Total knee arthroplasty is one of the most successful reconstructive procedures for patients with advanced symptomatic knee osteoarthritis. The principal goals of TKA are pain relief, correction of deformity, restoration of knee stability and improvement in functional capacity. Despite excellent implant survival and substantial improvement in validated clinical scores, a proportion of patients remain dissatisfied following TKA. Residual pain, inadequate flexion, instability, abnormal gait and inability to reproduce normal activities are among the principal contributors to dissatisfaction [1–3]. Traditional posterior-stabilized prostheses use a femoral cam articulating with a tibial post to substitute for the posterior cruciate ligament and facilitate posterior femoral rollback during flexion. Although this mechanism provides satisfactory anteroposterior stability, fluoroscopic and biomechanical investigations have demonstrated that conventional TKA does not completely reproduce native knee kinematics. Paradoxical anterior translation of the femur during early flexion has been described after PS-TKA and may contribute to abnormal joint mechanics and patellofemoral symptoms [7,11]. The medial-pivot concept was developed to more closely reproduce the functional behavior of the native knee. The design incorporates a highly conforming medial compartment and a less-conforming lateral compartment. The medial compartment therefore acts as a relatively stable pivot while the lateral femoral condyle undergoes anteroposterior translation during flexion. This combination theoretically permits rotation around a stable medial compartment and may improve mid-flexion stability [6,8]. Biomechanical investigations have suggested that medial-pivot designs may provide favorable contact mechanics, improved stability and reduced polyethylene contact stresses. However, clinical evidence has not been completely uniform. Systematic reviews and comparative clinical studies have reported both advantages and equivalent outcomes between MP and PS designs [2–5]. Patient-reported outcome measures have become increasingly important in contemporary arthroplasty research. WOMAC evaluates pain, stiffness and physical disability; OKS provides a disease-specific assessment of pain and function; KSS combines clinical and functional components; and FJS assesses the degree to which patients are aware of their artificial joint during activities of daily living [9,15,16]. The present study was designed to compare MP and PS TKA using objective ROM assessment and validated patient-reported outcome measures. The primary hypothesis was that MP-TKA would demonstrate superior postoperative ROM and functional outcomes because of improved replication of native knee kinematics. AIM AND OBJECTIVES Aim: To compare the clinical, functional and patient-reported outcomes of medial-pivot versus posterior-stabilized total knee arthroplasty over a two-year follow-up period. Objectives: 1. To compare postoperative knee ROM between MP and PS TKA. 2. To compare Oxford Knee Scores between the two groups. 3. To compare WOMAC pain, stiffness, disability and total scores. 4. To compare KSS clinical and functional scores. 5. To compare Forgotten Joint Scores at one and two years. 6. To compare postoperative complications including anterior knee pain, instability, clicking and infection. 7. To assess whether MP-TKA provides clinically meaningful advantages over PS-TKA.

Study design: Prospective comparative study. Study place and duration : This was a Multicentric study conducted between November 2023 to November 2025 at 1.Bangalore Medical College and Research Institute ,Bengaluru 2.Sagar Hospitals ,Bengaluru 3.Fortis Hospitals ,Bengaluru 4.Sri Lakshmi Multispeciality Hospital ,Sunkadakatte ,Bengaluru. Study population: 100 patients undergoing primary TKA for symptomatic end-stage knee osteoarthritis. Groups: MP-TKA, n=50; PS-TKA, n=50. Follow-up: Preoperative assessment, one-year postoperative assessment and two-year postoperative assessment. Inclusion criteria: Primary symptomatic osteoarthritis requiring TKA; failure of appropriate conservative treatment; medical fitness for elective arthroplasty; ability to provide informed consent; ability to participate in postoperative rehabilitation; and availability for scheduled follow-up. Exclusion criteria: Previous knee infection; previous revision or conversion arthroplasty; neurological disease significantly affecting lower-limb function; inability to tolerate anaesthesia; severe medical comorbidity precluding elective surgery; and inability to complete follow-up. Surgical technique: Standardized primary TKA was performed through a midline incision and medial parapatellar approach. Distal femoral and proximal tibial preparation, gap balancing, cemented components, standardized perioperative antibiotics, tranexamic acid according to institutional protocol and postoperative physiotherapy were used. The implant design was the principal difference between groups. Outcome measures: Active knee ROM was measured with a goniometer. Patient-reported outcomes included OKS, WOMAC, KSS and FJS. Complications including anterior knee pain, biomechanical instability, clicking and infection were recorded. Statistical analysis: Continuous variables were expressed as mean ± standard deviation and categorical variables as frequency and percentage. Independent-samples t tests were used for between-group continuous variables, paired/repeated-measures analyses for longitudinal changes, and chi-square/Fisher's exact tests for categorical variables. A two-sided significance level of α=0.05 was used.

The illustrative cohort included 100 patients, equally divided between MP-TKA and PS-TKA. Mean age was 68.3 ± 6.5 years in MP-TKA and 67.9 ± 6.4 years in PS-TKA (p=0.76). Mean BMI was 28.4 ± 2.7 and 28.6 ± 2.9 kg/m², respectively (p=0.72). Sex distribution, diabetes, hypertension, obesity, cardiac disease and preoperative deformity were comparable, with no statistically significant baseline difference.Preoperative ROM was comparable (95.4 ± 3.1° in PS-TKA versus 96.2 ± 3.1° in MP-TKA; p=0.200). At one year, ROM improved to 110.7 ± 5.0° and 114.2 ± 4.8°, respectively (p<0.001). At two years, mean ROM was 113.5 ± 4.6° versus 116.0 ± 3.5° (p=0.003). The mean gain from baseline to two years was 18.1° in PS-TKA and 19.8° in MP-TKA. Table 1. Baseline demographic characteristics Variable PS-TKA (n=50) MP-TKA (n=50) p value Age, years 67.9 ± 6.4 68.3 ± 6.5 0.76 BMI, kg/m² 28.6 ± 2.9 28.4 ± 2.7 0.72 Male 21 (42%) 19 (38%) 0.68 Female 29 (58%) 31 (62%) Diabetes mellitus 14 (28%) 12 (24%) 0.65 Hypertension 38 (76%) 34 (68%) 0.37 Obesity 8 (16%) 6 (12%) 0.56 Cardiac disease 13 (26%) 15 (30%) 0.66 Varus deformity 41 (82%) 43 (86%) 0.59 Valgus deformity 9 (18%) 7 (14%) Table 2. Postoperative complications Complication PS-TKA n (%) MP-TKA n (%) p value Anterior knee pain 10 (20%) 3 (6%) 0.037 Biomechanical instability 8 (16%) 2 (4%) 0.046 Clicking sound 11 (22%) 1 (2%) 0.002 Superficial infection 1 (2%) 0 (0%) 1.000 Infection requiring insert exchange 2 (4%) 1 (2%) 0.558 Two-stage revision for infection 1 (2%) 1 (2%) 1.000 Table 3. Knee ROM at different follow-up intervals Time point PS-TKA Mean ± SD MP-TKA Mean ± SD p value Preoperative 95.4 ± 3.1° 96.2 ± 3.1° 0.200 1 year 110.7 ± 5.0° 114.2 ± 4.8° <0.001 2 years 113.5 ± 4.6° 116.0 ± 3.5° 0.003 Table 4. Oxford Knee Score Time point PS-TKA MP-TKA p value Preoperative 22.5 ± 4.3 22.8 ± 3.8 0.712 1 year 40.5 ± 3.8 42.7 ± 4.1 0.007 2 years 41.8 ± 4.3 43.5 ± 4.1 0.046 Table 5. WOMAC outcomes Parameter Time PS-TKA MP-TKA p value Pain Preoperative 12.8 ± 2.1 13.2 ± 2.2 0.36 Pain 1 year 7.0 ± 2.0 6.3 ± 1.7 0.062 Pain 2 years 7.1 ± 2.2 5.1 ± 1.5 <0.001 Stiffness Preoperative 5.5 ± 1.3 5.3 ± 1.1 0.36 Stiffness 1 year 2.9 ± 0.8 2.2 ± 0.9 <0.001 Stiffness 2 years 2.4 ± 1.0 1.8 ± 0.9 0.002 Disability Preoperative 39.7 ± 2.6 40.3 ± 2.5 0.23 Disability 1 year 22.9 ± 3.3 19.7 ± 3.0 <0.001 Disability 2 years 19.8 ± 2.7 18.1 ± 2.2 <0.001 Total Preoperative 58.1 ± 4.4 59.0 ± 4.0 0.29 Total 1 year 32.1 ± 4.2 28.1 ± 4.0 <0.001 Total 2 years 21.9 ± 3.0 20.5 ± 2.8 0.018 Table 6. KSS clinical and functional scores Outcome Time PS-TKA MP-TKA p value KSS clinical Preoperative 44.5 ± 4.7 46.2 ± 4.9 0.077 KSS clinical 1 year 78.7 ± 6.8 82.6 ± 4.9 0.001 KSS clinical 2 years 81.0 ± 5.7 83.7 ± 6.0 0.023 KSS functional Preoperative 44.9 ± 4.3 46.5 ± 5.0 0.091 KSS functional 1 year 75.8 ± 5.3 78.3 ± 7.1 0.049 KSS functional 2 years 74.1 ± 6.8 76.7 ± 6.4 0.052 Table 7. Forgotten Joint Score Follow-up PS-TKA MP-TKA p value 1 year 64.7 ± 5.7 69.4 ± 4.8 <0.001 2 years 76.4 ± 4.6 81.1 ± 5.5 <0.001 Table 8. Two-year comparison of principal outcomes Outcome PS-TKA MP-TKA Interpretation ROM 113.5° 116.0° MP superior OKS 41.8 43.5 MP superior WOMAC pain 7.1 5.1 MP superior WOMAC stiffness 2.4 1.8 MP superior WOMAC disability 19.8 18.1 MP superior WOMAC total 21.9 20.5 MP superior KSS clinical 81.0 83.7 MP superior KSS functional 74.1 76.7 Trend favouring MP FJS 76.4 81.1 MP superior Preoperative OKS was similar (22.5 ± 4.3 versus 22.8 ± 3.8; p=0.712). At one year it increased to 40.5 ± 3.8 in PS-TKA and 42.7 ± 4.1 in MP-TKA (p=0.007). At two years the scores were 41.8 ± 4.3 and 43.5 ± 4.1 (p=0.046). The two-year improvement from baseline was 19.3 points in PS-TKA and 20.7 points in MP-TKA. WOMAC total score fell from 58.1 ± 4.4 to 21.9 ± 3.0 in PS-TKA and from 59.0 ± 4.0 to 20.5 ± 2.8 in MP-TKA. At two years, pain was 7.1 versus 5.1 (p<0.001), stiffness 2.4 versus 1.8 (p=0.002), disability 19.8 versus 18.1 (p<0.001), and total score 21.9 versus 20.5 (p=0.018). Lower values indicate better outcome. KSS clinical score improved from 44.5 ± 4.7 to 81.0 ± 5.7 in PS-TKA and from 46.2 ± 4.9 to 83.7 ± 6.0 in MP-TKA. At one year the difference was 3.9 points (p=0.001) and at two years 2.7 points (p=0.023). KSS functional score improved substantially in both groups; the two-year difference of 2.6 points did not reach conventional significance (p=0.052). FJS was 64.7 ± 5.7 versus 69.4 ± 4.8 at one year and 76.4 ± 4.6 versus 81.1 ± 5.5 at two years in PS-TKA and MP-TKA, respectively. The MP advantage was 4.7 points at each postoperative assessment and was statistically significant (p<0.001). This represented the clearest patient-perceived separation between implant designs. Anterior knee pain occurred in 20% of PS-TKA versus 6% of MP-TKA (p=0.037). Instability occurred in 16% versus 4% (p=0.046). Clicking occurred in 22% versus 2% (p=0.002), representing the largest absolute difference. Superficial infection occurred in 2% versus 0%, insert exchange for infection in 4% versus 2%, and two-stage revision in 2% versus 2%; infection-related comparisons were not statistically significant. Both groups demonstrated substantial postoperative improvement across objective and patient-reported measures. MP-TKA consistently showed higher ROM, OKS, KSS clinical score and FJS and lower WOMAC scores. The largest patient-reported difference was in FJS, while the largest complication difference was postoperative clicking. These results are illustrative and should be interpreted as a model for presentation rather than actual clinical evidence.

The principal finding of this illustrative 100-patient comparative analysis is that both MP and PS TKA provide substantial improvements in pain, ROM and functional status, while MP-TKA demonstrates a consistent trend toward superior patient-reported outcomes and joint awareness. Range of motion: The MP group demonstrated greater mean ROM at one and two years. The proposed explanation is the more physiologic rotational pattern of the MP design, in which a highly conforming medial compartment provides a stable center of rotation while the lateral compartment permits controlled translation [6,8,11]. The literature remains heterogeneous, however, and not all comparative studies demonstrate a clinically important ROM difference [2–5,20]. Oxford Knee Score: Both groups improved markedly. The higher OKS in the MP group is consistent with studies reporting favorable early outcomes and patient satisfaction with medial-pivot designs [4,5,17]. However, the magnitude of benefit may depend on patient characteristics, surgical technique, implant geometry and rehabilitation. WOMAC pain, stiffness and disability improved substantially in both groups, with a greater reduction in the MP group in this illustrative dataset. Differences may relate to improved mid-flexion stability and tibiofemoral kinematics. Biomechanical investigations have demonstrated differences in loading and motion between MP and PS designs [12,13]. Nevertheless, postoperative pain remains multifactorial and should not be attributed exclusively to implant design. KSS clinical scores favored MP-TKA, while the functional component showed a smaller difference. Functional KSS can be influenced by age, cardiovascular fitness, contralateral knee disease and general mobility, which may dilute the effect attributable to implant design. FJS showed the clearest difference. This measure is particularly useful in modern arthroplasty because patients increasingly expect not merely pain relief but a knee that feels natural during daily activities. Previous work has established the validity and reliability of FJS, and comparative studies have reported favorable joint-awareness outcomes with medial-pivot designs [9,15–17]. The illustrative analysis demonstrated higher rates of anterior knee pain, instability and clicking in the PS group. The cam-post mechanism and intercondylar box of PS designs provide a plausible mechanism for certain patellofemoral and fibrosynovial complications. The reference study similarly reported substantially more clicking in PS-TKA than MP-TKA. Infection and revision: No meaningful difference was observed in infection-related complications. This is expected because infection risk is influenced predominantly by host factors, perioperative contamination, wound management and postoperative care rather than by the fundamental difference between MP and PS geometry. Comparison with literature: Existing evidence remains heterogeneous. Randomized and comparative studies have reported favorable patient satisfaction and functional outcomes with MP-TKA, whereas systematic reviews have also concluded that medial-stabilized designs may provide broadly comparable clinical outcomes to other TKA designs [2–5,17]. Biomechanical and fluoroscopic studies provide a plausible rationale for MP stability and more physiologic motion [7,11–13]. Therefore, MP-TKA should not be interpreted as universally superior to PS-TKA, but as a design with potential advantages in selected domains such as stability, deep flexion and joint awareness. Comparison of outcomes with published literature Outcome Published study Sample / follow-up Literature MP Literature PS Literature finding Present MP Present PS Comparison OKS Kim et al., prospective RCT [21] 43 MP / 45 PS; 2 years 42.7 ± 8.1 42.3 ± 6.7 p=0.18; NS 43.5 ± 4.1 41.8 ± 4.3 Similar overall; present study shows greater MP–PS separation OKS Obada et al., 2025 [22] 600; 2 years Higher than PS Lower than MP Group × time interaction p=0.003 43.5 ± 4.1 41.8 ± 4.3 Direction agrees with present study OKS Systematic review, 2023 Multiple comparative studies 43.6 ± 3.4* 45.4 ± 2.5* p>0.05 43.5 ± 4.1 41.8 ± 4.3 MP value closely matches literature; PS somewhat lower WOMAC total Stolarczyk et al., 2022 [23] Comparative study 29.3 24.6 p>0.05 20.5 ± 2.8 21.9 ± 3.0 Present study has lower WOMAC values; direction differs WOMAC pain Obada et al., 2025 [22] 600; 2 years Lower than PS Higher than MP MP favored 5.1 ± 1.5 7.1 ± 2.2 Direction agrees with present study WOMAC stiffness Stolarczyk et al., 2022 [23] Comparative study 3.0 1.1 p<0.05; PS favored 1.8 ± 0.9 2.4 ± 1.0 Present values lower overall; direction differs WOMAC disability Obada et al., 2025 [22] 600; 2 years Lower than PS Higher than MP MP favored 18.1 ± 2.2 19.8 ± 2.7 Direction agrees with present study KSS clinical Kim et al., prospective RCT [21] 43 MP / 45 PS; 2 years 82.9 ± 16.96 81.42 ± 10.45 p=0.12; NS 83.7 ± 6.0 81.0 ± 5.7 Very similar values; same direction KSS clinical Papagiannis et al. [24] Comparative study 84.6 ± 5.7 85.5 ± 5.1 p>0.05 83.7 ± 6.0 81.0 ± 5.7 MP comparable; PS lower in present study KSS clinical Obada et al., 2025 [22] 600; 2 years Higher than PS Lower than MP Interaction p<0.001 83.7 ± 6.0 81.0 ± 5.7 Direction strongly agrees FJS Samy et al. [6] Comparative; ~1 year 59.72 ± 31.68 44.77 ± 28.53 p=0.007 81.1 ± 5.5 76.4 ± 4.6 Higher scores in present study; same MP advantage FJS Tan et al., 2021 [25] Comparative study 60.7 ± 15.35 51.3 ± 17.62 p>0.05 81.1 ± 5.5 76.4 ± 4.6 Same direction; present study has higher absolute scores FJS Bianchi et al., 2020 [26] Comparative study 91.9 (88–95) 75.3 (68–82) p<0.05 81.1 ± 5.5 76.4 ± 4.6 MP advantage agrees; present values fall between reported ranges FJS Obada et al., 2025 [22] 600; 1–2 years Higher than PS Lower than MP p<0.001 at 1 and 2 years 81.1 ± 5.5 76.4 ± 4.6 Strong agreement with present study Summary comparison of principal two-year outcomes Outcome Present MP Present PS MP–PS difference Literature trend Overall interpretation OKS 43.5 ± 4.1 41.8 ± 4.3 +1.7 Generally comparable; some studies trend toward MP Favors MP WOMAC total 20.5 ± 2.8 21.9 ± 3.0 −1.4 Generally comparable; some studies favor MP Favors MP KSS clinical 83.7 ± 6.0 81.0 ± 5.7 +2.7 Mostly comparable; some studies show MP advantage Favors MP FJS 81.1 ± 5.5 76.4 ± 4.6 +4.7 Literature frequently reports higher FJS with MP Strongest support for MP STRENGTHS AND LIMITATIONS Strengths include a prospective comparative framework, equal group allocation, two-year follow-up, multiple validated outcome measures, objective ROM assessment, patient-reported outcomes and complication assessment. The major limitation of this document is that the numerical Results are illustrative/simulated and were not generated from an actual patient-level dataset. They must therefore not be presented as genuine clinical observations. For an actual journal submission, every mean, standard deviation, confidence interval, effect size and p value should be recalculated from the original patient data. Additional study limitations include the relatively modest sample size, limited duration for assessment of long-term survivorship, possible surgeon and implant-specific effects, and the influence of patient and rehabilitation factors on functional outcomes.

Both medial-pivot and posterior-stabilized total knee arthroplasty provide substantial improvement in pain, range of motion and functional status in patients with end-stage knee osteoarthritis.In the illustrative 100-patient comparative model, MP-TKA demonstrated greater postoperative ROM, higher Oxford Knee Scores, lower WOMAC scores, higher KSS clinical scores and higher Forgotten Joint Scores. Anterior knee pain, instability and postoperative clicking were less frequent in the MP group.The most consistent potential advantage of the medial-pivot design was improvement in joint awareness and functional performance, reflected particularly by FJS. These findings support the biomechanical rationale for medial-pivot TKA, while recognizing that component positioning, ligament balancing, patellar tracking, rehabilitation and patient expectations remain major determinants of outcome. MP-TKA may therefore be considered a valuable alternative to PS-TKA, particularly in patients for whom stability, functional performance and a more natural-feeling knee are important priorities.

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