A historical journey through total knee arthroplasty: the evolutionary milestones

This study aims to examine historical progressions to demonstrate how current debates in alignment philosophy, implant personalization, robotic surgery, and ligament management serve as direct extensions of past concepts.

The history of TKA was divided into four major evolutionary phases: the era of experimentation between 1860 and 1970, the period of implant design and biomechanical standardization between 1970 and 2000, the rise of personalization and morphologic understanding between 1985 and 2020, and the modern era of perioperative and technological evolution beginning in the early 2000's.

One of the earliest total joint replacement concepts was introduced in 1890 by Gluck, who implanted an ivory hinged knee prosthesis fixed with primitive cement materials. Modern hinged knee arthroplasty emerged during the 1950s to address severe arthritis and ligamentous instability, which constrained out-of-plane movement by allowing only flexion-extension. During the 1980s, modularity and mobile-bearing concepts gained widespread popularity. Metal-backed tibial components allowed polyethylene exchange and improved intraoperative flexibility, a concept exemplified by the Insall Burstein Posterior Stabilized II prosthesis. Beginning in the late 1980s and accelerating during the 1990s and early 2000s, researchers increasingly recognized that standardized implant geometries did not accurately reproduce native anatomy in many patients. During the 2000s and 2010s, alignment philosophy underwent a major paradigm shift. The twenty-first century introduced major advances in digital surgery.

The future of total knee arthroplasty will be shaped by advances in implant design, surgical methods, digital technologies, and biologic reconstruction. These trends continue the goal of mimicking native knee anatomy, biomechanics, and function. Future implants will likely shift from standard components to more personalized solutions.