Robotic-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized and Quasi-randomized Controlled Trials Evaluating Perioperative and Radiographic Outcomes

Robotic-assisted total knee arthroplasty (RATKA) has garnered attention in the field of orthopedic surgery. It has been developed to improve surgical precision and prosthesis alignment in comparison to conventional total knee arthroplasty (CTKA). It utilizes advanced robotic workflow systems as opposed to manual jig-based techniques. This review evaluated perioperative and radiographic outcomes to assess the overall safety and effectiveness of RATKA with CTKA. A comprehensive search for randomized and quasi-randomized control trials was conducted across 3 databases, PubMed/MEDLINE, Cochrane Library and Embase, from 1st January 2021 to 1st January 2026. Studies were chosen that compared RATKA to CTKA, where the primary indication was knee osteoarthritis. The primary objectives were operative time, length of stay, adverse events and blood loss. The secondary objectives were hip-knee-ankle (HKA) angle and absolute deviation of HKA angle from 180° (ΔHKA). The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Risk of bias was assessed using the Cochrane risk of bias tool (RoB 2). Quantitative analysis performed using the RevMan 5.4 software package. Results were presented using mean difference (MD), 95% confidence interval (CI), and risk ratio (RR). A total of 12 controlled trials were identified that met the inclusion criteria, with a total of 2269 participants. Meta-analysis revealed a statistically significant difference in operative duration, with RATKA taking longer than CTKA (MD = 23.81, 95% CI = 13.39 to 34.24, P <0.00001). There were no statistically significant differences in hospital stay (MD = 0.11, 95% CI = -0.19 to 0.42, P = 0.47), intraoperative blood loss (MD = 9.00, 95% CI = -9.46 to 27.46, P = 0.34) and adverse events (RR = 0.80, 95% CI = 0.54 to 1.18, P = 0.28). However, a statistically significant difference was identified in postoperative mechanical alignment, favoring RATKA. Postoperative HKA angle (MD: 0.71°, 95% CI: 0.43 to 1.00, P <0.00001) and absolute deviation from 180° ΔHKA (MD = -1.33, 95% CI -2.12 to -0.55, P = 0.009). RATKA is associated with longer operating times but is associated with improved mechanical alignment. The intraoperative blood loss, length of hospitalization and complications were comparable to CTKA. Considering these findings, further studies are required to assess the long-term implications and clinical benefits of RATKA.