Gait analysis after TKA: Do different alignment strategies lead to different outcomes? A systematic review

Total knee arthroplasty (TKA) provides reliable pain relief and implant survival; however, a clinically relevant proportion of patients still report residual symptoms, functional limitations, or an unnatural joint perception. Instrumented gait analysis may objectively assess postoperative function and clarify whether alignment strategies influence gait recovery.

This systematic review followed PRISMA 2020 recommendations. PubMed/MEDLINE and the Cochrane Library were searched from January 1990 to November 2024. Eligible studies reported instrumented gait-analysis outcomes after primary fixed-bearing TKA performed with mechanical, kinematic, anatomical, functional, inverse kinematic, restricted kinematic, or other personalized alignment techniques, with at least 12 months of follow-up. Revision TKA, unicompartmental knee arthroplasty, case reports, reviews, and studies without an appropriate comparison group were excluded.

Six studies met the inclusion criteria, underscoring the limited available evidence. The studies were heterogeneous in design, alignment strategy, gait-analysis protocol, and reported outcomes. Four studies compared kinematic and mechanical alignment, one inverse kinematic and adjusted mechanical alignment, and one gap-balanced TKA with healthy controls. No consistent gait advantage of one alignment strategy was demonstrated. Some studies reported lower knee adduction moment or gait patterns closer to healthy controls after kinematic or inverse kinematic alignment, but findings were inconsistent.

Evidence on gait analysis after TKA with different alignment strategies remains limited and heterogeneous. Current data do not allow firm conclusions regarding the superiority of any alignment strategy. Larger prospective studies using standardized gait-analysis protocols are needed.