Alignment boundaries and soft tissue balancing goals are inconsistently reported in robotic-assisted total knee arthroplasty studies: A narrative methodological review

As robotic-assisted total knee arthroplasty (RATKA) continues to expand in clinical adoption, accurate and transparent reporting of surgical technique is critical for reproducibility and meaningful comparison of outcomes. This study aimed to assess the adequacy of reporting RATKA methods, with a focus on alignment and balancing philosophies; hypothesising that current RATKA literature may be variant and insufficient in reporting. A PubMed search conducted on 10 March 2025, identified studies from the top 50 orthopedic journals ranked by impact factor using the terms 'robot' and 'total knee arthroplasty'. Eligible studies included those reporting outcomes of primary RATKA procedures using patient-reported, surgical, medical, or radiographic data. A total of 134 studies met inclusion criteria and were assessed for reporting completeness across three domains: technology, technique and surgeon. The technology domain included the robotic system, software version, and implant; the technique domain included alignment philosophy, coronal and sagittal alignment boundaries, and quantitative soft tissue balancing goals; and the surgeon domain included surgeon experience and case volume. Only six studies (4.5%) reported all technology domain variables, while the robotic system was identified in 97.0%, software version in 4.5%, and implant in 89.6%. For the technique domain, 32 studies (23.9%) reported all variables, with alignment philosophy reported in 79.1%, coronal boundaries in 68.7%, sagittal boundaries in 42.5%, and soft tissue balancing goals in 47.8%. Only 17 studies (12.7%) reported both surgeon-related variables, with experience and volume documented in 50.0% and 16.4% of studies, respectively. These findings reveal that key methodological aspects of RATKA, particularly alignment philosophy, balancing strategy, and surgeon experience, are inconsistently reported in the literature. As robotic technology becomes increasingly integrated into total knee arthroplasty, standardised and comprehensive reporting is essential to ensure reproducibility, enable accurate comparison of outcomes, and promote evidence-based adoption of RATKA techniques. Level V.