Dogma Under the Knife: Challenging the Status Quo in Primary Total Knee Arthroplasty

Primary total knee arthroplasty (TKA) is among the most successful procedures in orthopaedic surgery, reliably providing pain relief, functional improvement, and durable implant survivorship. Despite these achievements, approximately 10 to 20% of patients report persistent dissatisfaction following primary TKA, even in the absence of technical failure. This disconnect between implant longevity and patient-perceived success has prompted renewed examination of the foundational principles that have historically guided TKA practice. Advances in implant design, biomaterials, surgical technology, and a changing patient population have challenged long-standing dogma related to alignment philosophy, fixation strategy, bearing surface selection, and patellar resurfacing.

This symposium manuscript reviews contemporary evidence addressing the evolving paradigms in primary TKA, with a focus on individualized alignment strategies, the growing role of cementless fixation, expanded bearing design options, and selective approaches to patellar resurfacing.

In each of these areas, the goal is not to promote a single new standard, but rather to provide an evidence-based framework to support thoughtful, patient-specific decision-making.

As the field continues to evolve, moving beyond rigid dogma toward personalized reconstruction strategies may represent a critical step in improving patient satisfaction while preserving the excellent survivorship that defines modern TKA.