Expert consensus on clinical pathway of high-conformity total knee arthroplasty under the enhanced recovery after surgery protocol_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 Expert Consensus Development Group on Clinical Pathways for High-Conformity Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocols , Project Team of the “Application Demonstration of Laser Additive Manufacturing for High-Conformity Total Knee Arthroplasty,” a Key Project under the National Key Research and Development Program of China for “Additive Manufacturing and Laser Manufacturing” (Fiscal Year 2023)

Corresponding?author：

Expert Consensus Development Group on Clinical Pathways for High-Conformity Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocols, Email: shenbin_1971@163.com

Keywords：

Total knee arthroplasty; high-conformity; enhanced recovery after surgery; clinical pathway; expert consensus; modified Delphi method

DOI：

10.7507/1002-1892.202606094

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

The integration of enhanced recovery after surgery (ERAS) principles with high-conformity total knee arthroplasty (TKA) technology provides a novel strategy for improving clinical outcomes and patient satisfaction following TKA. As a personalized and patient-specific prosthetic solution, high-conformity knee implants can more accurately match the individual anatomical morphology of the diseased knee joint than conventional prostheses, thereby maximizing postoperative functional restoration. However, standardized clinical protocols and unified management pathways for high-conformity TKA within an ERAS framework remain lacking in China. To standardize clinical practice and promote precision-based and homogeneous management, this consensus was developed by a multidisciplinary panel of Chinese experts in joint arthroplasty and related fields. A modified Delphi methodology was adopted. Relevant domestic and international literature was systematically reviewed, and an initial draft was developed based on the best available evidences and clinical experiences in China. Subsequently, two rounds of expert questionnaires and one round of online expert discussions were conducted to evaluate, revise, and refine the proposed statements, culminating in the final consensus. Consensus was defined as an agreement rate of ≥85% and categorized as strong consensus (95.0%-100%), general consensus (90.0%-94.9%), and moderate consensus (85.0%-89.9%). This consensus provides recommendations on key aspects of high-conformity TKA within an ERAS pathway, including preoperative precision assessment, multimodal imaging evaluation, patient selection, personalized implant design and accurate implantation, perioperative management, pain control, functional rehabilitation, and long-term follow-up. The objective is to offer practical guidance for orthopedic surgeons and rehabilitation specialists, facilitate the standardized implementation of high-conformity TKA integrated with ERAS protocols, optimize perioperative care, and ultimately improve functional recovery and quality of life for patients undergoing TKA.

Citation： Expert Consensus Development Group on Clinical Pathways for High-Conformity Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocols, Project Team of the “Application Demonstration of Laser Additive Manufacturing for High-Conformity Total Knee Arthroplasty,” a Key Project under the National Key Research and Development Program of China for “Additive Manufacturing and Laser Manufacturing” (Fiscal Year 2023). Expert consensus on clinical pathway of high-conformity total knee arthroplasty under the enhanced recovery after surgery protocol. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(8): 1163-1171. doi: 10.7507/1002-1892.202606094 Copy

1.	Steinmetz JD, Culbreth GT, Haile LM, et al. Global, regional, and national burden of osteoarthritis, 1990—2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021[J]. Lancet Rheumatol, 2023, 5(9): e508-e522.
2.	Chen S, Chen MJ, Chen C, et al. Epidemiological trends and characteristics ofosteoarthritis in China during 1990—2021[J]. J Orthop Translat, 2025, 51: 218-226.
3.	梅軼芳. 中國骨關節炎流行病學研究現狀及規范[J]. 中國實用內科雜志, 2019, 39(8): 663-665.
4.	夏瑞陽, 王文波. 髖膝關節置換日間手術研究進展[J]. 實用骨科雜志, 2025, 31(12): 1102-1106.
5.	Matar HE, Platt SR, Gollish JD, et al. Overview of randomized controlled trials in total knee arthroplasty (47, 675 patients): what have we learnt?[J]. J Arthroplasty, 2020, 35(6): 1729-1736.
6.	孫長鮫, 蔡谞. 基于個性化截骨導板的高適配假體在全膝關節置換術中的應用進展[J]. 中華醫學雜志, 2026, 106(13): 1261-1265.
7.	Gong S, Xu WH, Wang RY, et al. Patient-specific instrumentation improved axial alignment of the femoral component, operative time and perioperative blood loss after total knee arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(4): 1083-1095.
8.	沈彬, 翁習生, 廖刃, 等. 中國髖、膝關節置換術加速康復—圍術期疼痛與睡眠管理專家共識[J]. 中華骨與關節外科雜志, 2016, 9(2): 91-97.
9.	Morrell AT, Layon DR, Scott MJ, et al. Enhanced recovery after primary total hip and knee arthroplasty: a systematic review[J]. J Bone Joint Surg (Am), 2021, 103(20): 1938-1947.
10.	童培建, 翁習生, 楊仁池, 等. 中國血友病性骨關節病髖膝關節置換圍手術期管理指南[J]. 中華骨與關節外科雜志, 2022, 15(7): 481-490.
11.	Kim BI, LaValva SM, Parks ML, et al. Glucagon-like peptide-1 receptor agonists decrease medical and surgical complications in morbidly obese patients undergoing primary TKA[J]. J Bone Joint Surg (Am), 2025, 107(4): 348-355.
12.	Park HJ, Chang MJ, Kim TJ, et al. Intravenous dexamethasone transiently elevates blood glucose levels and reduces pain after TKA in patients with type-2 diabetes mellitus: a randomized controlled study[J]. J Bone Joint Surg (Am), 2025, 107(10): 1073-1081.
13.	徐麗麗, 劉序強. 全膝關節置換術后膝關節功能加速康復專家共識[J]. 山東大學學報 (醫學版), 2024, 62(10): 48-61.
14.	Graber J, Churchill L, Struessel T, et al. Expert consensus for the use of outpatient rehabilitation visits after total knee arthroplasty: a delphi study[J]. J Orthop Sports Phys Ther, 2023, 53(9): 566-574.
15.	陳天午. 采用新一代人工韌帶重建前十字韌帶的關鍵技術和不良事件——基于改良Delphi法制訂的中國專家共識(二)[J]. 中國修復重建外科雜志, 2022, 36(9): 1047-1055.
16.	中華醫學會重癥醫學分會. 中國成人ICU患者營養評估與監測臨床實踐指南[J]. 中華危重病急救醫學, 2023, 35(11): 1121-1146.
17.	Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study[J]. Arthritis Care Res (Hoboken), 2014, 66(3): 411-423.
18.	Culler SD, Martin GM, Swearingen A. Comparison of adverse events rates and hospital cost between customized individually made implants and standard off-the-shelf implants for total knee arthroplasty[J]. Arthroplasty Today, 2017, 3(4): 257-263.
19.	Reimann P, Brucker M, Arbab D, et al. Patient satisfaction—A comparison between patient-specific implants and conventional total knee arthroplasty[J]. J Orthop, 2019, 16(3): 273-277.
20.	Ogura T, Le K, Merkely G, et al. A high level of satisfaction after bicompartmental individualized knee arthroplasty with patient-specific implants and instruments[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1487-1496.
21.	Schroeder L, Martin G. In vivo tibial fit and rotational analysis of a customized, patient-specific TKA versus off-the-shelf TKA[J]. J Knee Surg, 2019, 32(6): 499-505.
22.	Talmo CT, Anderson MC, Jia ES, et al. High rate of early revision after custom-made unicondylar knee arthroplasty[J]. J Arthroplast, 2018, 33(7): S100-S104.
23.	Steinert AF, Sefrin L, Jansen B, et al. Patient-specific cruciate-retaining total knee replacement with individualized implants and instruments (iTotal^TM CR G2)[J]. Oper Orthop Traumatol, 2021, 33(2): 170-180.
24.	Wang H, Foster J, Franksen N, et al. Gait analysis of patients with an off-the-shelf total knee replacement versus customized bi-compartmental knee replacement[J]. International Orthopaedics, 2018, 42(4): 805-810.
25.	Schwarzkopf R, Brodsky M, Garcia GA, et al. Surgical and functional outcomes in patients undergoing total knee replacement with patient-specific implants compared with “off-the-shelf” implants[J/OL]. Orthop J Sports Med, 2015, 3(7): 2325967115590379. doi: 10.1177/2325967115590379.
26.	White PB, Ranawat AS. Patient-specific total knees demonstrate a higher manipulation rate compared to “off-the-shelf”[J]. J Arthroplast, 2016, 31(1): 107-111.
27.	Wheatley B, Nappo K, Fisch J, et al. Early outcomes of patient-specific posterior stabilized total knee arthroplasty implants[J]. J Orthop, 2018, 16(1): 14-18.
28.	Zeller IM, Sharma A, Kurtz WB, et al. Customized versus patient-sized cruciate-retaining total knee arthroplasty: an in vivo kinematics study using mobile fluoroscopy[J]. J Arthroplasty, 2017, 32(4): 1344-1350.
29.	Fitz W. Unicompartmental knee arthroplasty with use of novel patient-specific resurfacing implants and personalized jigs[J]. J Bone Joint Surg (Am), 2009, 91 Suppl 1: 69-76.
30.	Kumar P, Elfrink J, Daniels JP, et al. Higher component malposition rates with patient-specific cruciate retaining TKA than contemporary posterior stabilized TKA[J]. J Knee Surg, 2021, 34(10): 1085-1091.
31.	Koeck FX, Beckmann J, Luring C, et al. Evaluation of implant position and knee alignment after patient-specific unicompartmental knee arthroplasty[J]. Knee, 2011, 18(5): 294-299.
32.	Meheux CJ, Park KJ, Clyburn TA. A retrospective study comparing a patient-specific design total knee arthroplasty with an off-the-shelf design: unexpected catastrophic failure seen in the early patient-specific design[J/OL]. J Am Acad Orthop Surg Glob Res Rev, 2019, 3(11): e19.00143. doi: 10.5435/JAAOSGlobal-D-19-00143.
33.	O'Connor MI, Blau BE. The economic value of customized versus off-the-shelf knee implants in medicare fee-for-service beneficiaries[J]. Am Health Drug Benefits, 2019, 12(2): 66-73.
34.	Demange MK, Von Keudell A, Probst C, et al. Patient-specific implants for lateral unicompartmental knee arthroplasty[J]. Int Orthop, 2015, 39(8): 1519-1526.
35.	Li X, Wang C, Guo Y, et al. An approach to developing customized total knee replacement implants[J/OL]. J Healthc Eng, 2017, 2017: 9298061. doi: 10.1155/2017/9298061.

1. Steinmetz JD, Culbreth GT, Haile LM, et al. Global, regional, and national burden of osteoarthritis, 1990—2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021[J]. Lancet Rheumatol, 2023, 5(9): e508-e522.
2. Chen S, Chen MJ, Chen C, et al. Epidemiological trends and characteristics ofosteoarthritis in China during 1990—2021[J]. J Orthop Translat, 2025, 51: 218-226.
3. 梅軼芳. 中國骨關節炎流行病學研究現狀及規范[J]. 中國實用內科雜志, 2019, 39(8): 663-665.
4. 夏瑞陽, 王文波. 髖膝關節置換日間手術研究進展[J]. 實用骨科雜志, 2025, 31(12): 1102-1106.
5. Matar HE, Platt SR, Gollish JD, et al. Overview of randomized controlled trials in total knee arthroplasty (47, 675 patients): what have we learnt?[J]. J Arthroplasty, 2020, 35(6): 1729-1736.
6. 孫長鮫, 蔡谞. 基于個性化截骨導板的高適配假體在全膝關節置換術中的應用進展[J]. 中華醫學雜志, 2026, 106(13): 1261-1265.
7. Gong S, Xu WH, Wang RY, et al. Patient-specific instrumentation improved axial alignment of the femoral component, operative time and perioperative blood loss after total knee arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(4): 1083-1095.
8. 沈彬, 翁習生, 廖刃, 等. 中國髖、膝關節置換術加速康復—圍術期疼痛與睡眠管理專家共識[J]. 中華骨與關節外科雜志, 2016, 9(2): 91-97.
9. Morrell AT, Layon DR, Scott MJ, et al. Enhanced recovery after primary total hip and knee arthroplasty: a systematic review[J]. J Bone Joint Surg (Am), 2021, 103(20): 1938-1947.
10. 童培建, 翁習生, 楊仁池, 等. 中國血友病性骨關節病髖膝關節置換圍手術期管理指南[J]. 中華骨與關節外科雜志, 2022, 15(7): 481-490.
11. Kim BI, LaValva SM, Parks ML, et al. Glucagon-like peptide-1 receptor agonists decrease medical and surgical complications in morbidly obese patients undergoing primary TKA[J]. J Bone Joint Surg (Am), 2025, 107(4): 348-355.
12. Park HJ, Chang MJ, Kim TJ, et al. Intravenous dexamethasone transiently elevates blood glucose levels and reduces pain after TKA in patients with type-2 diabetes mellitus: a randomized controlled study[J]. J Bone Joint Surg (Am), 2025, 107(10): 1073-1081.
13. 徐麗麗, 劉序強. 全膝關節置換術后膝關節功能加速康復專家共識[J]. 山東大學學報 (醫學版), 2024, 62(10): 48-61.
14. Graber J, Churchill L, Struessel T, et al. Expert consensus for the use of outpatient rehabilitation visits after total knee arthroplasty: a delphi study[J]. J Orthop Sports Phys Ther, 2023, 53(9): 566-574.
15. 陳天午. 采用新一代人工韌帶重建前十字韌帶的關鍵技術和不良事件——基于改良Delphi法制訂的中國專家共識(二)[J]. 中國修復重建外科雜志, 2022, 36(9): 1047-1055.
16. 中華醫學會重癥醫學分會. 中國成人ICU患者營養評估與監測臨床實踐指南[J]. 中華危重病急救醫學, 2023, 35(11): 1121-1146.
17. Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study[J]. Arthritis Care Res (Hoboken), 2014, 66(3): 411-423.
18. Culler SD, Martin GM, Swearingen A. Comparison of adverse events rates and hospital cost between customized individually made implants and standard off-the-shelf implants for total knee arthroplasty[J]. Arthroplasty Today, 2017, 3(4): 257-263.
19. Reimann P, Brucker M, Arbab D, et al. Patient satisfaction—A comparison between patient-specific implants and conventional total knee arthroplasty[J]. J Orthop, 2019, 16(3): 273-277.
20. Ogura T, Le K, Merkely G, et al. A high level of satisfaction after bicompartmental individualized knee arthroplasty with patient-specific implants and instruments[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1487-1496.
21. Schroeder L, Martin G. In vivo tibial fit and rotational analysis of a customized, patient-specific TKA versus off-the-shelf TKA[J]. J Knee Surg, 2019, 32(6): 499-505.
22. Talmo CT, Anderson MC, Jia ES, et al. High rate of early revision after custom-made unicondylar knee arthroplasty[J]. J Arthroplast, 2018, 33(7): S100-S104.
23. Steinert AF, Sefrin L, Jansen B, et al. Patient-specific cruciate-retaining total knee replacement with individualized implants and instruments (iTotal^TM CR G2)[J]. Oper Orthop Traumatol, 2021, 33(2): 170-180.
24. Wang H, Foster J, Franksen N, et al. Gait analysis of patients with an off-the-shelf total knee replacement versus customized bi-compartmental knee replacement[J]. International Orthopaedics, 2018, 42(4): 805-810.
25. Schwarzkopf R, Brodsky M, Garcia GA, et al. Surgical and functional outcomes in patients undergoing total knee replacement with patient-specific implants compared with “off-the-shelf” implants[J/OL]. Orthop J Sports Med, 2015, 3(7): 2325967115590379. doi: 10.1177/2325967115590379.
26. White PB, Ranawat AS. Patient-specific total knees demonstrate a higher manipulation rate compared to “off-the-shelf”[J]. J Arthroplast, 2016, 31(1): 107-111.
27. Wheatley B, Nappo K, Fisch J, et al. Early outcomes of patient-specific posterior stabilized total knee arthroplasty implants[J]. J Orthop, 2018, 16(1): 14-18.
28. Zeller IM, Sharma A, Kurtz WB, et al. Customized versus patient-sized cruciate-retaining total knee arthroplasty: an in vivo kinematics study using mobile fluoroscopy[J]. J Arthroplasty, 2017, 32(4): 1344-1350.
29. Fitz W. Unicompartmental knee arthroplasty with use of novel patient-specific resurfacing implants and personalized jigs[J]. J Bone Joint Surg (Am), 2009, 91 Suppl 1: 69-76.
30. Kumar P, Elfrink J, Daniels JP, et al. Higher component malposition rates with patient-specific cruciate retaining TKA than contemporary posterior stabilized TKA[J]. J Knee Surg, 2021, 34(10): 1085-1091.
31. Koeck FX, Beckmann J, Luring C, et al. Evaluation of implant position and knee alignment after patient-specific unicompartmental knee arthroplasty[J]. Knee, 2011, 18(5): 294-299.
32. Meheux CJ, Park KJ, Clyburn TA. A retrospective study comparing a patient-specific design total knee arthroplasty with an off-the-shelf design: unexpected catastrophic failure seen in the early patient-specific design[J/OL]. J Am Acad Orthop Surg Glob Res Rev, 2019, 3(11): e19.00143. doi: 10.5435/JAAOSGlobal-D-19-00143.
33. O'Connor MI, Blau BE. The economic value of customized versus off-the-shelf knee implants in medicare fee-for-service beneficiaries[J]. Am Health Drug Benefits, 2019, 12(2): 66-73.
34. Demange MK, Von Keudell A, Probst C, et al. Patient-specific implants for lateral unicompartmental knee arthroplasty[J]. Int Orthop, 2015, 39(8): 1519-1526.
35. Li X, Wang C, Guo Y, et al. An approach to developing customized total knee replacement implants[J/OL]. J Healthc Eng, 2017, 2017: 9298061. doi: 10.1155/2017/9298061.

Next Article
Interpretation of 2024 United Kingdom National Osteoporosis Guideline Group (NOGG) Clinical Guidelines: Prevention and Treatment of Osteoporosis

Chinese Journal of Reparative and Reconstructive Surgery

Expert consensus on clinical pathway of high-conformity total knee arthroplasty under the enhanced recovery after surgery protocol

Abstract Full text Figures/Tables Video References Cited by

Next Article

Format

Content