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Total knee arthroplasty (TKA) remains the gold standard for advanced knee osteoarthritis, yet persistent patient dissatisfaction rates of 15–20% and the pursuit of physiological knee kinematics have driven innovation in both surgical technique and implant design. Two significant developments—robotic-assisted systems and medial pivot knee designs—have emerged as potential solutions to enhance outcomes. This narrative review synthesizes current evidence comparing robotic-assisted TKA (RA-TKA) with conventional TKA (C-TKA), with specific attention to medial pivot implant designs. While robotic assistance demonstrates superior mechanical alignment precision, functional outcomes remain comparable to conventional methods in the short to medium term. Medial pivot designs, conversely, provide meaningful improvements in patient satisfaction and knee kinematics, particularly regarding paradoxical anterior femoral translation prevention and deep knee flexion capacity. The convergence of these two technologies—robotic-assisted medial pivot TKA—represents an emerging frontier, though long-term outcome data remain limited. Cost-effectiveness is heavily volume-dependent, with robotic systems achieving favorable cost-effectiveness only in high-volume surgical centers.
Traditional total knee arthroplasty, though effective in pain relief and functional restoration, reproduces only approximately 50% of normal knee kinematics, with many contemporary designs exhibiting paradoxical anterior femoral translation during early knee flexion—a phenomenon inconsistent with physiological movement patterns. This biomechanical divergence from the native knee contributes to the persistent dissatisfaction observed in 15–20% of TKA recipients, despite excellent pain control and prosthesis survivorship. (1,2)
The past two decades have witnessed parallel innovations addressing this limitation. Robotic-assisted surgical systems leverage preoperative imaging, real-time intraoperative navigation, and robotic-arm guidance to enhance component positioning precision. Simultaneously, medial pivot knee designs have been engineered to replicate the natural biomechanics of the knee, wherein the medial compartment acts as a near-stationary pivot point while the lateral femoral condyle rotates posteriorly during flexion.(2,3)
This review integrates evidence from recent systematic reviews, meta-analyses, and comparative studies to address three clinical questions: (1) Does robotic assistance confer superior functional outcomes compared to conventional TKA? (2) What are the demonstrated advantages of medial pivot knee designs over conventional posterior-stabilized prostheses? (3) Are there emerging data on combined robotic-assisted medial pivot TKA?
Robotic-Assisted vs. Conventional Total Knee Arthroplasty: Alignment and Functional Outcomes
A 2025 systematic review and meta-analysis of 21 randomized controlled trials (2,692 patients) provides the most current synthesis of evidence on RA-TKA versus C-TKA outcomes. The analysis encompasses studies published from inception through August 2024, utilizing multiple robotic platforms (ROBODOC, NAVIO, Mako, TSolution-One, YUANHUA) and conventional manual techniques across diverse geographic centers.(4)