Robotic-Assisted Total Knee Arthroplasty: Evolution, Comparative Evidence, Economic Considerations, and Future Integration with Artificial Intelligence
Abstract
Govindbhai Jashvantlal Purohit, Yogesh Purohit and Aditya Purohit
Total knee arthroplasty (TKA) has undergone substantial technological evolution over the past four decades, progressing from conventional jig-based mechanical instrumentation to computer-assisted navigation and, more recently, robotic- assisted platforms. Conventional TKA, although highly successful in relieving pain and restoring function, is associated with alignment variability and surgeon-dependent inconsistencies. Computer navigation emerged to enhance intra operative accuracy and reduce radiological outliers, improving coronal plane alignment and component positioning. Building upon these advancements, robotic-assisted TKA integrates preoperative imaging or imageless mapping with real-time haptic guidance, aiming to optimize bone preparation, soft-tissue balancing, and implant positioning with enhanced reproducibility. Despite these technical advantages, the magnitude of clinical benefit and long-term superiority over conventional methods remain subjects of ongoing debate.
This review critically examines the evolution of TKA technology, synthesizing contemporary literature, national joint registry data, randomized controlled trials, and recent meta-analyses comparing conventional, navigated, and robotic-assisted techniques. Particular emphasis is placed on alignment accuracy, functional outcomes, complication rates, survivorship, cost-effectiveness, and implementation challenges. Current evidence consistently demonstrates that robotic-assisted TKA achieves superior radiological precision, significantly reducing alignment outliers and improving component positioning accuracy. Studies report decreased variability in femoral and tibial cuts, improved restoration of mechanical or functional alignment strategies, and more consistent gap balancing. Early postoperative outcomes suggest modest improvements in pain scores, early range of motion, and short-term functional recovery. Some reports also indicate reduced soft-tissue trauma and lower early inflammatory response markers. However, mid-term outcomes generally show equivalence between robotic and conventional TKA in terms of implant survivorship, complication rates, and revision risk.
A key limitation in the literature is the scarcity of long-term data exceeding 10 years, making definitive conclusions regarding implant longevity premature. Economic considerations remain central to adoption decisions, as robotic systems involve substantial capital investment, maintenance costs, and disposable instrumentation expenses. Additionally, operative time and learning curve factors may initially affect workflow efficiency, although these typically improve with surgical experience and institutional standardization. Robotic-assisted TKA represents a technological refinement that enhances precision, reproducibility, and surgeon confidence. While short-term clinical benefits and radiological improvements are well documented, conclusive evidence demonstrating long-term survivorship advantage and cost-effectiveness is still evolving. Ongoing longitudinal studies and registry analyses will be essential to determine whether enhanced accuracy translates into sustained clinical superiority and broader healthcare value.