Abstract
Background: Osteoarthritis (OA) of the knee is a common, disabling condition influenced by multiple biopsychosocial factors and often requiring a total knee replacement (TKR). However, most rehabilitation programmes are developed in high-income countries, potentially limiting transferability to lower-income settings with distinct health equity challenges.
Objectives: This study aimed to describe the demographic and health equity profiles of adults undergoing TKR for primary OA across low-, middle- and high-income countries.
Method: A systematic literature search was conducted in PubMed, Scopus, EBSCOhost, Web of Science and ProQuest for peer-reviewed primary research, including observational studies, randomised controlled trials and grey literature published between 2020 and 2024. Studies reporting on individuals undergoing TKR were selected. Data extraction followed the PROGRESS-Plus framework, and a descriptive synthesis of demographic and health equity information was performed.
Results: The review included 101 studies with over 3.2 million participants, predominantly from high- and upper-middle-income countries, with no representation from Africa. Although females consistently represented the majority (54% – 86%), key health equity indicators such as socioeconomic status and education were inadequately reported. Clinical characteristics also varied, with a higher mean BMI observed in high-income country studies. Substantial methodological heterogeneity precluded meta-analysis.
Conclusion: There is extensive global research on TKR; however, data from lower-income countries is scarce, and health equity factors are poorly reported.
Clinical implications: Inconsistent reporting of outcome measures and limited reporting of health equity in global studies limit the implementation of rehabilitation programmes in low-resource settings. These settings would benefit from detailed equity data to adapt interventions to local patient needs. In addition, better integration of social determinants of health into physiotherapy practice can enhance personalised care and fair resource distribution.
Keywords: osteoarthritis; total knee replacement; PROGESS-Plus; health equity; patient profile; rehabilitation; physiotherapy.
Introduction
Osteoarthritis (OA) most frequently affects the knee joint. While its estimated global prevalence is 22% in individuals over 40 years of age (Cui et al. 2020), the condition predominantly impacts older adults, and its global, regional and national burden continues to rise significantly, with analyses projecting this burden to 2050 (Steinmetz et al. 2023).
Furthermore, the burden of OA is escalating, particularly among postmenopausal women globally. The classification of knee OA is typically demarcated into two main categories: primary OA, which lacks a clear causal factor for articular degeneration, and secondary OA, which is associated with specific factors such as joint trauma (e.g. previous fractures, ligament and meniscus injuries) or inflammatory conditions such as rheumatoid arthritis (Hsu & Silwec 2023).
The risk factors for the development of primary knee OA include age, gender, genetics, increased body mass index (BMI), physical activity levels and occupational demands (Cui et al. 2020). Additionally, factors that affect both the clinical progression (level of pain, functional ability) and the structural progression of knee OA also include socioeconomic indicators (e.g. level of education and social class), psychological factors (coping, mechanisms, anxiety, depressive states) and the presence of comorbidities (Bastick et al. 2016; Chen et al. 2025; Deveza, Loeser & Katz 2017; Li et al. 2024; Silverwood et al. 2015; Swinnen et al. 2021). Many of these risk factors are interconnected within the social context of the individual, and in conjunction with personal factors, community perceptions and psychological influences, they exert a considerable influence on the health-related outcomes for individuals presenting with knee OA (Luong, Lohmander & Sowers 2012). An important aspect of managing primary knee OA is the identification of modifiable risk factors, as these can be more effectively addressed through targeted interventions (Georgiev & Angelo 2019).
Given the complex and diverse presentation of knee OA, management strategies should consider the individual within their biopsychosocial context. However, a significant limitation is that data exploring risk factors, social determinants and progression trajectories primarily come from high-income countries (HICs). These data may not accurately reflect the profiles of individuals experiencing knee OA in low-middle-income countries (LMICs), where a significant proportion of the population faces lower socioeconomic circumstances (Dell’ Isola et al. 2016, 2018; Deveza et al. 2017; Li et al. 2024; Luong et al. 2012; Steinmetz et al. 2023). Existing international OA management interventions are typically designed for HIC contexts and may therefore not be generalisable or transferable to local contexts in LMIC because of health equity differences. Health equity differences may introduce barriers to the implementation of best-evidence OA care such as fragmented healthcare systems, inadequate human resources and inexperience among health professionals in managing OA post TKR (Castro et al. 2021; Keller & Sankah 2025).
Evidence suggests that physiotherapy plays a vital role in addressing the complex biopsychosocial factors following a TKR, as physiotherapists possess specialised expertise in understanding the multifaceted contributors to chronic pain and functional limitations (Kohia et al. 2015; Nishimoto et al. 2025). However, the availability and scope of physiotherapy services may vary considerably between high-income and LMICs, potentially creating additional barriers to comprehensive post-TKR rehabilitation.
To develop effective, context-specific programmes, the global demographic profile of individuals with OA should be designed using an equity lens that considers key factors influencing health outcomes. The PROGRESS-Plus equity lens framework is an acronym representing the following key factors: place of residence, race or ethnicity or culture or language, occupation, gender or sex, religion, education, socioeconomic status (SES), social capital, age, disability, sexual orientation and other vulnerable groups (Kavanagh, Oliver & Lorenc 2008). This framework was developed for description and assessment of social determinants related to health equity across populations, offering insights for translating interventions into different contexts (Kavanagh et al. 2008), by including descriptors linked to the variability in health outcomes (O’ Neill et al. 2014).
To the authors’ knowledge, no studies have comprehensively described the global demographic and social profiles of individuals undergoing TKR. An overview of these profiles through an equity-focused lens, such as the PROGRESS-Plus framework, can facilitate the adaptation of existing rehabilitation interventions to diverse local contexts. Therefore, this systematic review aims to describe the demographic characteristics and PROGRESS-Plus profiles of adults undergoing TKR for primary knee OA across low-, middle- and high-income countries. The findings are intended to identify evidence-based interventions and highlight critical gaps in research from lower-income contexts, particularly African settings. This will inform future research priorities and adapted implementation strategies for underrepresented contexts.
Research methods and design
Eligibility criteria
The systematic review used specific criteria for the inclusion of studies, as detailed in Table 1. The eligibility criteria for this systematic review included studies involving adults (≥ 18 years) awaiting or undergoing TKR surgery for primary knee OA. Eligible study designs comprised observational studies (cross-sectional, cohort, case-control) and randomised controlled trials. Studies were required to recruit participants sequentially or consecutively, with minimal age restrictions permissible. Only studies reporting baseline pre-surgical information specific to knee OA were included. To maintain feasibility and relevance, the review was limited to studies published between 2020 and 2024 because of the vast number of publications on the topic. Studies focusing on patellofemoral joint OA, secondary OA because of trauma or primary OA diagnoses not related to TKR individuals were excluded. Case studies and systematic reviews were excluded. Studies with restricted age ranges or those that selectively excluded participants based on factors such as BMI or comorbidities were not considered. Additionally, studies presenting combined hip and knee data, duplicate cohorts or those superseded by a more comprehensive included study were excluded. Studies published outside the specified 5-year period were also excluded to ensure manageability, given the volume of literature.
| TABLE 1: Eligibility criteria for the inclusion of studies in the systematic review. |
For the purpose of our review, ‘undergoing Total Knee Replacement (TKR)’ refers to individuals who are either awaiting TKR surgery or have already received the procedure, provided that baseline pre-surgical information is reported. Classification of countries by income group was based on the World Bank’s List of Income Classification of Economies (available at www.worldbank.org/en/home), which categorises economies according to the Atlas Gross National Income (GNI) per capita into four groups: low-income, lower-middle-income, upper-middle-income and high-income countries. Primary OA was defined as articular degeneration occurring without any identifiable underlying cause (Hsu & Siwec 2023). In contrast, secondary OA was considered to result from either abnormal mechanical loading of the joint, such as post-traumatic events, or conditions affecting normal articular cartilage (Hsu & Siwec 2023).
Search strategy
In collaboration with a faculty librarian who was experienced in conducting systematic searches, an initial exploratory search was conducted using the Stellenbosch University online library to identify databases containing relevant peer-reviewed literature, as well as grey literature, including academic theses. The following databases, PubMed (Medline), Scopus (abstracts from Elsevier or other sources), EBSCOhost (Africa Wide, CINAHL, Academic Premier, Health Source Nursing), Web of Science and ProQuest, were accessed for our review. Key search terms were identified by reviewing author keywords and index terms in relevant articles retrieved from PubMed and the Cochrane Library. A full list of these terms is provided in Online Appendix 1 – Table 1-A1, and the specific search strings used for each database are detailed in Online Appendix 1 – Table 2-A1.
Study selection and procedure
Following the database searches outlined in Online Appendix 1 – Table 2-A1, the identified studies were exported as comma-separated values (CSV) files containing the titles and abstracts. These CSV files were imported into the Rayyan Intelligent Systematic Review web-based software (https://www.rayyan.ai/) where automated duplicate detection was performed by the software. After duplicates were removed, the remaining titles were screened using the eligibility criteria. Articles not meeting the criteria based on their titles were excluded, after which the abstracts of the remaining studies were assessed for relevance and potential inclusion. Full-text versions of eligible articles were retrieved for further review by the main author and research assistant, and where conflicts arose, the supervisory team were consulted.
Both the primary researcher and a research assistant independently reviewed the titles, abstracts and full texts according to the eligibility criteria. Upon selection of the final studies, the supervisory team reviewed the articles and the extracted data. Any conflicts were resolved by the supervisory team. Reporting of the review process was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram for new systematic reviews, which included database and register search results (Page et al. 2021). This flowchart can be seen in Figure 1 in the results section.
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FIGURE 1: Identification of included studies according to the PRISMA 2020 flow diagram for new systematic reviews. |
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Assessment of reporting quality
Reporting quality of the final list of included studies was assessed using the appropriate study design appraisal tool from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (Von Elm et al. 2007) or the JBI Critical Appraisal Checklist for Randomised Controlled Trials (Tufanaru et al. 2020). The focus on assessing the reporting quality of the included studies was prioritised because of the descriptive nature of the data sought and to understand the profile of participants, especially in observational studies, where quality reporting is essential. Because of time constraints, two research assistants were educated on using the STROBE checklist by the primary researcher and conducted the quality of reporting assessment, each taking half of the studies. All uncertainties and queries were resolved by the primary researcher. The STROBE checklist is presented in Online Appendix 1 – Table 3-A1.
Data extraction and management
In addition to the study characteristics (which included title, authors, date of publication, aims and objectives, study design, study setting, sample size and results), the PROGRESS Plus framework was used as a guide to extract the relevant information required for applying an equity lens. This included place of residence, race or ethnicity or culture or language, occupation, gender or sex, religion, education, SES, social capital, age, disability and other vulnerable groups (Dell’Isola & Steultjens 2018). Furthermore, smoking, BMI and severity of OA were also extracted for descriptive purposes. Data were extracted by the main reviewer into a Microsoft Excel spreadsheet for recordkeeping and analysis, and a description of the factors can be seen in Table 2.
| TABLE 2: The PROGRESS-Plus factors assessed and the description of the extracted data. |
Data synthesis and reporting
Basic synthesis of the data was done using the descriptive quantitative information available from the studies. Most of the studies reported the demographic and social data using percentages, averages and ranges. Data are reported in the ranges provided by the studies, and counts were combined as a total and percentages calculated according to the total counts of the combined studies.
Ethical considerations
This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (review number 284634 on https://www.crd.york.ac.uk/prospero/) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement (Page et al. 2021). Our study was approved by the Stellenbosch University Health and Research Ethics Committee under Ethics number S20/11/315. The protocol was published and can be accessed online on https://hdl.handle.net/10520/ejc-sajp_v78_i1_a1649 (Coetzee et al. 2022).
Results
The systematic review identified a total of 101 studies (Figure 1) from diverse global regions, encompassing East Asia and the Pacific (n = 23), Europe and Central Asia (n = 38), the Middle East (n = 3), North America (n = 33) and South Asia (n = 4). Of these, only five were conducted in lower middle-income countries, specifically the Philippines and India (Bakshi et al. 2021; Chaudhary et al. 2024; Chhaya, Padmashri & Krishnan 2020; Devasenpathy et al. 2020; Dumlao, Delgado & Azores 2020), and nine in upper middle-income countries (Bian et al. 2021; Bradbury et al. 2024; Chan et al. 2020; Kaya, Seyman & Kaya 2024; Kocic et al. 2024; Liu et al. 2020, 2021; Moghtadaei et al. 2020; Wang et al. 2022). The rest were conducted in HICs. No African studies were included. Detailed information regarding the selected articles is presented in Table 3, segmented by geographic region.
| TABLE 3: Study characteristics and participant information from the included studies according to region. |
| TABLE 3 (Continues…): Study characteristics and participant information from the included studies according to region. |
| TABLE 3 (Continues…): Study characteristics and participant information from the included studies according to region. |
| TABLE 3 (Continues…): Study characteristics and participant information from the included studies according to region. |
| TABLE 3 (Continues…): Study characteristics and participant information from the included studies according to region. |
Table 4 summarises the PROGRESS-Plus data extracted from the studies, and Table 5 summarises the PLUS factors such as smoking, BMI and severity. When combining the results of different studies for one country, the range of the results is reported. Sample sizes varied widely, ranging from 11 to over 490 000 participants, and the final sample of individuals included in our review is 3 203 292. Australia, Denmark, the United Kingdom (UK) and the United States (US) used large knee replacement databases for their studies and were able to provide retrospective data on basic demographic profiles of their OA population. Most studies employed retrospective or prospective hospital databases and national or regional registries, with a smaller number using cross-sectional, descriptive or longitudinal designs. Common data collection instruments included validated patient-reported outcome measures (PROMs), reflecting a focus on functional recovery, patient satisfaction, mental health, pain and quality of life post-TKR.
| TABLE 4: Summary of the PROGRESS-Plus factors from all the countries included (2020–2024) according to the income level of the country. |
| TABLE 5: Summary of the Plus factors, including smoking, body mass index and osteoarthritis severity, from all the countries included (2020–2024) according to the income level of the country. |
Across all income levels, the majority of study participants were female, typically ranging from 54% to 86%. The mean age of participants ranged between 65 years and 75 years. Some variations across countries, such as Georgia, Germany and Japan, which had an older average age than India, which had the youngest cohort. Information on race/ethnicity was limited, with only a few countries reporting data on the percentage of white participants. Data on occupation, education and SES were sparse, particularly for lower-income countries. In HICs, such as Canada, the Netherlands and the US, where data were available, a significant proportion of participants had secondary education or higher (ranging from 24% to 98%) and were employed or receiving pensions. Low SES was reported for 17.7% of participants in the US and 26.8% in Canada. Social capital, measured by the percentage of participants with a partner, was reported only for a few HICs, with the highest percentage (94%) observed in China.
Smoking prevalence was reported for a few HICs, ranging from 5% to 17.2% of participants. Mean BMI tended to be higher in HICs (ranging from 25.6 kg/m2 to 36.7 kg/m2) compared to upper-middle and lower-middle-income countries (23.5 kg/m to 32.1 kg/m). Osteoarthritis severity, assessed using the Kellgren–Lawrence (KL) grading system, was reported for some HICs. The percentage of participants with severe OA (KL grade IV) ranged from 10.7% in Belgium to 78.5% in Switzerland. American Society of Anaesthesiologists (ASA) physical status classification was reported for several HICs, with a substantial proportion of participants classified as ASA II (ranging from 42.5% in the US to 80.5% in Korea) or ASA III (ranging from 8.3% in Sweden to 53.7% in the US). Previous surgery was reported for a few HICs, with percentages ranging from 34.6% in Belgium to 55% in Switzerland.
Discussion
The purpose of our review was to describe the demographic and health equity profiles of adults undergoing TKR for primary OA in lower, middle- and high-income countries. The review included 101 studies encompassing over 3.2 million individuals and represents the first comprehensive examination of the global demographic and health equity profile of adults undergoing TKR for primary OA through the PROGRESS-Plus equity lens.
Although a substantial volume of published research demonstrates ongoing clinical and academic interest in TKR, the findings show critical geographic biases and equity reporting deficiencies that fundamentally limit the clinical utility of the current evidence base in different contexts.
The concentration of TKR research in high-income and upper-middle-income countries underscores a significant gap in understanding the diverse populations affected by OA. This lack of representation from low-income countries is a significant limitation, as this may affect the generalisability of findings and limit the understanding of how socioeconomic factors influence outcomes in TKR across diverse populations. For example, no African studies met the criteria for inclusion, and this is problematic as the health system-related factors may significantly impact access to and quality of OA care in African contexts. Africa contributes significantly to the increasing global prevalence (estimated more than 37%), unmet needs and treatment burden for people with OA (Steinmetz et al. 2023). Despite the availability of evidence-based practice recommendations for OA management, evidence suggests that the implementation of these guidelines among African health professionals remains poor (Keller & Sankah 2025). Individuals often report a lack of support from clinics, with treatments predominantly focusing on pharmacological management (painkillers) and minimal mention of rehabilitation or pain management (Keller & Sankah 2025). There is an urgent need for a system-wide initiative that prioritises comprehensive, affordable and evidence-based OA care in low-resource settings, including improved education, consistent care pathways and better access to a range of appropriate health professionals and facilities (Owoyemi et al. 2025).
The application of the PROGRESS-Plus framework showed systematic underreporting of social determinants of health across all income levels, although particularly pronounced in lower-income countries. Equity indicators were inconsistently documented, limiting understanding of how these factors shape TKR access, outcomes and recovery trajectories.
This reporting gap is not merely a methodological oversight but represents a fundamental barrier to addressing documented health inequities. Without comprehensive equity data, service planning cannot be appropriately tailored, interventions risk perpetuating existing disparities, and the mechanisms through which social determinants influence clinical outcomes remain unsolved (Rizvi et al. 2022). Data pertaining to occupation, education and SES were particularly scarce, especially in the studies originating from lower-income countries. This is in contrast with the HICs such as Canada, the Netherlands and the US, which reported more comprehensive data on socioeconomic factors such as education and employment status. In these regions, 24% to 98% of participants undergoing TKR had attained secondary education or higher, and the majority of participants were either reemployed or receiving a pension (Ashkenazi et al. 2024). However, low SES was still a concern among this population, with figures indicating that approximately 17.7% of participants in the US and 26.8% in Canada were classified as having low SES. Social capital, which was most commonly defined as the percentage of participants with a partner, was reported in only a few HICs. In the included studies, China exhibited the highest percentage at 94%. This suggests a potential correlation between social support and health outcomes in OA populations (Wylde et al. 2019).
Despite geographic and methodological variation, the demographic profile demonstrated remarkable consistency, showing that individuals awaiting and undergoing TKR comprise 54% – 86% females, with a mean age consistently between 65 years and 75 years. This female predominance aligns with established literature attributing elevated OA burden in postmenopausal women to declining oestrogen levels, age-related degenerative changes and heightened pain sensitivity (Xu et al. 2025). However, this consistency contrasts with the clinical profile heterogeneity, particularly regarding BMI. The tendency towards higher mean BMI in HICs (25.6 kg/m2 – 36.7 kg/m2) compared with upper-middle and lower-middle-income countries (23.5 kg/m2 – 32.1 kg/m2) likely reflects differing lifestyle factors, dietary patterns and obesity prevalence (World Health Organization 2023). This variation underscores the necessity for context-specific pre-operative interventions, particularly weight optimisation programmes delivered by physiotherapists. The wide variation in reported severe OA (KL grade IV: 10.7% in Belgium to 78.5% in Switzerland) further suggests differing thresholds for surgical intervention, access barriers or disease progression patterns across settings.
Strengths and limitations
This systematic review is the first review to look at a global profile of individuals undergoing TKR surgery. Furthermore, the use of the PROGRESS-PLUS framework for data extraction in our study underscores an equity lens that may not be consistently applied in other research.
This method of portraying a wider range of the social determinants of health is crucial for understanding health outcomes. It also highlights critical gaps in representation and the need for improved reporting practices in the field. Our study adhered to reporting guidelines, such as STROBE and PRISMA, to ensure clarity and consistency in published studies.
The reporting quality of the final list of included studies was assessed using the appropriate study design appraisal tool from the STROBE, and the PRISMA checklist for reporting systematic reviews was completed and is presented in Online Appendix 1 – Table 4-A1.
Despite the overall large sample size, the limited representation from low-income countries is a significant limitation. The absence of data from these regions restricts our understanding of how socioeconomic factors influence TKR outcomes. Because of the search being limited to studies published after 2020, studies published in Africa may have been missed. In addition, a meta-analysis of the data was not possible because of the heterogeneity in outcome measures used and the reporting methods; therefore, our study could only report on the similarities and differences between countries and reference the range of reported data.
Implications for rehabilitation and physiotherapy
The implications of our review for rehabilitation are significant, particularly with regard to enhancing individualised management and addressing health equity in individuals undergoing TKR. Our study found significant gaps in the reporting and consideration of socioeconomic and equity-related information, especially in LMIC. This highlights the need for rehabilitation professionals involved in the management of individuals undergoing TKR, such as physiotherapists, to include socioeconomic indicators in pre-operative assessment, as this will assist with the tailoring of post-operative support and enhancing in postoperative recovery (Clynes et al. 2019). These indicators could include factors such as income, education and employment status. The reporting of demographic variables is essential to illustrate how social determinants of health influence pain, function and quality-of-life outcomes after TKR and is important to inform equitable service planning in the future management of these individuals (Castro et al. 2021; O’Neill et al. 2014).
In addition, physiotherapists are well positioned to implement recommended pre-operative lifestyle interventions such as education on exercise, weight optimisation and other self-management strategies (Rice et al. 2019). Incorporating interventions into the care pathway could improve postoperative outcomes by addressing modifiable risk factors and preparing individuals for surgery and recovery within their social context. More research within the field of physiotherapy should investigate the efficacy of these pre-operative lifestyle interventions on postoperative outcomes. This could provide insights into how pre-operative health behaviours influence recovery and overall satisfaction with surgical outcomes.
Implications for physiotherapy practice, policy and research
Our review identifies critical evidence gaps with direct implications for physiotherapy practice, health equity, and service delivery for individuals undergoing TKR.
Physiotherapy practice: Equity-informed, biopsychosocial rehabilitation
The substantial underreporting of SES and equity indicators, particularly in LMICs, could potentially impact evidence-informed rehabilitation and patient outcomes for individuals awaiting or undergoing TKR.
Physiotherapists should systematically integrate socioeconomic indicators (income, education, employment status, housing stability) into pre-operative assessments to enable individualised care planning (Clynes et al. 2019). These data constitute essential clinical information, as social determinants fundamentally shape pain experiences, functional recovery and quality-of-life outcomes following TKR (Castro et al. 2021; O’Neill et al. 2014).
The findings highlight the importance of a biopsychosocial, equity-focused rehabilitation approach that explicitly accounts for socioeconomic and cultural contexts, especially in underrepresented LMIC populations, where comorbidity burdens, healthcare access barriers and socioeconomic disadvantage affect post-surgical recovery (Alvarez 2022). The observed higher baseline BMI in HICs reinforces the clinical relevance of weight optimisation, although the absence of African and broader LMIC data prevents assumptions about optimal strategies across diverse contexts.
In addition, the effectiveness of pre-operative physiotherapy interventions on post-TKR outcomes remains inadequately evaluated. Research must rigorously examine how pre-operative health behaviours, delivered within culturally appropriate frameworks, influence recovery, functional outcomes and patient satisfaction across diverse socioeconomic and geographic populations.
Policy implications: Addressing structural inequities
The geographic concentration of evidence reflects systemic research inequities requiring policy intervention. Research funding bodies must prioritise studies in LMICs and underrepresented settings to comprehensively understand TKR outcomes and develop contextually appropriate care pathways. Current evidence cannot support confident translation to populations facing substantially different socioeconomic circumstances and healthcare systems. Standardised reporting of health equity metrics should become mandatory in orthopaedic and rehabilitation research. The PROGRESS-Plus framework (place of residence, race or ethnicity, occupation, gender, religion, education, SES, social capital) provides validated structure for equity-focused data collection (O’Neill et al. 2014). Without such data, equitable service planning remains unattainable. Low-resource settings require system-wide reform where OA care remains fragmented and pharmacologically focused. Policy must support comprehensive, evidence-based care models ensuring equitable access to appropriately trained health professionals, including physiotherapists, and necessary facilities. The disproportionate disability burden in LMIC populations requires coordinated action.
Research priorities
Future studies should prospectively collect comprehensive equity indicators, employ standardised outcome measures and intentionally recruit diverse populations. Only through addressing these methodological imperatives can the evidence base support equitable, effective TKR care globally.
Conclusion
This systematic review of 101 studies (including over 3.2 million individuals) highlights that while abundant research exists on the population of patients awaiting or undergoing TKR, the evidence base remains geographically concentrated in high-income and upper-middle-income countries, with a complete absence of African representation and profound underreporting of health equity indicators across all settings. This limits the generalisability of clinical guidelines to populations with the greatest disability burden from knee OA. Addressing this disparity requires coordinated action from researchers, who should systematically collect and report equity metrics, and policymakers, who should prioritise research funding for lower-income countries and mandate standardised equity reporting. Physiotherapists should adopt biopsychosocial, equity-focused rehabilitation approaches that integrate socioeconomic indicators into clinical assessment and deliver contextually appropriate pre-operative interventions.
Acknowledgements
The authors wish to acknowledge Alexandra Breuer, from the University of Paderborn, for her research assistance.
This article includes content that partially overlaps with research (Chapter 2) that was originally conducted as part of Marisa Coetzee’s doctoral thesis titled ‘Evidence-based supported self-management guidance algorithms for individuals awaiting knee arthroplasty’, submitted to the Faculty of Medicine and Health Sciences at Stellenbosch University in 2025. The thesis was supervised by Quinette Louw and Amanda Clifford. Portions of the data, analysis and discussion have been revised, updated and adapted for publication as a journal article. This is not yet available online. The author affirms that this article complies with ethical standards for secondary publication, and appropriate acknowledgement has been made of the original work.
Competing interests
The authors reported that they received funding from the National Research Foundation (NRF), which may be affected by the research reported in the enclosed publication. The authors have disclosed those interests fully and have implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated university in accordance with its policy on objectivity in research.
CRediT authorship contribution
Marisa Coetzee: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualisation, Writing – original draft, Writing – review & editing. Amanda Clifford: Conceptualisation, Methodology, Supervision, Visualisation, Writing – original draft, Writing – review & editing. Dominique C. Leibbrandt: Writing – original draft, Writing – review & editing. Jacobus Jordaan: Data curation, Formal analysis, Methodology, Visualisation. Quinette Louw: Conceptualisation, Formal analysis, Methodology, Supervision, Writing – original draft. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.
Funding information
This research was funded by the NRF, and this funding supported postgraduate bursaries and research assistance.
Data availability
The data that support the findings of this study are available on request from the first author, Marisa Coetzee (marcoetzee@sun.ac.za).
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or the publisher. The authors are responsible for this article’s results, findings and content.
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