Kinematically aligned total knee arthroplasty via subvastus approach using the Mako® 2.0 total knee system: a surgical technique

Total knee arthroplasty (TKA) is among the most commonly utilised and cost-effective surgical musculoskeletal procedures, with up to 700,000 TKAs performed annually in the United States alone. Traditionally, the standard approach in TKA has been for mechanical alignment (MA) which provides equal medial and lateral gaps in extension and flexion. However, there remains a high rate of patient dissatisfaction with their TKA. Kinematic alignment (KA) aims to restore pre-arthritic alignment by placing the femoral and tibial components in alignment with the three kinematic axes of the knee while avoiding soft tissue releases. KA TKAs have produced favourable clinical outcomes and implant survivorship that are comparable and even superior to mechanical alignment TKAs in some studies. As technology advances, robotic-assisted systems such as the Mako® 2.0 Total Knee system are increasing in popularity due to its benefit of surgical precision and accuracy. To perform a KA TKA effectively, accurate bone resections, particularly the femur aspect, are required to ensure that the pre-arthritic alignment and joint line are restored. The Mako® 2.0 Total Knee system provides accurate and precise assistance in performing a KA TKA through the combination of meticulous computer tomography-based pre-operative planning and AccuStop™ haptic technology. Currently, there is a lack in existing literature that describes the technique of performing a KA TKA while using Mako® Total Knee 2.0 system. In this article, we describe specific procedures for pre-operative planning, intra-operative steps, and soft tissue evaluation using the Mako® 2.0 Total Knee system to perform a KA TKA. The aim is to describe a practical and efficient workflow that integrates kinematic alignment principles with the precision, reproducibility, and intraoperative feedback provided by robotic assistance.