Effect of tibia‐first, restricted functional alignment technique on gap width changes, and component positioning in robotic arm‐assisted total knee arthroplasty

Abstract Purpose This study aims to quantitatively assess the predictability of post‐resection gap dimensions and the attainment of balanced gaps using robotic arm‐assisted total knee arthroplasty (TKA). Methods This retrospective cohort study included 100 consecutive patients who underwent robotic arm‐assisted TKA for knee osteoarthritis using a restricted functional alignment (FA) technique. Tibial cuts were performed based on preoperative tibial anatomy within predefined boundaries, followed by femoral component adjustments according to tensioned soft tissues to optimise gap balance. The primary outcome was the proportion of balanced gaps, defined as differential laxities of ≤2 mm, across extension, flexion, lateral, and medial gap measurements. Ligament balancing in lateral and medial compartments was assessed using a robotic system at 10° and 90° flexion to evaluate if restricted FA facilitated a balanced knee. Secondary outcomes included implant alignment, resection depth, and patient‐reported outcome measures (PROMs). Results Significant increases in both lateral and medial gaps at 10° and 90° flexion were observed following tibial and femoral bone resections ( p < 0.001). At extension, average gap changes were 0.9 mm (lateral) and 1.6 mm (medial) after tibial cuts, and 0.5 mm (lateral) and 1.2 mm (medial) after femoral cuts. At 90° flexion, changes were 0.3 mm (lateral) and 1.7 mm (medial) following tibial cuts, and 1.0 mm (lateral) and 1.4 mm (medial) after femoral cuts. Despite these variations, the tibia‐first, gap‐balancing technique achieved overall balance in 98% of gap measurements. The tibial component was placed at an average of 2.1° varus, while the femoral component was positioned at 0.3° varus and 1.3° external rotation relative to the surgical transepicondylar axis. Significant improvements in PROMs were noted between preoperative and one‐year postoperative evaluations (all p < 0.05). Conclusions The tibia‐first, restricted FA technique achieved a well‐balanced knee in 98% of cases, despite inconsistent gap increments observed between initial assessments and post‐resection. Level of Evidence Therapeutic Level IV.