• Filippo Migliorini, Marco Pilone, Luise Schäfer, Francesco Simeone, Andreas Bell, and Nicola Maffulli.
• Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany. migliorini.md@gmail.com.
• Arch Orthop Trauma Surg. 2024 Apr 1; 144 (4): 174117491741-1749.

PurposeThe present study systematically reviewed current evidence on functional alignment (FA) in robotic total knee arthroplasty (TKA), discussing advantages and limitations, possible pitfalls, and prospects.MethodsThis study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase with no additional filters or time constraints. All the clinical studies investigating functional alignment in robotic TKA were accessed. Only studies published in peer-reviewed journals were considered. The risk of bias was evaluated following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Non-randomized controlled trials (non-RCTs) were evaluated using the Risk of Bias in Nonrandomised Studies of Interventions (NRSI) (ROBINS-I) tool.ResultsData from 1198 patients (seven studies) were retrieved. The mean length of the follow-up was 17.1 ± 6.4 months. The mean age was 67.2 ± 5.4 years, and the mean BMI was 30.9 ± 2.7 kg/m2.ConclusionFA might improve resection accuracy, implant alignment, and gap balancing in TKA, and additional high-quality clinical trials are necessary to properly establish the superiority of FA to other alignment techniques in TKA. Long-term clinical trials are needed to investigate the impact of FA on implant survivorship.Level Of EvidenceLevel IV, systematic review and meta-analysis.© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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