Robotic-Assisted Total Knee Arthroplasty in Complex Primary and Revision Cases: A Systematic Review

This study systematically reviews outcomes of robotic-assisted total knee arthroplasty (rTKA) in complex primary and revision cases, compared with conventional TKA (cTKA). Complex cases include severe coronal deformity, high BMI, fixed flexion deformity, and revision arthroplasty. Outcomes assessed included coronal alignment, perioperative metrics, and patient-reported outcomes.

Nineteen studies comprising 2,482 patients (2,535 knees: 1,931 rTKA, 604 cTKA) were included. Robotic-assisted TKA consistently restored coronal alignment, with greatest improvements observed in moderate-to-severe varus and valgus deformities. In revision cases, robotic assistance achieved near-neutral hip-knee-ankle alignment (mean deviation - 1.05°), low complication rates (4-17.9%), and high implant survival (97.1%). In obese patients, robotic-assisted TKA improved alignment precision, though functional outcomes were similar to conventional techniques. Robotic systems reduced the need for extensive soft tissue releases and enabled reliable early functional recovery. Most studies were retrospective, with moderate-to-serious risk of bias due to confounding and heterogeneity in patient populations, surgical complexity, and robotic platforms. Robotic-assisted TKA reliably restored coronal alignment and achieved perioperative andpatient-reported outcomes comparable to conventional techniques in complex primary andrevision cases. Alignment advantages were particularly evident in severe deformities oranatomically challenging knees. While these findings are encouraging, they should be3interpreted in the context of predominantly retrospective data, heterogeneous outcomereporting, and limited long-term follow-up. Future prospective, longitudinal randomizedstudies with standardized reporting are needed to confirm the impact of robotic-assistedapproaches on long-term functional outcomes and implant survival, in complex TKA.