The use of artificial joints for the treatment of osteoarthritis is expected to expand considerably over the next decade. While newer technologies can offer yet further improvements in total knee systems, implementation will be strongly affected by the need to satisfy apparently competing requirements. Patients expect quicker rehabilitation, improved performance, and lifelong durability; on the other hand, economic constraints require a reduction in cost for each procedure, as well as early intervention and preventative measures, while there is increased pressure from health care systems to use evidence-based medicine as the standard of choice for implants and techniques. The success of a knee replacement depends on the design itself, the surgical technique, the rehabilitation, and, not least, the patient. The major goal of the implant design can be redefined as a restoration of normal knee mechanics, whether by maximum preservation of tissues, or by guiding surfaces that replace their function. Surgical technique needs to be less invasive but achieve optimal patient-specific alignment and soft tissue balancing. Rehabilitation procedures must achieve the expectations of realistic patients. Testing and evaluation methods need to be upgraded for enhanced predictability. This paper discusses current trends and future possibilities to address this expansive scope of design criteria.