This document discusses several topics related to total knee arthroplasty (TKA), including: 1. Expectations for recovery after TKA are often misaligned between patients and surgeons, with over 50% of patients expecting higher levels of function than surgeons. 2. Moderate sports and physical activity after TKA do not appear to negatively impact implant durability or increase revision rates in the short or medium term. High-impact sports should still be avoided. 3. Knee rehabilitation protocols must account for numerous patient-specific variables to optimize outcomes, such as age, BMI, pre-operative activity level, type of implant, and adherence to home exercises. A one-size-fits-all approach is inadequate.

1. Ancona 2013 San Marino 2014 Roma 2016 Cesena 2017 Cattolica 2018
Rehabilitator Opinion

2. 2030 demand for arthroplasties in USA
Surgery Primary Revision
Hip + 174% =
572.000
+ 137%
Double in the 2026
Knee + 673% =
3.48 million
+ 601%
Double respect by 2015
Patients < 65 years old
> 50% surgery
From 2010 to 2030
Future young patient demand for primary and revision joint replacement: national projections
from 2010 to 2030.
Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ.
Clin Orthop Relat Res. 2009 Oct;467(10):2606-12. Epub 2009 Apr 10. Free PMC Article

3. http://dev.aaos.waterfallmedia.net/value/total-knee-replacement-surgery-numbers/
The future of Total Knee Remplacement
The results of this model illustrate the need
to account for the implications of treatment
choices, not only at the individual patient
level, but also for society at large.
When deciding among available treatment
options, patients, physicians, payers, and
policymakers must consider individual
treatment cost and effectiveness but also
should account for future potential earnings
generated when a treatment may restore a
patient's ability to contribute to society.
Economic benefit to society at large of total knee arthroplasty in younger patients:
a Markov analysis.
Bedair H, Cha TD, Hansen VJ.
J Bone Joint Surg Am. 2014 Jan 15;96(2):119-26.

4. Surgeon
Physical Therapist
Patient
TREATMENT GOALS
How Often are Patient and Surgeon Recovery Expectations for Total Joint Arthroplasty Aligned
? Results of a Pilot Study.
Ghomrawi HM, Franco Ferrando N, Mandl LA, Do H, Noor N, Gonzalez Della Valle A.
HSS J. 2011 Oct;7(3):229-34. Epub 2011 Jun 25. Free PMC Article

5. 1. Anatomical surgical reconstruction
2. Regaining the normal arthro-kinematics
and joint motion
3. Primary stable fixation
4. Treating the associate injuries (if needed)
5. Letting immediate protect motion and
weight bearing (if tolerated)
6. Early return to ADL ,work and activities
7. Avoid complication and failure (early and
late)
8. Return to pre-surgery ADL, leasure and
sports practice (if possible)
SURGEON GOALS
Measuring expectations in orthopaedic surgery: a systematic review.
Zywiel MG, Mahomed A, Gandhi R, Perruccio AV, Mahomed NN.
Clin Orthop Relat Res. 2013 Nov;471(11):3446-56. Review. Free PMC Article

6. PHYSIOTHERAPIST GOALS
1. Prevent the complication and implant
failure (early and late)
2. Educate the patient an active approach
3. Help to get through surgical trauma
minimizing the joint reactivity
4. Remove the symptoms (pain, sweeling,
oedema, hemathoma, stiffness,
arthrogenic muscle inibition, ect. …)
5. Normal gait and function of ADL
6. Safe and fast return of ADL, work and light
sports
7. Restore Biologic Homeostasis
8. No recurrence of stiffness or functional
instability or painful joint
9. The result don’ t deteriorate in time
Arthrofibrosis
Loss of motion
Hemarthrosis
Septic arthritis
High level of residual symptoms in young patients after total knee arthroplasty.
Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr, Ruh EL, Clohisy JC, Hamilton WG, Della Valle
CJ, Barrack RL.
Clin Orthop Relat Res. 2014 Jan;472(1):133-7. Free PMC Article
Painful Knee
Loosening

7. 1. Have a stable, mobile
asimptomatic knee
2. A joint and soft tissue without
pain
3. Return to ADL, work, liesure and
sports activities like before
trauma or surgery
4. The outcome don’ t deteriorate
in time
PATIENT GOALS
Patients' expectations of knee surgery.
Mancuso CA, Sculco TP, Wickiewicz TL, Jones EC, Robbins L, Warren RF, Williams-Russo P.
J Bone Joint Surg Am. 2001 Jul;83-A(7):1005-12.

8. Whats the patients wants
Adults attending private physiotherapy practices seek diagnosis, pain relief, improved
function, education and prevention: a survey.
McRae M, Hancock MJ.
J Physiother. 2017 Oct;63(4):250-256. Epub 2017 Sep 28.

9. Total knee arthroplasty (TKA) has revolutionized the care of patients with end-stage knee
arthritis.
Despite substantial advances in primary TKA patient selection, surgical technique, and implant
design, numerous studies indicate only 82% to 89% of patients
were satisfied with their primary total knee arthroplasty .
Patient satisfaction after total knee arthroplasty: who is satisfied and who is not ?
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD.
Clin Orthop Relat Res. 2010 Jan;468(1):57-63. Free PMC Article

10. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not ?
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD.
Clin Orthop Relat Res. 2010 Jan;468(1):57-63. Free PMC Article
Patient satisfaction = important outcome measure
Discrepancy between clinician and patient ratings of health status
Satisfaction = pain relief and the ability to perform daily and leisure activities
Wylde et al. utilized this satisfaction scale in a comparison of fixed- versus mobile-bearing total
knee arthroplasties (n = 250 knees)
No satisfaction differences between the implant types
Low satisfaction with specific activities
(ie, 66% “very satisfied” with pain relief, 52% with return to normal activities of daily living
and 44% with the ability to perform leisure activities).

11. Participation in sporting activities following knee replacement: total versus
unicompartimental.
Hopper GP, Leach WJ.
Knee Surg Sports Traumatol Arthrosc. 2008 Oct;16(10):973-9. Epub 2008 Aug 12.

12. Sports activities after joint replacement are possible and are best
indicated for patients who were previously active.
High-impact sports should be discouraged, as concern exists
about premature polyethylene failure

13. Etiology and Failure Rate of TKA
Insall Award paper. Why are total knee arthroplasties failing today?
Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM.
Clin Orthop Relat Res. 2002 Nov;(404):7-13.

14. Etiology and Failure Rate of TKA
Current failure mechanisms after knee arthroplasty have changed: polyethylene wear is less
common in revision surgery.
Thiele K, Perka C, Matziolis G, Mayr HO, Sostheim M, Hube R.
J Bone Joint Surg Am. 2015 May 6;97(9):715-20

15. Epidemiology of Failure Rate of TKA
The success and survivorship of TKAs are
dependent on:
1. the demographics of the patient
2. surgical technique
3. implant-related factors
Currently the risk of failure of a TKA
requiring revision surgery
ten years post-operatively is 5%.
The most common indications for revision
include:
aseptic loosening (29.8%),
infection (14.8%), and pain (9.5%).
The epidemiology of failure in total knee arthroplasty: avoiding your next revision.
Khan M, Osman K, Green G, Haddad FS.
Bone Joint J. 2016 Jan;98-B(1 Suppl A):105-12.

16. Athletic activity after total joint arthroplasty.
Healy WL, Sharma S, Schwartz B, Iorio R.
J Bone Joint Surg Am. 2008 Oct;90(10):2245-52. Review.
Knee Society Survey: 1999 vs 2005

17. Sports at Risk
Athletic activity after total joint arthroplasty.
Healy WL, Sharma S, Schwartz B, Iorio R.
J Bone Joint Surg Am. 2008 Oct;90(10):2245-52. Review.

18. Return to Sports and Physical Activity After Total and Unicondylar Knee Arthroplasty:
A Systematic Review and Meta-Analysis.
Witjes S, Gouttebarge V, Kuijer PP, van Geenen RC, Poolman RW, Kerkhoffs GM.
Sports Med. 2016 Feb;46(2):269-92. Review. Free PMC Article
Return to sports after TKA or UKA: yes or not ???
Return to sports after TKA or UKA
Total Knee Arthroplasty Uni-Condylar Arthroplasty
Low Impact Sports High Impact Sports
Confounding factors
Preoperative sports level
Restricting Comorbidities
Negative Advice from Surgeons
Assessment of the Preoperative Sports Level
Pre-symptomatic Phase
An important role in defining return to sports percentages

19. Physical activity and risk of revision total knee arthroplasty in individuals with knee
osteoarthritis: a matched case-control study.
Jones DL, Cauley JA, Kriska AM, Wisniewski SR, Irrgang JJ, Heck DA, Kwoh CK, Crossett LS.
J Rheumatol. 2004 Jul;31(7):1384-90.
Return to sports after TKA or UKA: yes or not ???
While some studies indeed
found higher radiological
wear and potential
implant failure in active
patients,
they did
not show an increase in
revision rates due to high
activities at mid-term

20. TKA Sport and durability: 12 years F.U.
Does Sports Activity Influence Total Knee Arthroplasty Durability ? Analysis with a Follow-Up
of 12 Years.
Valle C, Sperr M, Lemhöfer C, Bartel KE, Schmitt-Sody M.
Sportverletz Sportschaden. 2017 Jun;31(2):111-115. Epub 2017 Jun 7. German.
Retrospective Study
Follow-up period of 12 years
130 patients sport activities 22 months before and after total knee replacement (2003).
Sports Group (group A)
NO Sports Activity (group B)
Control 7 years and 12 years after surgery
88 (67.7 %) practice sports for a minimum of 3 times a week (group A),
42 (32.3 %) patients reported that they practiced no sports (group B).
In 2010 - 7 years postoperatively - 60 patients of group A and 27 patients of group B took part in the survey;
their levels of sports activity had not changed over the previous 7 years.
In 2015, 46 patients out of group A and 21 patients out of group B were questioned.
Revision rate of 15.2 % (7 out of 46 patients) in the group A Sports Activity
Revision rate of 23.8 % (5 out of 21 patients) in the group B without any sports
activity
We conclude that moderate sports activities have no negative influence on total knee
arthroplasty and may even lead to improved osteointegration with a decrease in
osteolytic changes and less prosthesis loosening.

21. When Can I Drive After Orthopaedic Surgery ? A Systematic Review.
DiSilvestro KJ, Santoro AJ, Tjoumakaris FP, Levicoff EA, Freedman KB.
Clin Orthop Relat Res. 2016 Dec;474(12):2557-2570. Review
Doc when I can drive after surgery...????
The patients are not created all the same .....

22. More than 50% of the
patients had higher
expectations than their
surgeon and this was driven
by expectations of high-
level activities and extreme
range of motion
How Often are Patient and Surgeon Recovery Expectations for Total Joint Arthroplasty Aligned
? Results of a Pilot Study.
Ghomrawi HM, Franco Ferrando N, Mandl LA, Do H, Noor N, Gonzalez Della Valle A.
HSS J. 2011 Oct;7(3):229-34. Epub 2011 Jun 25. Free PMC Article

23. John Hill MD, DO, Sports Medicine Specialist
Age 61 Run since High School
2011 TKA secondary RA
One marathon a year from 2011 to 2017
Bear Chase 50 km Trail Run
Multiple Ultra-Trail like Grand Canyon Journey

24. Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee
arthroplasty.
Talbot S, Hooper G, Stokes A, Zordan R.
J Arthroplasty. 2010 Feb;25(2):268-73. doi: 10.1016/j.arth.2008.09.019. Epub 2008 Dec 3.
HAAS: High-Activity Arthroplasty Score
The High-Activity Arthroplasty Score (HAAS) was
specifically developed to assess subtle variations in
functional ability after lower limb arthroplasty with
particular regard to highly functioning individuals.
The score was a 4-item self-assessment measure
covering the 4 domains of walking, running, stair
climbing, and general activities, with a possible score
ranging from 0 to 18 points.
The score was validated in 22 patients (total hip
arthroplasty [THA], n = 11; total knee arthroplasty
[TKA], n = 11) by comparison with the Oxford, Knee
Society, Harris Hip, and Short WOMAC scores.
The HAAS was then administered to 152 high-
functioning arthroplasty patients (THA, n = 99; TKA, n
= 53), all younger than 66 years.
The HAAS produced a much wider range of scores,
allowing greater differentiation of level of function
between patients in assessing performance after TKA
or THA.

25. HAAS: High-Activity Arthroplasty Score
Development of the Italian version of the High-Activity Arthroplasty Score (HAAS-I) following hip and knee
total arthroplasty: cross-cultural adaptation, reliability, validity and sensitivity to change.
Monticone M, Capone A, Frigau L, Marongiu G, Abelli P, Mola F, Maffulli N, Foti C.
J Orthop Surg Res. 2018 Apr 11;13(1):81. Free PMC Article

26. H.igh-A.ctivity A.rthroplasty S.core: Italian Version
The tested hypothesis was following: the High Activity
Arthroplasty Score has a significant lower ceiling effect than
American Knee Society Score and Oxford Knee Score after total
knee arthroplasty.
One hundred patients operated on for total knee arthroplasty
with more than one-year follow-up have been included.
The ceiling effect was 53% for the American Knee Society Score,
33% for the Oxford Knee Score, and 0% for the High Activity
Arthroplasty Score. High Activity Arthroplasty Score had a
significantly lower ceiling effect than American Knee Society Score
and Oxford Knee Score.
High Activity Arthroplasty Score has the potential
to detect more subtle differences in level of
function than standard scoring systems among a
non-selected total knee arthroplasty population.
High Activity Arthroplasty Score has a lower ceiling effect than standard scores after knee arthroplasty.
Jenny JY, Louis P, Diesinger Y.
J Arthroplasty. 2014 Apr;29(4):719-21. Epub 2013 Aug 13.

27. Knee Rehab = variables
The majority are not performing home-exercises correctly two weeks after their initial
instruction-an assessor-blinded study.
Faber M, Andersen MH, Sevel C, Thorborg K, Bandholm T, Rathleff M.
PeerJ. 2015 Jul 21;3:e1102. Free PMC Article
• Patient: coper vs non coper
• Age: young active adults vs old vs very old
• BMI: overweight vs obese vs normal weight
• Sports: amatorial vs leisure vs sedentary
• Type of OA: primary vs secondary
• Timing: chronic symptoms (years) vs
• Surgery: primary vs revision
• Type of Prosthesis: UKA vs TKA vs PFA
• Concomitant surgery: UKA + ACLR
• Preview pathology: fracture, instability, AR,
• Preview surgery: osteotomy vs UKA
• Surgeon: learning curve vs expertise
• Physiotherapist: learning curve vs expertise
• Rehabilitation: accelerated vs delayed vs accomodating

28. Unicompartmental
Bicompartmental Tricompartmental
Not a constraint Semi constraint Constraint
Is not only a problem of implant but the indication and selection ....
Bad Patient ...
Bad Surgery ...
Bad Healing ...
Bad Result ...
Henry Dejour

29. David J. Magee William S.Quillen James E. Zachazewski
Athletic Injuries and Rehabilitation
W.B. Saunders Company, 1996
Sports Rehab Pyramid
Knowledge, skill and ability of sports medicine team

30. Stability with Mobility
Active
Sub-
system
• Muscle
• Stiffness
• Force
• Endurance
• Power
Passive
Sub-
system
• Bone surfaces
• Ligaments
• Menisci
Control
Sub-
system
• Nervous System
• Central and
Peripheral
Shock Absorbing and Painless

31. The Ideal Patient
The majority are not performing home-exercises correctly two weeks after their initial
instruction-an assessor-blinded study.
Faber M, Andersen MH, Sevel C, Thorborg K, Bandholm T, Rathleff M.
PeerJ. 2015 Jul 21;3:e1102. Free PMC Article
• Patient: coper
• Age: young active adult
• BMI: normal weight
• Sports: amatorial
• Type of OA: primary vs secondary
• Timing: few times symptoms
• Surgery: primary
• Type of Prosthesis: UKA
• Concomitant surgery: UKA + ACLR
• Preview pathology: medial knee OA
• Preview surgery: osteotomy or meniscus +-ACLR
• Surgeon: knee expert
• Physiotherapist: knee expert
• Rehabilitation: accelerated BUT accomodating AND individualized

32. Accelerated
but
Accomodating
and
Individualized
Rehabilitation
Knee Rehab = variables

33. Systematic, stepwise rehabilitation with
criteria-based progression is recommended for an
individualized rehabilitation of each patient not only to
achieve initial return to sport at the preinjury level but
also to continue sports participation and reduce risk
for reinjury or remplacement failure under the high
mechanical demands of athletic activity.
Current concepts for rehabilitation and return to sport after
knee articular cartilage repair in the athlete.
Mithoefer K, Hambly K, Logerstedt DS, Ricci M, Silvers H, Della Villa S.
J Orthop Sports Phys Ther. 2012;42(3):254-73. Epub 2012 Feb 29.
Knee Rehab and return to sport

34. The Battle ?
Patient-reported outcome measures in arthroplasty registries: Report of the Patient-Reported Outcome
Measures Working Group of the International Society of Arthroplasty Registries
Part II. Recommendations for selection, administration, and analysis
Ola Rolfson, Eric Bohm, Patricia Franklin, Stephen Lyman, Geke Denissen, Jill Dawson, Jennifer Dunn, Kate
Eresian Chenok, Michael Dunbar, Søren Overgaard, Göran Garellick, Anne Lübbeke, Patient-Reported
Outcome Measures Working Group of the International Society of Arthroplasty Registries
Acta Orthop. 2016 Jul; 87(Suppl 1): 9–23. Published online 2016 May 5.

35. Team Work
Surgeon-Therapist Communication: Do All Members See Eye-to-Eye ?
Longstaffe R, Slade Shantz J, Leiter J, Peeler J.
Phys Sportsmed. 2015 Nov;43(4):381-7.

36. Thanks for your
kind attention
science explain what is possible to make
ethics tell us what is right (Socrates)
la scienza spiega cio’ che e’ possibile fare,
l’etica dice cio’ che e’ giusto fare (Socrate)