Smart Knee Implants and Functional Outcome for Total Knee Arthroplasty

Abstract

Smart knee implants integrate advanced sensor-based technologies, forming a unique technology-embedded total knee arthroplasty (TKA) implant. Such implants introduce the ability to capture new elements of patient-related data for use in the context of recovery in real time including subjective reported outcomes and objective outcomes related to range of motion, and gait parameters. This technology allows for real-time data capture and patient-specific insights, creating opportunities to optimize postoperative care. This brief narrative review discusses the foundations and origin of technology-embedded implants, beginning with research-related roots relating to the derivation of fundamental knee joint force measurements. Analyzing the current market of implants, the present review investigates the technological capacities of modern designs including form and function. Further discussed is an evaluation of smart knee implant effectiveness, focusing on its impact on recovery outcomes such as patient-reported outcome measures (PROMs), functional improvement, gait patterns, and patient adherence/satisfaction. Smart implants represent a significant technological advancement in personalized care, leveraging real-time data including joint motion, alignment, and patient motion to assist surgeons in optimizing rehabilitation protocols. These implants provide insights into recovery progression postoperatively, with the potential for early identification of at-risk individuals. Preliminary studies demonstrate favorable patient outcomes and satisfaction, although further research is necessary to establish the long-term benefits and efficacy of smart knee implants.

Keywords

Total Knee Arthroplasty - functional outcomes - sensors - smartphone applications - range of motion

Publication History

Received: 31 December 2024

Accepted: 03 March 2025

Accepted Manuscript online:
04 March 2025

Article published online:
07 April 2025

• References

• 1 Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100 (17) 1455-1460
• 2 Pagan CA, Karasavvidis T, Cohen-Rosenblum AR, Hannon CP, Lombardi Jr AV, Vigdorchik JM. Technology in total knee arthroplasty in 2023. J Arthroplasty 2024; 39 (9S2): S54-S59
• 3 Sheridan GA, Abdelmalek M, Howard LC, Neufeld ME, Masri BA, Garbuz DS. Navigated versus conventional total knee arthroplasty: a systematic review and meta-analysis of prospective randomized controlled trials. J Orthop 2023; 50: 99-110
• 4 Daoub A, Qayum K, Patel R, Selim A, Banerjee R. Robotic assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomised controlled trials. J Robot Surg 2024; 18 (01) 364
• 5 Kelmers E, Szuba A, King SW. et al. “Smart knee implants: an overview of current technologies and future possibilities.”. Indian J Orthop 2022; 57 (05) 635-642
• 6 Ramkumar PN, Harris JD, Noble PC. Patient-reported outcome measures after total knee arthroplasty: a systematic review. Bone Joint Res 2015; 4 (07) 120-127
• 7 Lyman S, Omori G, Nakamura N. et al. Development and validation of a culturally relevant Japanese KOOS. J Orthop Sci 2019; 24 (03) 514-520
• 8 Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br 1998; 80 (01) 63-69
• 9 Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res 2012; 470 (01) 3-19
• 10 Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988; 15 (12) 1833-1840
• 11 Taylor SJ, Walker PS. Forces and moments telemetered from two distal femoral replacements during various activities. J Biomech 2001; 34 (07) 839-848
• 12 Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am 1975; 57 (07) 961-967
• 13 Colwell CW, D'Lima DD. The electronic knee. In: Bellemans J, Ries MD, Victor JMK. eds. Total Knee Arthroplasty: A Guide to Get Better Performance. Springer; 2005: 282-287
• 14 Wallace AL, Harris ML, Walsh WR, Bruce WJ. Intraoperative assessment of tibiofemoral contact stresses in total knee arthroplasty. J Arthroplasty 1998; 13 (08) 923-927
• 15 Takahashi T, Wada Y, Yamamoto H. Soft-tissue balancing with pressure distribution during total knee arthroplasty. J Bone Joint Surg Br 1997; 79 (02) 235-239
• 16 Taylor SJ, Walker PS, Perry JS, Cannon SR, Woledge R. The forces in the distal femur and the knee during walking and other activities measured by telemetry. J Arthroplasty 1998; 13 (04) 428-437
• 17 Taylor SJ, Perry JS, Meswania JM, Donaldson N, Walker PS, Cannon SR. Telemetry of forces from proximal femoral replacements and relevance to fixation. J Biomech 1997; 30 (03) 225-234
• 18 Taylor S. A telemetry system for measurement of forces in massive orthopaedic implants in vivo. Proceedings of 18th Annual International Conference of the IEEE Engineering in Medicine and Biology Society. 1996 1: 290-292
• 19 Kaufman KR, Kovacevic N, Irby SE, Colwell CW. Instrumented implant for measuring tibiofemoral forces. J Biomech 1996; 29 (05) 667-671
• 20 Morris BA, D'Lima DD, Slamin J. et al. e-Knee: evolution of the electronic knee prosthesis. Telemetry technology development. J Bone Joint Surg Am 2001; 83-A (Pt 1): 62-66
• 21 D'Lima DD, Steklov N, Patil S, Colwell Jr CW. The Mark Coventry Award: in vivo knee forces during recreation and exercise after knee arthroplasty. Clin Orthop Relat Res 2008; 466 (11) 2605-2611
• 22 D'Lima DD, Townsend CP, Arms SW, Morris BA, Colwell Jr CW. An implantable telemetry device to measure intra-articular tibial forces. J Biomech 2005; 38 (02) 299-304
• 23 D'Lima DD, Patil S, Steklov N, Slamin JE, Colwell Jr CW. Tibial forces measured in vivo after total knee arthroplasty. J Arthroplasty 2006; 21 (02) 255-262
• 24 Heinlein B, Graichen F, Bender A, Rohlmann A, Bergmann G. Design, calibration and pre-clinical testing of an instrumented tibial tray. J Biomech 2007; 40 (Suppl. 01) S4-S10
• 25 Bergmann G, Bender A, Graichen F. et al. Standardized loads acting in knee implants. PLoS One 2014; 9 (01) e86035
• 26 Almouahed S, Gouriou M, Hamitouche C, Stindel E, Roux C. Self-powered instrumented knee implant for early detection of postoperative complications. Annu Int Conf IEEE Eng Med Biol Soc 2010; 2010: 5121-5124
• 27 Almouahed S, Gouriou M, Hamitouche C, Stindel E, Roux C. Design and evaluation of instrumented smart knee implant. IEEE Trans Biomed Eng 2011; 58 (04) 971-982
• 28 Kutzner I, Heinlein B, Graichen F. et al. Loading of the knee joint during activities of daily living measured in vivo in five subjects. J Biomech 2010; 43 (11) 2164-2173
• 29 Halder A, Kutzner I, Graichen F, Heinlein B, Beier A, Bergmann G. Influence of limb alignment on mediolateral loading in total knee replacement: in vivo measurements in five patients. J Bone Joint Surg Am 2012; 94 (11) 1023-1029
• 30 Wasielewski RC, Galat DD, Komistek RD. An intraoperative pressure-measuring device used in total knee arthroplasties and its kinematics correlations. Clin Orthop Relat Res 2004; (427) 171-178
• 31 Crescini D, Sardini E, Serpelloni M. An autonomous sensor for force measurements in human knee implants. Procedia Chem 2009; 1 (01) 718-721
• 32 Crescini D, Sardini E, Serpelloni M. Design and test of an autonomous sensor for force measurements in human knee implants. Sens Actuators Phys 2011; 166 (01) 1-8
• 33 Persona IQ® | Smart Knee Implant Technology for Surgeons. Accessed November 25, 2024 at: https://www.zimmerbiomet.com/en/products-and-solutions/specialties/knee/persona-iq.html
• 34 Zimmer Biomet and Canary Medical Announce FDA De Novo Classification Grant and Authorization to Market the World's First and Only Smart Knee Implant. Accessed December 4, 2024 at: http://investor.zimmerbiomet.com/news-and-events/news/2021/08-30-2021-120155075
• 35 Iyengar KP, Gowers BTV, Jain VK, Ahluwalia RS, Botchu R, Vaishya R. Smart sensor implant technology in total knee arthroplasty. J Clin Orthop Trauma 2021; 22: 101605
• 36 Park CH, Song SJ. Sensor-assisted total knee arthroplasty: a narrative review. Clin Orthop Surg 2021; 13 (01) 1-9
• 37 User Guide VERASENSE. Accessed December 6, 2024 at: https://www.zimmerbiomet.com/content/dam/zimmer-biomet/medical-professionals/knee/verasense-sensor-assisted-tka/verasense-sensor-assisted-tka-brochure.pdf
• 38 eLIBRA Dynamic Knee Balancing System® (DKBS). Accessed December 6, 2024 at: https://www.zimmerbiomet.lat/en/medical-professionals/knee/product/elibra-dynamic-knee-balancing-system.html
• 39 Gordon AM, Nian P, Baidya J, Scuderi GR, Mont MA. Randomized controlled studies on smartphone applications and wearable devices for postoperative rehabilitation after total knee arthroplasty: a systematic review. J Arthroplasty 2025;S0883-5403(25)00062-2
• 40 Mathijssen NMC, Verburg H, London NJ, Landsiedl M, Dominkus M. Patient reported outcomes and implant survivorship after total knee arthroplasty with the persona knee implant system: two year follow up. BMC Musculoskelet Disord 2019; 20 (01) 97
• 41 Clement ND, MacDonald D, Simpson AHRW. The minimal clinically important difference in the Oxford knee score and Short Form 12 score after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2014; 22 (08) 1933-1939
• 42 Beard DJ, Harris K, Dawson J. et al. Meaningful changes for the Oxford hip and knee scores after joint replacement surgery. J Clin Epidemiol 2015; 68 (01) 73-79
• 43 Guild III GN, Najafi F, DeCook CA. et al. Evaluating knee recovery beyond patient reports: a comparative study of smart implantable device-derived gait metrics versus patient-reported outcome measures in total knee arthroplasty. J Arthroplasty 2024; 39 (12) 2961-2969.e1
• 44 Yocum D, Elashoff B, Verta P, Armock G, Yergler J. Patient reported outcomes do not correlate to functional knee recovery and range of motion in total knee arthroplasty. J Orthop 2023; 43: 36-40
• 45 Cushner FD, Hunter OF, Lee DC. How active are our patients in the first 6 weeks following total knee arthroplasty?. J Arthroplasty 2024; 39 (8S1): S125-S129
• 46 Bergmann JHM, Chandaria V, McGregor A. Wearable and implantable sensors: the patient's perspective. Sensors (Basel) 2012; 12 (12) 16695-16709
• 47 DeFrance M, Lang J, Aprigliano C, Danoff JR, Nett M. Understanding patient perspectives regarding remote monitoring devices following total joint replacement. Arthroplast Today 2022; 19: 101056
• 48 Kurtz SM, Higgs GB, Chen Z. et al. Patient perceptions of wearable and smartphone technologies for remote outcome monitoring in patients who have hip osteoarthritis or arthroplasties. J Arthroplasty 2022; 37 (7S): S488-S492 , 492.e2
• 49 Parikh N, Redfern R, Yocum D. , D VA, Yergler J. MT46 Patient experience and outcomes with post-surgical remote monitoring for patients with total knee arthroplasty (TKA). Value Health 2024; 27 (06) S290
• 50 Constantinescu D, Pavlis W, Rizzo M, Vanden Berge D, Barnhill S, Hernandez VH. The role of commercially available smartphone apps and wearable devices in monitoring patients after total knee arthroplasty: a systematic review. EFORT Open Rev 2022; 7 (07) 481-490