Stratification-Based Surgical Algorithm for Total Knee Arthroplasty in Post-Traumatic Knee Osteoarthritis

Background: Post-traumatic knee osteoarthritis (PTOA) presents unique challenges for total knee arthroplasty (TKA), including deformity, stiffness, bone loss, and ligament instability. Existing literature describes isolated risk factors but lacks integrated, clinically actionable frameworks. Methods: A prospective cohort of 84 PTOA patients undergoing primary TKA was evaluated using a stratification-based surgical algorithm. Six domains were assessed: deformity severity/direction, soft tissue envelope, prior surgery, bone defect classification (AORI), preoperative stiffness, and ligament stability. Composite risk profiles guided implant selection. Outcomes were assessed radiographically and functionally (Oxford Knee Score [OKS], Knee Society Score [KSS]) at baseline, 6, 12, and 24 months. Results: Mean age was 58.9 years; 60% were male. Etiologies included fracture-related PTOA (62%) and ligament-related PTOA (38%). Mechanical axis deviation improved from 10.7° to 1.9° (p < 0.001). At 24 months, OKS improved from 21.4 to 37.8 (Δ +16.4, p < 0.001) and KSS from 52.1 to 86.7 (Δ +34.6, p < 0.001). Gains were smaller in fracture-related PTOA and in patients with stiffness or gross ligament instability. Implant selection included cruciate-retaining/posterior-stabilized (49%), constrained condylar (37%), and rotating-hinge (14%). The complication rate was 12.5%, with implant survival of 95.6% in 24 months. Conclusion: A stratification-based algorithm enhances predictability, guides implant selection, and improves patient counselling in PTOA TKA. Outcomes remain inferior to primary OA, but the framework provides a reproducible tool for precision-based surgery.