Knee arthroplasty: growing trends and future problems

In 1861, Ferguson reported a resection arthroplasty as treatment for severe arthritis of the knee [1]. To our knowledge this was the first report of a surgical intervention to treat arthritis. In the late 18th century, Verneuil performed an interposition arthroplasty of the knee, when he used flaps of joint capsule to cover resected articular surfaces in an attempt to decrease the pain and increase the quality of life of patients [2]. Subsequent to these two papers, many other materials, including skin, muscle, fat, chromicized pig bladder, cellophane and nylon, were tried as interposition materials in the ‘resurfacing’ of diseased articular surfaces. Stimulated by the success of Smith-Petersen [3] with mold arthroplasty of the hip, Campbell and Boyd performed the first mold arthroplasty of the knee [4]. In 1971, Gunston reported good early results with a metal femoral component and a high-density polyethylene tibial component fixed to the bone with polymethylmethacrylate (PMMA) using the polycentric knee [5]. In 1973, Insall and others at the Hospital for Special Surgery (NY, USA) developed total condylar prosthesis that dramatically improved the standards for survivorship of total knee arthroplasty (TKA). Insall, Ranawat and colleagues reported 94% efficacy with a knee system that evolved from that original design at 15-year follow-up [6]. In 2008, approximately 550,000 TKAs were performed in the USA. The total expenditures on this procedure alone exceeded US$18 billion. It is now expected that by 2030 the number of primary TKAs will reach 3.48 million annually [7]. We have previously reported on the cost–effectiveness of TKA [8]. In most cases, this procedure restores function and motion and provides significant pain relief. When compared with other surgical and medical interventions its cost–utility profile makes it one of the most effective procedures in medicine (Figure 1).