Robotic-assisted total knee arthroplasty: A systematic review of clinical, radiographic, biomechanical, and perioperative outcomes

Abstract

Background: Robotic-assisted total knee arthroplasty (rTKA) has emerged as a technological evolution aimed at improving the accuracy and reproducibility of implant positioning, soft-tissue balancing, and functional outcomes. Despite rapid adoption, variability remains in reported benefits across platforms and clinical settings. This systematic review evaluates the clinical, radiographic, biomechanical, and perioperative outcomes of rTKA compared with conventional and navigated TKA. Methods: A systematic search of PubMed/MEDLINE and ScienceDirect/Scopus databases was conducted for studies published between 2015 and 2025. Eligible studies included randomized trials, cohort studies, registry analyses, cadaveric investigations, biomechanical assessments, and imaging-technology evaluations involving rTKA. Data extraction and synthesis followed PRISMA 2020 guidelines. Thirty-four studies met the inclusion criteria. Results: Robotic-assisted TKA demonstrated superior alignment accuracy, reduced mechanical outliers, and improved control of patellofemoral and tibiofemoral kinematics across multiple study types. Several investigations showed fewer soft-tissue releases and enhanced gap symmetry, contributing to faster early functional recovery and improved gait biomechanics. Large database studies revealed reduced perioperative complications, lower opioid consumption, and shorter hospital stays in robotic cohorts. Although long-term patient-reported outcomes often converged with conventional TKA, early postoperative improvements and reduced complications were consistently observed. Cost-effectiveness findings were heterogeneous, reflecting differences in institutional workflows and surgical volume. Conclusion: Evidence from 34 included studies indicates that robotic-assisted TKA provides clinically meaningful advantages over conventional techniques, particularly in alignment precision, soft-tissue preservation, and early recovery. While long-term functional superiority and economic sustainability require further investigation, current data support rTKA as a reliable and increasingly important advancement in contemporary knee arthroplasty.