Abstract

Total knee arthroplasty (TKA) is increasingly performed in younger, more active patients who expect to return to recreational and sporting activities. Understanding return to sport (RTS) outcomes is essential for pre operative counseling and shared decision-making. This systematic review was conducted following PRISMA guidelines. A comprehensive literature search of MEDLINE, Embase, CINAHL, Scopus, and SPORTDiscus identified studies published between 2021 and 2026 reporting RTS outcomes after primary TKA. Sixteen studies met the inclusion criteria. Quality assessment was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Pooled analysis demonstrated an overall RTS rate of 82% (95% CI, 72%–89%) within the first year postoperatively. Low-impact activities (walking, swimming, cycling) showed the highest participation rates (76%–90%), while high-impact sports (running, skiing) demonstrated significantly lower rates (35%–48%). Time to RTS ranged from 12 weeks to 12 months. Predictors of successful RTS included male sex, younger age, higher preoperative activity levels, higher education, and non-smoking status. Implant design (cruciate-retaining vs. posterior-stabilized) did not significantly influence RTS outcomes. Only 34.6% of patients achieved their desired activity level, highlighting a substantial expectation-outcome gap. Unicompartmental knee arthroplasty (UKA) demonstrated superior RTS rates for high-impact activities compared to TKA. Most patients can successfully RTS following TKA, particularly for low-impact activities. However, the gap between desired and achieved activity levels underscores the critical importance of preoperative expectation management. Standardized RTS definitions and evidence-based guidelines are needed to optimize patient counseling and postoperative outcomes.

Key words: Total knee arthroplasty, return to sport, sports participation, physical activity, knee osteoarthritis, patient-reported outcomes