Most of the advancements come from tribology and better implant materials. Golden replacement with multiple layers of coating, single radius knee, and patient specific instrumentation (PSI) using patient specific cutting jigs are another frontier.

Besides it use of computer assisted Orthopaedic surgery (CAOS) with advancements in precision of angles and axes is more reoutine now.

In the future 3D assisted technology may help provide better implants for complex cases.

I agree with Ganesh. Materials are constantly improved to reduce wear. As far as the technique is concerned, robotic surgery was introduced but still scarcely used because of the still unfavorable ratio accuracy/high costs.

Materials may improve, facilities to "custom made" to patient specific instrumentation are available, computer assisted surgery is possible, but still the success of the operation is in the hands of the able to control the "facilities" (even if they are expensive), but also to overcome difficulties within the short time that they may occur during the operation. On top we may not forget that knee replacement is not the operation that we only cut and replace bones but also to know how to balance the soft tissues.

As a footnote, I would say that the procedure is still undergoing evolution. As we evolve newer things crop up like loosening, adverse reaction to metal debris(ARMD, although more in THA) , prosthetic joint infections (PJIs) with constantly changing parameters and consensus etc...

Thus it is work in progress and we are in race to match the native knee as much as possible.

Without a radical rethink (bio materials etc.) there are only really a handful of things that can make a difference as things stand:

• materials - improving fixation and wear; primarily Improving survival
• design / geometry - improving the shape of implants; likely to manifest in improved functional outcomes.
• procedural technology - improving the positioning and reproducibility of the procedure.
• Patient selection vs implant / procedure choice.

They are clearly all linked however the last one is perhaps most intrinsically linked with all three of the first point. With the increased use of robotics patient and implant selection could shift as people access procedures that surgeons were perhaps unwilling / unable to perform with manual instrumentation.

Just my opinion!