virtual environments, gaming activities, and feedback mechanisms to supplement traditional physical therapy exercises. Virtual rehabilitation for TKA encourages clinician-patient interaction beyond the hospital setting and offers the advantages of cost savings, convenience, at-home monitoring, and coordination of care, improved functional outcomes, increased exercise adherence, better balance performance, and psychological benefits like reduced stress and anxiety, all of which are geared to improve adherence and overall patient satisfaction. This review article outlines the importance of virtual rehabilitation in TKA, emphasizing cost-effectiveness and improved balance and function while maintaining enhanced adherence and exercise performance. This article also delves into the mode of administration of VR-based rehabilitation and its delivery, safety concerns, advantages and disadvantages, as well as the most common VR-based rehabilitation protocols for TKA. Further, it discusses the implications of virtual rehabilitation in the healthcare system and future directions for virtual rehabilitation in TKA. In conclusion, the evidence indicates that virtual physical therapy (PT) with remote clinical oversight is a safe, effective, and more cost-effective alternative to traditional in-person PT for patients undergoing TKA. Keywords: Virtual rehabilitation, virtual physical therapy, telehealth, telerehabilitation, total knee arthroplasty.

Acute peroneal nerve palsy is a well-known complication of total knee arthroplasty (TKA) that causes a neurological deficit typically seen within hours or days postoperatively. Peroneal nerve dysfunction presents more subtlely than peroneal nerve palsy, with decreased knee range of motion, lateral knee pain, or both following TKA. The diagnosis of peroneal nerve dysfunction may not be suspected for weeks, months, or even years after TKA. Electromyography and nerve conduction studies can support the diagnosis. Historically, peroneal nerve palsy following TKA has been treated nonoperatively but has had an unsatisfactory rate of complete recovery. Recently, a few reports have demonstrated that patients with either peroneal nerve palsy or dysfunction after TKA have had excellent results with surgical decompression of the peroneal nerve.The authors describe a 63-year-old woman who reported transient episodes of lateral knee and leg pain for years after undergoing TKA. She eventually underwent electromyography and nerve conduction studies that indicated a diagnosis of peroneal nerve dysfunction. Approximately 10 years after the TKA, she underwent surgical decompression of the peroneal nerve and has done well since, with significant pain relief and an increased activity level.This case supports the recent literature describing peroneal nerve dysfunction as an uncommon but surgically treatable cause of lateral knee pain following TKA. Increased awareness of the condition and its facile treatment via surgical decompression may result in improved outcomes years after TKA.

Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients. Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models. 2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts. Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes. This suggests that both clinical and research populations may recover similarly from TKA.