Background: Total knee arthroplasty (TKA) has evolved significantly, yet achieving consistently optimal outcomes remains challenging across diverse patient populations. This comprehensive narrative review identifies evidence-based “game changers” that genuinely transform TKA success while distinguishing them from interventions lacking clinical superiority. The analysis organizes findings across three perioperative phases: preoperative optimization, intraoperative techniques, and postoperative management. Preoperative game changers include end-stage bone-on-bone osteoarthritis, preoperative medical optimization of patients performed by dedicated practitioners, cryocompression therapy, and perioperative dexamethasone administration. Intraoperative interventions demonstrating substantial impact encompass reduced surgical time and optimized surgical instrumentation, personalized alignment, medial congruent bearings, cementless implants for high-demanding and high-BMI patients, and perioperative tranexamic acid. Postoperative game changers include early mobilization following surgery, venous thrombo-embolic prophylaxis avoiding high-bleeding-risk pharmaceuticals, and multimodal pain management. The review also identifies those initial promises without established clinical advantages, or “fake game changers”, that consume resources without meaningful benefits. This evidence synthesis demonstrates that TKA optimization requires systematic implementation of validated interventions rather than pursuing technological innovations indiscriminately. The future of TKA lies in evidence-based adoption of proven strategies that translate to genuine patient outcome improvements rather than merely increasing procedural complexity.

Background: Comparisons of cemented and cementless TKA have focused on mean outcomes and generally reported equivalence. We hypothesized that a 3D-printed full-titanium cementless TKA and the same-design cemented implant would not differ significantly in average joint awareness but would differ in the proportion of patients with the poorest results, and we compared the two both at the mean and across the outcome distribution. Methods: Prospective two-cohort study of 109 primary unilateral TKAs (54 cementless, 55 cemented) for end-stage knee osteoarthritis, with complete 24-month follow-up. Exclusion criteria were valgus deformity and bilateral surgery. The primary outcome was the FJS-12, analysed both at the mean (multivariable linear regression, with propensity score overlap weighting as sensitivity analysis) and across its distribution (quantile regression). Secondary outcomes were PASS achievement (FJS-12 ≥ 33.3), OKS, and time to functional satisfaction. Results: The cementless group was younger ( P < 0.001) with more men ( P = 0.008). Mean FJS-12 was not different between groups after adjustment (β = 7.4, 95% CI − 1.8 to 16.6, P = 0.115), although the confidence interval did not exclude a difference exceeding the minimal clinically important difference; this finding was reproduced by overlap weighting. On quantile regression, cementless patients scored significantly higher at the 10th and 25th percentiles (adjusted P = 0.028 and 0.021) but not at the median or above. A greater proportion of cementless patients achieved the PASS (96.3% vs. 76.4%; absolute difference 19.9%, 95% CI 7.1 to 32.9; number needed to treat 5), which persisted after adjustment ( P = 0.005). No significant differences were observed in OKS ( P = 0.91) or time to functional satisfaction (adjusted P = 0.39). No revisions or loosening occurred. Conclusion: The 3D-printed full-titanium cementless TKA did not produce a significantly higher mean FJS-12 than the same-design cemented device at 24 months, but it significantly reduced the proportion of patients with poor joint awareness outcomes. Level of evidence: III.