The first attempts to reconstruct a damaged or degenerated knee joint were reported at the end of nineteenth and the beginning of twentieth century. Resection arthroplasty of the knee was first reported by Fergusson in 1861, a procedure in which an incision was made and excess bone was removed to improve motion and stability [3]. Verneuil et al. [4] in 1863 tried to prevent bone growth between the resected joint surfaces by inserting a flap of joint capsule between them. In an attempt to simplify the mechanics of the knee, Gluck proposed the complete resection of articulating surfaces and cruciate ligaments and used a hinged prosthesis made of ivory to recreate the joint. The beginning of 1900 was the era of interposition arthroplasty and several substances were used, like fat (Lexer in 1917), chromatized pig’s bladder (Baer in 1918), fat and fascia lata (Murphy in 1913, Putti in 1921 and Albee in 1928), cellophane (Sampson in 1949), sheets of nylon (Kuhns in 1950) and skin (Brown in 1958). Campbell popularized the use of free fascial transplants as an interposition material. Some of these techniques had limited success in ankylosed knees, but in general the mid and long-term results were disappointing [5–13].

Between 1950 and 1960 several authors used different types of metallic molds in the form of femoral or tibial hemiarthroplasties [14, 15], while other surgeons designed and developed specific hinged implants for cases of severe arthritis and instability. The application of intramedullary stems improved the function of these prostheses which was an extra motivation for further development. Judet presented the first hinged prosthesis made of acrylic [16], while Magnoni, Waldius and Shiers reported similar devices which also used medullary stems to provide stability and restore limb alignment [17–19]. To deal with the problems of patellofemoral pain and loosening, McKeever [20] and MacIntosh [21] introduced the concept of patellar prostheses and the use of metal tibial components. However, biomechanical issues, poor metallurgy, improper fixation and frequent infection resulted in high failure rates.

Innovations such as the use of bone cement as a fixation material and the introduction of high density polyethylene plastic as a bearing surface gave great impetus to the further development of TKA. The polycentric and geometric designs launched the era of first generation knee replacements and Gunston was one of the first surgeons to experiment on these prostheses [22]. The Gunston polycentric knee was a minimally constrained implant and consisted of two separate high density polyethylene surfaces. Mimicking the low friction concept used earlier by Charnley in THA, minimizing bone cuts and preserving both cruciate ligaments, Gunston tried to reproduce the polycentric motion of the normal knee.

During the same year, Eftekhar presented his design using a metal-backed tibial component with modular polyethylene inserts [23]. Implants were fixed with cement and the use of long intramedullary stems would secure fixation. The Eftekhar Mark I knee would evolve into a condylar TKA design later, the Eftekhar Mark II. The first geometric knee arthroplasty (Geomedic or Geometric I Knee) was presented by Coventry, Riley, Finerman, Turner and Upshaw [24]. The preservation of both cruciate ligaments, high conformity, improved fixation of the tibial component with the use of small pegs and non-resurfacing of the patella were the main concepts of this design. The evolution of this implant was the Geometric II knee. The concept of geometric design was applied to another two implants manufactured by Zimmer in 1975. The Geotibial knee had a tibial peg to improve fixation and the Geopatellar knee had a femoral flange to improve patellar tracking. The evolution of these implants was the Multi-Radius, Miller Galante, Miller Galante II, and Nexgen knees. In the same year, Howmedica presented a similar but more anatomical design, the Anametric knee which would evolved into the porous coated anatomical knee (PCA) and eventually the Duracon knee.

Simultaneously with the development of first generation arthroplasties, several hinged prostheses were developed, like the Sheehan, Attenborough, Stanmore and the most popular Guepar prosthesis. Despite the initial enthusiasm, however, these prostheses failed because of a high rate of patellofemoral complications, breakage of the implant, early wear and loss of fixation. Nowadays, hinged arthroplasties are used in revision, tumour and cases with a high risk of instability.

Alongside with the development of the polycentric and geometric knees the idea of creating total condylar TKA evolved. Aiming to reconstruct normal joint surfaces, these designs consisted of a single piece femoral component covering both medial and lateral condyles, a single piece tibial component resurfacing both the medial and lateral plateaus, and bone cement was used for fixation. The patella femoral joint was not necessarily included in the design; some types had a femoral flange, but patellar buttons had not yet come into use. Surgical techniques were based on two philosophies: the anatomic and functional approaches. According to the first approach, only the articular surfaces were replaced or resurfaced, both cruciate ligaments and most of the soft tissue constraints were preserved and the implant surfaces were designed in such a way as to minimize the risk of soft tissue impingement. According to the functional approach, the mechanics of the knee were simplified by resection of the condyles and the cruciate ligaments and the main concern was to create parallel and equal gaps in flexion and extension.