Robotic-Arm Assisted vs Manual Total Knee Arthroplasty: A Comparative Analysis of Pre and Post-operative Gait and Posture in a Case-Control Study

Robotic-Arm Assisted vs Manual Total Knee Arthroplasty: A Comparative Analysis of Pre and Post-operative Gait and Posture in a Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robotic-Arm Assisted vs Manual Total Knee Arthroplasty: A Comparative Analysis of Pre and Post-operative Gait and Posture in a Case-Control Study Dimitrios Koukoulias, Eustathios Kenanidis, Nikolaos Mylonakis, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8419899/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background. Few studies assess gait in robotically assisted total knee arthroplasty (raTKA); none in ROSA raTKA patients. Methods Maximum voluntary isometric strength (MVIS), body centre-of-mass (COM) walking kinematics, body-weight distribution, time-up-and-go (TUG) test, quality of life, and range of motion (ROM) were evaluated in three postoperative months between manually TKA (mTKA) and raTKAs. A surgeon performed all procedures using the same technique. Results Forty-six uncomplicated primary raTKAs and 24 mTKAs were included, showing similar demographics, grip strength, and preoperative KOOS scores. At three months, there were no significant differences in quadriceps (p = 0.869), tibialis MVIS (p = 0.327), COM kinematics (p = 0.801), body-weight distribution (p = 0.189), TUG (p = 0.59), and ROM (p = 0.165). Patient satisfaction was significantly higher in the raTKA group (p = 0,048) and furthermore numerical differences favoring the raTKA group were observed in tibialis anterior MVIS, weight distribution, TUG, and ROM, even though there were no statistically significant differences. Conclusions At three months post-operation, ROSA raTKA resulted in significantly higher patient satisfaction but did not yield statistically differences in gait, posture, or strength outcomes compared to mTKA. The observed non-significant numerical differences in favor of the raTKA grpoup, should be explored in larger, long-term, randomized controlled trials. ROSA robotically assisted TKA raTKA total knee arthroplasty gait posture Background Robotically assisted total knee arthroplasty (raTKA) enhances the precision of implant alignment and facilitates optimal knee joint balancing during surgical procedures [ 1 ]. Emerging evidence indicates that raTKA significantly increases the likelihood of improved functional outcomes in the early postoperative period compared to manual total knee arthroplasty (mTKA) [ 2 ]. However, the lack of long-term comparative outcomes represents a significant gap in our understanding. The existing evidence regarding robotic systems shows that each robot displays a distinct combination of quantity and quality, emphasising their diverse capabilities and applications [ 3 ]. Each robotic system possesses unique characteristics and must be evaluated based on its significance concerning release time, the availability of imageless or image-based options, control type, boundary management, gap analysis, and implant type [ 3 ]. Recent studies have indicated that the precision of implantation with ROSA raTKA significantly influences early functional outcomes for patients, emphasising its effectiveness and potential benefits [ 2 , 4 ]. Gait analysis offers an objective biomechanical assessment of joint function and improves the accuracy of measurements following TKA. Research on gait analysis in raTKA is limited, revealing a notable knowledge gap that needs further exploration [ 5 ]. Three studies evaluated functional gait assessment and spatiotemporal changes with active and semi-active robotic systems [ 5 – 7 ]. To the author's knowledge, no research has been published on the functional ambulation of patients who have undergone ROSA raTKA. This gap in the literature presents a significant opportunity for further investigation and highlights the need for comprehensive studies in the field. This comparative cohort study assessed the functional gait and posture differences between patients receiving mTKA and ROSA raTKA. The same senior orthopaedic surgeon performed all procedures using the same implant and functional alignment technique. The null hypothesis suggested that raTKA and mTKA would not yield comparable outcomes three months after the surgery. Materials and Methods This prospective comparative study was approved by the Academic Health Research Ethics Board (6.237-29/07/2020). Before inclusion, all patients provided written informed consent. All data were recorded in the regional academic arthroplasty registry. The raTKA group consisted of consecutive primary unilateral raTKAs performed using the ROSA (Robotic Surgical Assistant) Knee System (Zimmer-Biomet, Warsaw, IN, USA). A senior arthroplasty surgeon performed these procedures within three months using posterior-stabilized prostheses (NexGen Legacy, Zimmer Biomet, Warsaw, IN) from October 2022 to December 2022. The control group comprised consecutive mTKAs performed by the surgeon, using the same implant throughout the study period. The study participants were adults suffering from symptomatic primary unilateral end-stage knee osteoarthritis. Complex primary or revision knee arthroplasties and those with different implants were excluded from the study. The choice between raTKA and mTKA was based on the patients' preferences. Robotic procedures were performed beyond the surgeon's initial learning curve. All patients received the same perioperative and postoperative care. They underwent general anaesthesia and adhered to a uniform protocol for postoperative chemoprophylaxis, pain management, and physiotherapy. The patients received a preoperative intravenous dose of 400 mg teicoplanin, which continued twice daily for 24 hours postoperatively. Intravenous paracetamol and tramadol were administered three times a day, while dexketoprofen trometamol was given twice daily to manage postoperative pain during the inpatient stay. All were mobilized within 12 hours post-surgery. Anti-thrombotic stockings were provided, and they were advised for partial weight-bearing mobilisation with a gradually increasing load of 30-60-90% of body weight per week for three weeks and then full weight-bearing until the first follow-up meeting in our clinics. All surgical procedures were performed using a gap-balancing technique to ensure functional alignment. Details of the surgical technique have been documented earlier [4]. Thigh tourniquet pressure was applied before the skin incision and maintained until the skin closed. Outcomes An experienced physiotherapist, not involved in the surgical procedures, performed clinical follow-up assessments and analysed gait and posture. The physiotherapist documented the following parameters for all patients both before and three months after the procedure: Clinical outcomes Before the surgery, a complete medical history and demographic information were collected. The physiotherapist recorded the range of motion (ROM) of the knee joint, the quality of life of the patients (Knee Injury and Osteoarthritis Outcome Score, KOOS), pain with VAS score, and patient satisfaction. Additionally, radiographic follow-up, perioperative medical events, and postoperative complications were recorded from the regional arthroplasty registry. Patients' satisfaction was evaluated using the question, "How satisfied are you with your operated knee?" Responses were recorded on a five-point scale: very satisfied, satisfied, neither, dissatisfied, and very dissatisfied [2]. Gait and Posture outcomes A. Evaluation of the muscle strength (a single evaluator performed all measurements) a. Grip strength A grip strength dynamometer (Kinvent, Montpellier, France) was used to test the overall muscle strength of the patients. Participants were instructed to sit with their shoulders at 0° flexion alongside their bodies, elbows bent at 90°, and forearms positioned neutrally. Both hands underwent testing. They were requested to squeeze the dynamometer as firmly as possible for three repetitions, maintaining each squeeze for five seconds and resting for 10 seconds between squeezes. Finally, we recorded the highest value (Kg) from the three attempt measurements for each hand and averaged the bilateral scores (Kg). b. Quadriceps and tibialis anterior maximum voluntary isometric strength (MVIS) We employed a hand-held dynamometer (HHD; Muscle Controller, Kinvent, Montpellier, France) for the MVIS assessment. Quadriceps strength was evaluated while seated at a 90-degree knee flexion angle, and tibialis anterior strength was measured supine, with the ankle joint at a neutral position. Both legs underwent the same testing protocol: the dynamometer was pressed to its maximum for three repetitions, each lasting five seconds, followed by a 10-second rest period between them. Finally, we recorded the highest value from the three attempt measurements for each muscle bilaterally. B. Body center-of-mass (COM) kinematics during walking The walking pattern was examined using inertial measurement unit (IMU) sensors (Movesense ™ , Finland). These sophisticated wearable sensors utilise a nine-axis IMU to capture movement data, comprising an accelerometer, gyroscope, and magnetometer, each featuring three axes. We linked the IMU sensor to a receiving device during data collection. Each participant was outfitted with a sensor on the sacrum. After setting up the sensor, participants were instructed to walk comfortably at 4–5 meters and return twice. Our study aims to measure the COM trajectories in gait, which may reveal crucial insights into balance control during ambulation associated with disease progression or treatment in patients. C. Body weight distribution between legs. The patients stood barefoot on a grounded posturographic digital platform to assess weight distribution and stability. They were instructed to maintain a quiet bipedal stance for 10 seconds. Measuring 700 × 500 mm, the platform featured 2.304 resistive sensors with 0.001 kPa accuracy, sampled at 60 Hz. For the evaluation, patients stood upright in their socks, placing their feet comfortably. Their foot position was standardised in the anterior/posterior direction by aligning their heels with tape on the platform. The distance between the first metatarsal heads was recorded to ensure accurate follow-up measurements. Subjects' arms rested at their sides and were advised to stand relaxed and breathe normally. The platform recorded and analyzed foot pressure distributions using EPS; Foot Checker 4.1 (LorAn Engineering Srl, Castel Maggiore, Bologna, Italy). Weight distribution between the left and right legs was calculated as a percentage of the patient's overall weight, performed twice with closed or open eyes. We compared the weight distribution differences between the left and right leg across groups preoperatively and at the end of the third postoperative month. D. Time up and Go test (TUG) The TUG test is a validated assessment designed to evaluate an individual’s functional mobility and dynamic balance, offering vital insights into their capabilities for daily living [8]. This assessment measures the duration required for a person to rise from a seated position, ambulate three meters at their normal walking pace while using their customary assistive device, pivot, and return to the chair to resume a seated posture. This test involved patients wearing their usual footwear, and they could use a walking aid if necessary. The assessment starts with patients sitting down and standing up upon the therapist's cue. Each patient walked three meters, turned around a placed cone, returned to the chair, and sat down again. The timing stopped once the patient was seated. A practice trial was conducted before the timed trial. We measured each patient two times: once when they turned the cone left after the 3-meter distance and again when they turned the cone right. Finally, we compute the average time from the two measurement recordings. Statistical analysis The necessary sample size was determined according to reported differences and standard deviation of measurements between mTKA and raTKAs in previous gait analysis studies [5]. Using Lehr's formula, our statistical analysis found that with sufficient power of 0.8 and the α value of 0.05, to find significance for COM kinematics of 0.1 mm/sec between the groups, at least 24 patients had to be enrolled. Results The study included 46 raTKAs and 24 mTKAs; no patients were lost during the research follow-up. The sample comprised 51 females (72.9%) and 19 males (27.1%). The average age (± standard deviation/SD) at the time of surgery was 73.2 ± 7.1 years, and the average BMI (± SD) was 32.8 ± 5.2 kgr/m 2 . All patients were monitored for three months following the surgical procedure. The two groups were comparable in terms of mean age, body mass index (BMI), sex distribution, grip strength, and mean preoperative KOOS score (Tables 1 & 2 ). All procedures performed were primary TKAs. Table 1 A comparative analysis of the baseline characteristics between mTKA and raTKA groups. Characteristics Groups p mTKA raTKA Age * 72.6 (7.0) 73.5 (7.2) 0.766 & Sex ** Male 4 20 15 31 0.155 # Female BMI* 32.2 (6.3) 33.2 (6.5) 0.801 @ * The values are presented as the mean with the standard deviation in parentheses. ** The values are provided as raw numbers. & Tests were conducted using the Student’s T-test. @ Tests were conducted using the Mann-Whitney test. # Tests were conducted using the Chi-squared test. mTKA: manual total knee arthroplasty, raTKA: robotic total knee arthroplasty, BMI: body mass index. Table 2 A comparative analysis of the mean scores pertaining to the KOOS subcategories between mTKA and raTKA groups Characteristics Groups p mTKA raTKA KOOS score preoperative * Pain 56.9 (16.8) 57 (19.6) 0.252 & ADL 50.9 (19.2) 47.7 (16.7) 0.25 & QoL 27.2 (16.8) 26.4 (14.9) 0.681 @ KOOS score postoperative * Pain 88.4 (11.6) 86.4 (14.4) 0.681 @ ADL 81.67 (14.3) 83.72 (13.3) 0.581 @ QoL 62.5 (25.5) 67.3 (22.6) 0.506 @ * The values are presented as the mean with the standard deviation in parentheses. @ Tests were conducted using the Mann-Whitney test. & Tests were conducted using the Student’s T-test. mTKA: manual total knee arthroplasty, raTKA: robotic total knee arthroplasty, BMI: body mass index, ADL: activities of daily life, QoL: quality of life. Clinical outcomes No intraoperative complications were observed in either group during the follow-up period. At the end of the third month, the mean ROM of the raTKA group (125.8 ± 9.2 0 ) was greater than that of the mTKA group (122.1 ± 10 0 ), but this difference was not statistically significant (Mann-Whitney test, p = 0.165). The mean KOOS score was significantly improved for the patients of both groups. In the third postoperative month, the mean scores of KOOS subcategories did not differ significantly between groups (Table 2 ). However, the patients of the raTKA group were significantly more satisfied than the mTKA group (x 2 test, p = 0.048) (Table 3 ). Table 3 Satisfaction level comparison data at three months post-surgery for raTKA and mTKA groups Question: Are you satisfied with your knee? * raTKA mTKA p-value Very Satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied 28 18 0 0 0 12 9 3 0 0 0.048 % * The values are given as raw numbers % Tests performed using Chi-square (x2) test raTKA: robotic-assisted total knee arthroplasty, mTKA: manual total knee arthroplasty, Gait and Posture outcomes Grip Strength The mean grip strength (kgr) of the raTKA group was comparable to that of the mTKA group before the operation (17.16± 7.68 vs 14.78 ± 6.08, Mann Whitney test, p = 0.801). In the third postoperative month, the mean grip strength (kgr) was similar between groups (15.4 ± 5.72 vs 14.25 ± 4.81, Mann-Whitney test, p = 0.932). Quadriceps and tibialis anterior maximum voluntary isometric strength (MVIS) The mean quadriceps MVIS (in kilograms) improved significantly for the whole group by the end of the third month (Wilcoxon Signed-Rank test, p = 0.042). Before surgery, the average quadriceps MVIS (in kilograms) of the raTKA group was higher yet comparable to that of the mTKA group (21.02 ± 7.45 vs 19.31 ± 6.53, Mann-Whitney test, p = 0.801). Three months after the surgical intervention, the average quadriceps MVIS, measured in kilograms, was greater for the raTKA group but there was no statistically significant difference (21.04 ± 8.09 vs 17.67 ± 5.1, Mann-Whitney test, p = 0.869). By the end of the third month, the mean MVIS of the tibialis anterior (measured in kilograms) showed significant improvement across the entire group (Wilcoxon Signed-Rank test, p < 0.001). Preoperatively, the mean tibialis anterior muscle MVIS (Kg) in the raTKA group was observed to be lower yet comparable to that of the mTKA group (11.78 ± 3.43 vs 12.37 ± 3.49, Student t-test, p = 0.504). In the third postoperative month, the average tibialis anterior MVIS (in kilograms) in the raTKA group was higher compared to the mTKA group (13.92 ± 2.92 vs 12.74 ± 2.36, Student t-test, p = 0.327). While this difference did not reach statistical significance, it warrants further investigation. Body COM kinematics during walking The COM vectors (mm/sec) showed no significant change for the entire group by the end of the third month (Wilcoxon Signed-Rank test p = 0.337). Before the surgical procedure, the mean COM vectors resultant (mm/sec) of the raTKA group was highly similar and comparable to that of the mTKA group (0.13 ± 0.08 vs 0.14 ± 0.08, Student t-test, p = 0.905). In the third month following surgery, the mean COM displacement for both groups displayed significant similarity and comparability with no statistically significant difference (0.12 ± 0.07 vs 0.12 ± 0.05, Mann-Whitney test, p = 0.801). Body weight distribution between legs The mean difference in the percentage of body weight distribution between the left and right legs during stance before the surgical intervention for the raTKA group was found to be markedly similar and comparable to that of the mTKA group (-4.55 ± 18.64 vs -4.92 ± 18.12, Mann Whitney test, p = 0.44). In the third month after surgery, individuals who underwent raTKA experienced a more balanced body weight distribution between their left and right legs during stance than those who underwent mTKA. The mean difference in weight distribution was notably smaller in the raTKA group; nonetheless, this difference was not statistically significant (-0.28 ± 23.08 vs -3.5 ± 15.13, Student t-test, p = 0.189). Time up and Go test (TUG) By the end of the third month, the mean TUG test (seconds) significantly decreased across the entire group (Wilcoxon Signed-Rank test, p < 0.001). Preoperatively, the mean TUG test, measured in seconds, for the raTKA group was lower yet comparable to that of the mTKA group (14.1 ± 8.76 vs 16.27 ± 19.99, Mann-Whitney test, p = 0.801). In the third postoperative month, the mean TUG test (in seconds) was significantly lower for both groups, with the raTKA group's mean being even lower; however, no statistical difference was found in the mean TUG test time between the two groups (11.15 ± 4.6 vs 12.32 ± 8.94, Mann-Whitney test, p = 0.59). Discussion This study represents the first comparative analysis of functional gait assessment in patients undergoing mTKA versus ROSA raTKA. The groups were comparable in demographic and clinical characteristics, grip strength, and all other static and dynamic gait and posture parameters evaluated preoperatively. Although both groups showed notable improvement by the third postoperative month, a trend indicated better clinical and gait outcomes for the raTKA group, though none reached statistical significance. The tibialis anterior MVIS, balanced body weight distribution between the left and right legs, the ROM, TUG, and patient satisfaction demonstrated better outcomes for the raTKA group, however the only statistically significant difference was higher patient satisfaction in the raTKA group. Although the differences did not reach significance, the short follow-up period, small sample size, and lack of randomisation indicate promising signs of potential enhancements for the raTKA group. Overall, the hypothesis that raTKA would provide improved metrics in functional gait analysis compared to mTKA in the early postoperative period remains valid yet unproven. Nevertheless, exploring this relationship establishes a foundation for future research and advancements in surgical practice techniques. Previous studies Various studies on different types of raTKAs have reported that the raTKA enhances the precision of implant alignment compared to the mTKA [ 1 , 2 , 4 ]. The relationship between implant precision accuracy and improved long-term functional outcomes and gait parameters requires further investigation. Few studies evaluated gait parameters for patients undergoing raTKA [ 5 – 7 ]. A recent randomised controlled trial with a limited sample size comparing MAKO-assisted raTKA to mTKA found benefits for both groups [ 5 ]. After 12 months, there were no significant differences in cadence, walking velocity, or plantar pressure ratios between the mTKA and raTKA groups. However, the raTKA group experienced less propulsion time and lateral sway, while the mTKA group showed reductions in foot flat and mid-stance durations. A separate non-comparative study evaluated 31 patients undergoing raTKA via the SkyWalker™ system (Suzhou MicroPort Changxing Robot Co., Ltd., China) [ 6 ]. Improvements in gait parameters for the operated leg were notable by the third month after surgery and persisted for six months post-TKA. Nonetheless, the operated leg still demonstrated considerable functional deficits compared to the contralateral knee. This study supported that 3D gait analysis is more sensitive than the WOMAC score in evaluating clinical effectiveness. Studies on ROSA raTKA suggest improved implantation accuracy and superior early functional outcomes compared to mTKA [ 2 ], yet no ROSA gait analysis study has been conducted thus far. Our study is the first to compare muscle strength, TUG test, static balance and other gait analysis parameters between mTKA and a ROSA raTKA group. We view patient satisfaction as a multifaceted measure that does not always indicate substantial improvements in gait and posture. However, we believe that the improved gait and posture outcomes of the raTKA group contributed to the enhancement of patient satisfaction. MVIS Our research shows that the raTKA group had better MVIS of the tibialis anterior muscle in the early postoperative phase, indicating potential benefits of the raTKA method for recovery. Patients with advanced knee osteoarthritis face challenges like knee stiffness and muscle atrophy [ 9 ], hindering mobility and causing a decline in muscular strength [ 9 ]. Articular muscle depression impairs quadriceps activation, causing knee swelling, pain, and stiffness [ 10 , 11 ]. Patients with knee osteoarthritis often experience greater thigh muscle weakness than normal adults [ 12 ]. TKA recovery emphasises muscle strength and joint function restoration [ 9 ]. By the third month, Wang et al. observed improvements in muscle strength and joint mobility, but differences remained compared to non-arthritic individuals. By six months, knee function improved significantly [ 9 ]. In our study, both quadriceps and tibialis anterior muscle strength significantly increased by the end of the third postoperative month for both groups. Although the anterior tibialis and quadriceps muscle strength were higher for the raTKA group at three months postoperatively, and although no significant differences were noted between the groups, there is a strong indication that raTKA leads to better measurable gait and postural results. The results of our study warrant further investigation with an extended follow-up and an alternative design for a randomised study that could reveal statistical differences between robotic and manual TKA techniques. Body weight distribution between legs Our research revealed a trend, though not significant, toward better body weight distribution between the left and right legs during stance in the raTKA group. Postural stability difficulties contribute to falls in older adults, creating a public health challenge for osteoarthritis [ 13 , 14 ]. In osteoarthritis patients, impaired stability arises from proprioceptive deficits, muscle weakness, and knee pain [ 15 ]. Knee osteoarthritis patients exhibit increased postural sway, greater anterior-posterior sway in sit-stand transitions, and reduced control when shifting from double to single-leg positions [ 16 ]. Although functional scores improve after TKA, posture and balance issues tied to fall risks may remain [ 13 ]. Our study found that the raTKA group displayed a smaller average difference in body weight distribution between the left and right legs while standing, along with a potential trend indicating reduced sway postoperatively, compared to the mTKA group. A follow-up study with improved methods might yield different insights. Understanding this relationship could enhance stability and patient outcomes [ 17 ]. COM and TUG Measuring COM trajectories in natural settings shows how gait and balance change with diseases [ 18 ]. This method enhances understanding their impact on daily life, leading to improved management and interventions. Naili et al. found COM trajectory to be a sensitive indicator of functional compensations after TKA in knee osteoarthritis patients during a sit-to-stand test [ 19 ]. Our study introduced an innovative technique for accurately determining the displacement during unperturbed posture by using a single IMU attached to the sacrum, significantly enhancing the analysis of posture dynamics. Our results showed a notable enhancement in COM trajectory following surgery for both groups, with no differences, indicating similar posture dynamics for both techniques. We suggest a longer investigation than three months post-surgery to adequately capture and compare posture dynamics across groups. Our study showed improved TUG test scores for both groups at three months postoperatively, with a trend favoring better dynamic balance restoration in the raTKA group. Other TKA studies have shown a similar improvement in the TUG test 8 . Healthy individuals aged 60–80 usually complete the TUG test in 10 seconds. Older males and females may take 1–2 seconds longer [ 20 ]. The TUG test reliably assesses knee osteoarthritis patients' function, balance, and walking ability. It's a widely used performance measure for TKA [ 21 , 22 ], showing excellent test-retest reliability [ 23 ]. A 2.27-second change in the TUG signals a significant shift in post-TKA rehabilitation, indicating that patients not showing this progress may require additional rehabilitation [ 23 ]. The average improvement in the TUG test was over 2.2 seconds for both groups in our study, although it was greater for the raTKA group. Research shows that the TUG test improves notably three months post-TKA, with no further advancements [ 19 ]; however, a longer follow-up and randomized study may yield different results. Several limitations in our study should be considered when interpreting the findings. Firstly, this study focuses on short-term follow-ups. Longer follow-ups could yield different clinical outcomes. Therefore, it's essential to consider the implications of follow-up duration when evaluating results. Secondly, it is necessary to note that this study is not a randomised, blinded investigation; therefore, there exists the possibility of bias in the allocation of patients to the two groups. Nonetheless, the allocation was based on the patient's preference for raTKA and mTKA. Third, not all gait parameters were evaluated in this study. Fourth, the patients in the raTKA group knew that they would be undergoing surgery with robotic assistance, a factor that could influence their overall experience assessments. Fifth, and most importantly, this study may be underpowered to detect clinically meaningful differences in the primary gait and strength outcomes. The sample size calculation was based on a single parameter (COM kinematics). Consequently, the non-significant findings across multiple metrics should be interpreted as inconclusive rather than definitive evidence of equivalence. Although these limitations exist, a single surgeon conducted all procedures in this prospective case-control study using a consistent surgical approach, implant design, pain management, and rehabilitation protocol for both groups. Besides, the two groups were comparable in demographic and other clinical and gait posture characteristics. Conclusion This study is the first to evaluate gait and posture between a group receiving mTKA and another receiving ROSA raTKA. At three months, patient satisfaction was significantly higher in the raTKa group. Most of the gait and posture results are better for the raTKA group. Although they do not reach statistical significance in the early 3-month follow-up, they indicate a better functional outcome that aligns with improved patient satisfaction in the raTKA group. While the follow-up period is short, the sample size is limited, and there is no randomisation, this is a comparative series conducted by a single surgeon, employing the same gap balancing technique along with consistent perioperative protocols, anaesthetics, chemoprophylaxis, and anticoagulation, as well as the same physiotherapy schedule and implants in both groups, which is unique in the literature. We discovered differences that may not reach significance; however, they suggest consistent directional trends favoring the raTKA group across multiple gait analysis parameters compared to mTKA. Further well powered, randomised studies with longer follow-up and improved design, are necessary to confirm if the higher satisfaction translates into measurable advantages over time. Abbreviations raTKA robotically assisted total knee arthroplasty mTKA manual total knee arthroplasty ROSA Robotic Surgical Assistant (Zimmer-Biomet system) ) Knee System (Zimmer-Biomet, Warsaw, IN, USA) COM Body center-of-mass MVIS maximum voluntary isometric strength TUG Timed Up and Go (test) ROM range of motion KOOS Knee Injury and Osteoarthritis Outcome Score VAS Visual Analogue Scale (for pain) IMU inertial measurement unit BMI body mass index ADL activities of daily living QoL quality of life SD standard deviation Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all the individual participants included in the study. The study was approved by the Bioethics Committee of the Medical University of A.U.Th. (6.237-29/07/2020). Clinical trial registration number: not applicable. Consent for publication Not applicable . Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors did not receive support from any organisation for the submitted work. Authors' contributions All authors contributed to the study’s conception and design. D. Koukoulias, P. Tsaklis, E. Kenanidis and E. Tsiridis performed material preparation, data collection, and analysis. E. Kenanidis wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript. Acknowledgements Not applicable References Rajgor HD, Mayne A, Munasinghe C, Pagkalos J, Agrawal Y, Davis ET, Sharma AD. Mako versus ROSA: comparing surgical accuracy in robotic total knee arthroplasty. J Robot Surg. 2024;18:33. https://doi:10.1007/s11701-023-01786-6 . Kenanidis E, Paparoidamis G, Milonakis N, Potoupnis M, Tsiridis E. Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study. Eur J Orthop Surg Traumatol. 2023;33:1231–6. https://doi:10.1007/s00590-022-03274-3 . Vermue H, Batailler C, Monk P, Haddad F, Luyckx T, Lustig S. The evolution of robotic systems for total knee arthroplasty, each system must be assessed for its own value: a systematic review of clinical evidence and meta-analysis. Arch Orthop Trauma Surg. 2023;143:3369–81. https://doi:10.1007/s00402-022-04632-w . Gamie Z, Paparoidamis G, Milonakis N, Kenanidis E, Tsiridis E. The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case-control study. Eur J Orthop Surg Traumatol. 2024;34:2449–55. https://doi:10.1007/s00590-024-03942-6 . Ajekigbe B, Ramaskandhan J, Clement N, Galloway S, Gabrov N, Smith K, Weir D, Deehan D. Robotic-arm assisted versus manual total knee arthroplasty: Functional gait analysis from a randomised controlled trial. J Biomech. 2024;169:112112. https://doi:10.1016/j.jbiomech.2024.112112 . He R, Xiong R, Sun ML, Yang JJ, Chen H, Yang PF, Yang L. Study on the correlation between early three-dimensional gait analysis and clinical efficacy after robot-assisted total knee arthroplasty. Chin J Traumatol. 2023;26:8393. https://doi:10.1016/j.cjtee.2022.05.003 . Yeo JH, Seon JK, Lee DH, Song EK. No difference in outcomes and gait analysis between mechanical and kinematic knee alignment methods using robotic total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2019;27:1142–7. https://doi:10.1007/s00167-018-5133-x . Tsubosaka M, Muratsu H, Nakano N, Kamenaga T, Kuroda Y, Miya H, Kuroda R, Matsumoto T. Sequential changes in lower extremity function after total knee arthroplasty. J Orthop Surg (Hong Kong). 2020;28:2309499020965645. https://doi:10.1177/2309499020965645 . Wang XF, Ma ZH, Teng XR. Isokinetic Strength Test of Muscle Strength and Motor Function in Total Knee Arthroplasty. Orthop Surg. 2020;12:878–89. https://doi:10.1111/os.12699 . Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Athritis Rheum. 2010;40:250–66. https://doi:10.1016/j.semarthrit.2009.10.001 . Smith JW, Marcus RL, Peters CL, Pelt CE, Tracy BL, LaStayo PC. Muscle force steadiness in older adults before and after total knee arthroplasty. J Arthroplasty. 2014;29:1143–8. https://doi:10.1016/j.arth.2013.11.023 . Luc-Harkey BA, Safran-Norton CE, Mandl LA, Katz JN, Losina E. Associations among knee muscle strength, structural damage, and pain and mobility in individuals with osteoarthritis and symptomatic meniscal tear. BMC Musculoskelet Disord. 2018;19:258. https://doi:10.1186/s12891-018-2182-8 . Davut S, Huzmeli I, Hallaceli H, Kalacı A. Does Total Knee Arthroplasty positively affect body static-dynamic balance and fall risk parameters in patients with satisfactory functional scores? Cureus. 2022;14:e30207. https://doi:10.7759/cureus.30207 . Dunsky A. The effect of balance and coordination exercises on quality of life in older adults: a mini-review. Front Aging Neurosci. 2019;11:318. https://doi:10.3389/fnagi.2019.00318 . Schwartz I, Kandel L, Sajina A, Litinezki D, Herman A, Mattan Y. Balance is an important predictive factor for quality of life and function after primary total knee replacement. J Bone Joint Surg Br. 2012;94:782–6. https://doi:10.1302/0301-620X.94B6.27874 . Fu S, Duan T, Hou M, Yang F, Chai Y, Chen Y, Liu B, Ma Y, Liu A, Wang X, Chen L. (2021) Postural balance in individuals with knee osteoarthritis during stand-to-sit task. Front Hum Neurosci 15: 760960. https://doi:0.3389/fnhum.2021.760960. Bragonzoni L, Rovini E, Barone G, Cavallo F, Zaffagnini S, Benedetti MG. How proprioception changes before and after total knee arthroplasty: A systematic review. Gait Posture. 2019;72:1–11. https://doi:10.1016/j.gaitpost.2019.05.005 . Duong TTH, Uher D, Young SD, Farooquee R, Druffner A, Pasternak A, Kanner C, Fragala-Pinkham M, Montes J, Zanotto D. Accurate COM Trajectory Estimation in Healthy and Pathological Gait Using Multimodal Instrumented Insoles and Deep Learning Models. IEEE Trans Neural Syst Rehabil Eng. 2023;31:4801–11. https://doi:10.1109/TNSRE.2023.3338519 . Naili JE, Broström EW, Gutierrez-Farewik EM, Schwartz MH. The centre of mass trajectory is a sensitive and responsive measure of functional compensations in individuals with knee osteoarthritis performing the five times sit-to-stand test. Gait Posture. 2018;62:140–5. https://doi:10.1016/j.gaitpost.2018.03.016 . Steffen TM, Hacker TA, Mollinger L, Up T. & Go Test, and gait speeds. Phys Ther 82:128 – 37. https://doi:10.1093/ptj/82.2.128 Dobson F, Hinman RS, Roos EM, Abbott JH, Stratford P, Davis AM, Buchbinder R, Snyder-Mackler L, Henrotin Y, Thumboo J, Hansen P, Bennell KL. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1042. https://doi:10.1016/j.joca.2013.05.002 . Imada A, Nelms N, Halsey D, Blankstein M. Physical therapists collect different outcome measures after total joint arthroplasty as compared to most orthopaedic surgeons: a New England study. Arthroplast Today. 2018;4:113–7. https://doi:10.1016/j.artd.2017.08.003 . Yuksel E, Kalkan S, Cekmece S, Unver B, Karatosun V. Assessing minimal detectable changes and test-retest reliability of the timed up and go test and the 2-minute walk test in patients with total knee arthroplasty. J Arthroplasty. 2017;32:426–30. https://doi:10.1016/j.arth.2016.07.031 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8419899","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597870191,"identity":"2e59536c-6c61-48c5-acde-7fc5fa28da59","order_by":0,"name":"Dimitrios Koukoulias","email":"","orcid":"","institution":"Papageorgiou General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Koukoulias","suffix":""},{"id":597870192,"identity":"a615b927-48db-4fd7-8d3d-7da9501449ea","order_by":1,"name":"Eustathios Kenanidis","email":"","orcid":"","institution":"Aristotle University of Thessaloniki","correspondingAuthor":false,"prefix":"","firstName":"Eustathios","middleName":"","lastName":"Kenanidis","suffix":""},{"id":597870193,"identity":"7e680a48-8818-4276-ab6c-5413abc67727","order_by":2,"name":"Nikolaos Mylonakis","email":"","orcid":"","institution":"Aristotle University of Thessaloniki","correspondingAuthor":false,"prefix":"","firstName":"Nikolaos","middleName":"","lastName":"Mylonakis","suffix":""},{"id":597870194,"identity":"ac68484b-a7b9-490c-817b-517f20ff08a5","order_by":3,"name":"Alexandros Maslaris","email":"","orcid":"","institution":"Oxford University Hospitals NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Alexandros","middleName":"","lastName":"Maslaris","suffix":""},{"id":597870195,"identity":"0ff9b28e-9950-46b2-ba57-015b65b3debe","order_by":4,"name":"Michael Potoupnis","email":"","orcid":"","institution":"Aristotle University of Thessaloniki","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Potoupnis","suffix":""},{"id":597870196,"identity":"df545abc-2358-4ffc-b0d7-88bb5c88fb5e","order_by":5,"name":"Panagiotis Tsaklis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYJACxoYCCQZ+ECuhgBj1bCAtBhIMkg0gLQbEa2FgMDgA4hGjxVy+/eHHGQYW9sbnVyd+eGDAIM8vdgC/Fss2HmPJDQYSidtuvN0sAXSY4czZCfi1GBzjYZB8YCCRYHbj7AaQlgSD2wS1sD/+CdRibzzj7OYfRGphMAM5jHEDf+824myxbMsxs5wB9MuMG7zbLBIMJAj7xZz5+OObPRV19vz9Zzff/FFhI88vTchhcJYEWKUEfuWoWvgPEFY9CkbBKBgFIxMAAMs5QjFPtv/cAAAAAElFTkSuQmCC","orcid":"","institution":"University of Thessaly","correspondingAuthor":true,"prefix":"","firstName":"Panagiotis","middleName":"","lastName":"Tsaklis","suffix":""},{"id":597870197,"identity":"f487d93b-4954-492e-9179-97d546918af7","order_by":6,"name":"Eleftherios Tsiridis","email":"","orcid":"","institution":"Aristotle University of Thessaloniki","correspondingAuthor":false,"prefix":"","firstName":"Eleftherios","middleName":"","lastName":"Tsiridis","suffix":""}],"badges":[],"createdAt":"2025-12-22 01:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8419899/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8419899/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106320578,"identity":"40a2a3ed-0f9c-472f-89ae-7fbb1a874f97","added_by":"auto","created_at":"2026-04-07 12:12:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":829713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8419899/v1/9a40ed6d-8115-4d41-87b1-56e2287a8efd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic-Arm Assisted vs Manual Total Knee Arthroplasty: A Comparative Analysis of Pre and Post-operative Gait and Posture in a Case-Control Study","fulltext":[{"header":"Background","content":"\u003cp\u003eRobotically assisted total knee arthroplasty (raTKA) enhances the precision of implant alignment and facilitates optimal knee joint balancing during surgical procedures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Emerging evidence indicates that raTKA significantly increases the likelihood of improved functional outcomes in the early postoperative period compared to manual total knee arthroplasty (mTKA) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the lack of long-term comparative outcomes represents a significant gap in our understanding.\u003c/p\u003e \u003cp\u003eThe existing evidence regarding robotic systems shows that each robot displays a distinct combination of quantity and quality, emphasising their diverse capabilities and applications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Each robotic system possesses unique characteristics and must be evaluated based on its significance concerning release time, the availability of imageless or image-based options, control type, boundary management, gap analysis, and implant type [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent studies have indicated that the precision of implantation with ROSA raTKA significantly influences early functional outcomes for patients, emphasising its effectiveness and potential benefits [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGait analysis offers an objective biomechanical assessment of joint function and improves the accuracy of measurements following TKA. Research on gait analysis in raTKA is limited, revealing a notable knowledge gap that needs further exploration [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Three studies evaluated functional gait assessment and spatiotemporal changes with active and semi-active robotic systems [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To the author's knowledge, no research has been published on the functional ambulation of patients who have undergone ROSA raTKA. This gap in the literature presents a significant opportunity for further investigation and highlights the need for comprehensive studies in the field.\u003c/p\u003e \u003cp\u003eThis comparative cohort study assessed the functional gait and posture differences between patients receiving mTKA and ROSA raTKA. The same senior orthopaedic surgeon performed all procedures using the same implant and functional alignment technique. The null hypothesis suggested that raTKA and mTKA would not yield comparable outcomes three months after the surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis prospective comparative study was approved by the Academic Health Research Ethics Board (6.237-29/07/2020). Before inclusion, all patients provided written informed consent. All data were recorded in the regional academic arthroplasty registry.\u003c/p\u003e\n\u003cp\u003eThe raTKA group consisted of consecutive primary unilateral raTKAs performed using the ROSA (Robotic Surgical Assistant) Knee System (Zimmer-Biomet, Warsaw, IN, USA). A senior arthroplasty surgeon performed these procedures within three months using posterior-stabilized prostheses (NexGen Legacy, Zimmer Biomet, Warsaw, IN) from October 2022 to December 2022. The control group comprised consecutive mTKAs performed by the surgeon, using the same implant throughout the study period. The study participants were adults suffering from symptomatic primary unilateral end-stage knee osteoarthritis. Complex primary or revision knee arthroplasties and those with different implants were excluded from the study. The choice between raTKA and mTKA was based on the patients\u0026apos; preferences. Robotic procedures were performed beyond the surgeon\u0026apos;s initial learning curve.\u003c/p\u003e\n\u003cp\u003eAll patients received the same perioperative and postoperative care. They underwent general anaesthesia and adhered to a uniform protocol for postoperative chemoprophylaxis, pain management, and physiotherapy. The patients received a preoperative intravenous dose of 400 mg teicoplanin, which continued twice daily for 24 hours postoperatively. Intravenous paracetamol and tramadol were administered three times a day, while dexketoprofen trometamol was given twice daily to manage postoperative pain during the inpatient stay. All were mobilized within 12 hours post-surgery. Anti-thrombotic stockings were provided, and they were advised for partial weight-bearing mobilisation with a gradually increasing load of 30-60-90% of body weight per week for three weeks and then full weight-bearing until the first follow-up meeting in our clinics.\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed using a gap-balancing technique to ensure functional alignment. Details of the surgical technique have been documented earlier [4]. Thigh tourniquet pressure was applied before the skin incision and maintained until the skin closed.\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eOutcomes\u003c/h2\u003e\n \u003cp\u003eAn experienced physiotherapist, not involved in the surgical procedures, performed clinical follow-up assessments and analysed gait and posture. The physiotherapist documented the following parameters for all patients both before and three months after the procedure:\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eClinical outcomes\u003c/h3\u003e\n\u003cp\u003eBefore the surgery, a complete medical history and demographic information were collected. The physiotherapist recorded the range of motion (ROM) of the knee joint, the quality of life of the patients (Knee Injury and Osteoarthritis Outcome Score, KOOS), pain with VAS score, and patient satisfaction. Additionally, radiographic follow-up, perioperative medical events, and postoperative complications were recorded from the regional arthroplasty registry. Patients\u0026apos; satisfaction was evaluated using the question, \u0026quot;How satisfied are you with your operated knee?\u0026quot; Responses were recorded on a five-point scale: very satisfied, satisfied, neither, dissatisfied, and very dissatisfied [2].\u003c/p\u003e\n\u003cp\u003eGait and Posture outcomes\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA. Evaluation of the muscle strength (a single evaluator performed all measurements)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003ea. Grip strength\u003c/h3\u003e\n\u003cdiv\u003e\n \u003cp\u003eA grip strength dynamometer (Kinvent, Montpellier, France) was used to test the overall muscle strength of the patients. Participants were instructed to sit with their shoulders at 0\u0026deg; flexion alongside their bodies, elbows bent at 90\u0026deg;, and forearms positioned neutrally. Both hands underwent testing. They were requested to squeeze the dynamometer as firmly as possible for three repetitions, maintaining each squeeze for five seconds and resting for 10 seconds between squeezes. Finally, we recorded the highest value (Kg) from the three attempt measurements for each hand and averaged the bilateral scores (Kg).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eb. Quadriceps and tibialis anterior maximum voluntary isometric strength (MVIS)\u003c/h3\u003e\n\u003cdiv\u003e\n \u003cp\u003eWe employed a hand-held dynamometer (HHD; Muscle Controller, Kinvent, Montpellier, France) for the MVIS assessment. Quadriceps strength was evaluated while seated at a 90-degree knee flexion angle, and tibialis anterior strength was measured supine, with the ankle joint at a neutral position. Both legs underwent the same testing protocol: the dynamometer was pressed to its maximum for three repetitions, each lasting five seconds, followed by a 10-second rest period between them. Finally, we recorded the highest value from the three attempt measurements for each muscle bilaterally.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eB. Body center-of-mass (COM) kinematics during walking\u003c/h3\u003e\n\u003cdiv\u003e\n \u003cp\u003eThe walking pattern was examined using inertial measurement unit (IMU) sensors (Movesense\u003csup\u003e\u0026trade;\u003c/sup\u003e, Finland). These sophisticated wearable sensors utilise a nine-axis IMU to capture movement data, comprising an accelerometer, gyroscope, and magnetometer, each featuring three axes. We linked the IMU sensor to a receiving device during data collection. Each participant was outfitted with a sensor on the sacrum. After setting up the sensor, participants were instructed to walk comfortably at 4\u0026ndash;5 meters and return twice. Our study aims to measure the COM trajectories in gait, which may reveal crucial insights into balance control during ambulation associated with disease progression or treatment in patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eC. Body weight distribution between legs.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003eThe patients stood barefoot on a grounded posturographic digital platform to assess weight distribution and stability. They were instructed to maintain a quiet bipedal stance for 10 seconds. Measuring 700 \u0026times; 500 mm, the platform featured 2.304 resistive sensors with 0.001 kPa accuracy, sampled at 60 Hz. For the evaluation, patients stood upright in their socks, placing their feet comfortably. Their foot position was standardised in the anterior/posterior direction by aligning their heels with tape on the platform. The distance between the first metatarsal heads was recorded to ensure accurate follow-up measurements. Subjects\u0026apos; arms rested at their sides and were advised to stand relaxed and breathe normally. The platform recorded and analyzed foot pressure distributions using EPS; Foot Checker 4.1 (LorAn Engineering Srl, Castel Maggiore, Bologna, Italy). Weight distribution between the left and right legs was calculated as a percentage of the patient\u0026apos;s overall weight, performed twice with closed or open eyes. We compared the weight distribution differences between the left and right leg across groups preoperatively and at the end of the third postoperative month.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eD. Time up and Go test (TUG)\u003c/h2\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe TUG test is a validated assessment designed to evaluate an individual\u0026rsquo;s functional mobility and dynamic balance, offering vital insights into their capabilities for daily living [8]. This assessment measures the duration required for a person to rise from a seated position, ambulate three meters at their normal walking pace while using their customary assistive device, pivot, and return to the chair to resume a seated posture. This test involved patients wearing their usual footwear, and they could use a walking aid if necessary. The assessment starts with patients sitting down and standing up upon the therapist\u0026apos;s cue. Each patient walked three meters, turned around a placed cone, returned to the chair, and sat down again. The timing stopped once the patient was seated. A practice trial was conducted before the timed trial. We measured each patient two times: once when they turned the cone left after the 3-meter distance and again when they turned the cone right. Finally, we compute the average time from the two measurement recordings.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe necessary sample size was determined according to reported differences and standard deviation of measurements between mTKA and raTKAs in previous gait analysis studies [5]. Using Lehr\u0026apos;s formula, our statistical analysis found that with sufficient power of 0.8 and the \u0026alpha; value of 0.05, to find significance for COM kinematics of 0.1 mm/sec between the groups, at least 24 patients had to be enrolled.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 46 raTKAs and 24 mTKAs; no patients were lost during the research follow-up. The sample comprised 51 females (72.9%) and 19 males (27.1%). The average age (\u0026plusmn;\u0026thinsp;standard deviation/SD) at the time of surgery was 73.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 years, and the average BMI (\u0026plusmn;\u0026thinsp;SD) was 32.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2 kgr/m\u003csup\u003e2\u003c/sup\u003e. All patients were monitored for three months following the surgical procedure. The two groups were comparable in terms of mean age, body mass index (BMI), sex distribution, grip strength, and mean preoperative KOOS score (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u0026amp; \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All procedures performed were primary TKAs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eA comparative analysis of the baseline characteristics between mTKA and raTKA groups.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emTKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eraTKA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.6 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.5 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.766\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.155\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.2 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.2 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.801\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e*\u003c/sup\u003e The values are presented as the mean with the standard deviation in parentheses.\u003c/p\u003e \u003cp\u003e \u003csup\u003e**\u003c/sup\u003e The values are provided as raw numbers.\u003c/p\u003e \u003cp\u003e \u003csup\u003e\u0026amp;\u003c/sup\u003e Tests were conducted using the Student\u0026rsquo;s T-test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e@\u003c/sup\u003e Tests were conducted using the Mann-Whitney test.\u003c/p\u003e \u003cp\u003e \u003csup\u003e#\u003c/sup\u003e Tests were conducted using the Chi-squared test.\u003c/p\u003e \u003cp\u003emTKA: manual total knee arthroplasty, raTKA: robotic total knee arthroplasty, BMI: body mass index.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eA comparative analysis of the mean scores pertaining to the KOOS subcategories between mTKA and raTKA groups\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emTKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eraTKA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKOOS score preoperative\u003c/em\u003e\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.9 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.252\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.9 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.7 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.2 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.4 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.681\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKOOS score postoperative\u003c/em\u003e\u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.4 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.4 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.681\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.67 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.72 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.581\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.5 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.3 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.506\u003csup\u003e@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* The values are presented as the mean with the standard deviation in parentheses.\u003c/p\u003e \u003cp\u003e@ Tests were conducted using the Mann-Whitney test.\u003c/p\u003e \u003cp\u003e\u0026amp; Tests were conducted using the Student\u0026rsquo;s T-test.\u003c/p\u003e \u003cp\u003emTKA: manual total knee arthroplasty, raTKA: robotic total knee arthroplasty, BMI: body mass index, ADL: activities of daily life, QoL: quality of life.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcomes\u003c/h2\u003e \u003cp\u003eNo intraoperative complications were observed in either group during the follow-up period. At the end of the third month, the mean ROM of the raTKA group (125.8 \u0026plusmn; 9.2\u003csup\u003e0\u003c/sup\u003e) was greater than that of the mTKA group (122.1 \u0026plusmn; 10\u003csup\u003e0\u003c/sup\u003e), but this difference was not statistically significant (Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.165). The mean KOOS score was significantly improved for the patients of both groups. In the third postoperative month, the mean scores of KOOS subcategories did not differ significantly between groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, the patients of the raTKA group were significantly more satisfied than the mTKA group (x\u003csup\u003e2\u003c/sup\u003e test, p\u0026thinsp;=\u0026thinsp;0.048) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSatisfaction level comparison data at three months post-surgery for raTKA and mTKA groups\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion:\u003c/p\u003e \u003cp\u003eAre you satisfied with your knee? \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eraTKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emTKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Satisfied\u003c/p\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003cp\u003eNeither satisfied nor dissatisfied\u003c/p\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003cp\u003eVery dissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.048\u003csup\u003e%\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* The values are given as raw numbers\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e% Tests performed using Chi-square (x2) test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eraTKA: robotic-assisted total knee arthroplasty, mTKA: manual total knee arthroplasty,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGait and Posture outcomes\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eGrip Strength\u003c/h2\u003e \u003cp\u003eThe mean grip strength (kgr) of the raTKA group was comparable to that of the mTKA group before the operation (17.16\u0026plusmn; 7.68 vs 14.78 \u0026plusmn; 6.08, Mann Whitney test, p\u0026thinsp;=\u0026thinsp;0.801). In the third postoperative month, the mean grip strength (kgr) was similar between groups (15.4 \u0026plusmn; 5.72 vs 14.25 \u0026plusmn; 4.81, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.932).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuadriceps and tibialis anterior maximum voluntary isometric strength (MVIS)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe mean quadriceps MVIS (in kilograms) improved significantly for the whole group by the end of the third month (Wilcoxon Signed-Rank test, p\u0026thinsp;=\u0026thinsp;0.042). Before surgery, the average quadriceps MVIS (in kilograms) of the raTKA group was higher yet comparable to that of the mTKA group (21.02 \u0026plusmn; 7.45 vs 19.31 \u0026plusmn; 6.53, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.801). Three months after the surgical intervention, the average quadriceps MVIS, measured in kilograms, was greater for the raTKA group but there was no statistically significant difference (21.04 \u0026plusmn; 8.09 vs 17.67 \u0026plusmn; 5.1, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.869).\u003c/p\u003e \u003cp\u003eBy the end of the third month, the mean MVIS of the tibialis anterior (measured in kilograms) showed significant improvement across the entire group (Wilcoxon Signed-Rank test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Preoperatively, the mean tibialis anterior muscle MVIS (Kg) in the raTKA group was observed to be lower yet comparable to that of the mTKA group (11.78 \u0026plusmn; 3.43 vs 12.37 \u0026plusmn; 3.49, Student t-test, p\u0026thinsp;=\u0026thinsp;0.504). In the third postoperative month, the average tibialis anterior MVIS (in kilograms) in the raTKA group was higher compared to the mTKA group (13.92 \u0026plusmn; 2.92 vs 12.74 \u0026plusmn; 2.36, Student t-test, p\u0026thinsp;=\u0026thinsp;0.327). While this difference did not reach statistical significance, it warrants further investigation.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBody COM kinematics during walking\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe COM vectors (mm/sec) showed no significant change for the entire group by the end of the third month (Wilcoxon Signed-Rank test p\u0026thinsp;=\u0026thinsp;0.337). Before the surgical procedure, the mean COM vectors resultant (mm/sec) of the raTKA group was highly similar and comparable to that of the mTKA group (0.13 \u0026plusmn; 0.08 vs 0.14 \u0026plusmn; 0.08, Student t-test, p\u0026thinsp;=\u0026thinsp;0.905). In the third month following surgery, the mean COM displacement for both groups displayed significant similarity and comparability with no statistically significant difference (0.12 \u0026plusmn; 0.07 vs 0.12 \u0026plusmn; 0.05, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.801).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBody weight distribution between legs\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe mean difference in the percentage of body weight distribution between the left and right legs during stance before the surgical intervention for the raTKA group was found to be markedly similar and comparable to that of the mTKA group (-4.55 \u0026plusmn; 18.64 vs -4.92 \u0026plusmn; 18.12, Mann Whitney test, p\u0026thinsp;=\u0026thinsp;0.44). In the third month after surgery, individuals who underwent raTKA experienced a more balanced body weight distribution between their left and right legs during stance than those who underwent mTKA. The mean difference in weight distribution was notably smaller in the raTKA group; nonetheless, this difference was not statistically significant (-0.28 \u0026plusmn; 23.08 vs -3.5 \u0026plusmn; 15.13, Student t-test, p\u0026thinsp;=\u0026thinsp;0.189).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTime up and Go test (TUG)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eBy the end of the third month, the mean TUG test (seconds) significantly decreased across the entire group (Wilcoxon Signed-Rank test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Preoperatively, the mean TUG test, measured in seconds, for the raTKA group was lower yet comparable to that of the mTKA group (14.1 \u0026plusmn; 8.76 vs 16.27 \u0026plusmn; 19.99, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.801). In the third postoperative month, the mean TUG test (in seconds) was significantly lower for both groups, with the raTKA group's mean being even lower; however, no statistical difference was found in the mean TUG test time between the two groups (11.15 \u0026plusmn; 4.6 vs 12.32 \u0026plusmn; 8.94, Mann-Whitney test, p\u0026thinsp;=\u0026thinsp;0.59).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents the first comparative analysis of functional gait assessment in patients undergoing mTKA versus ROSA raTKA. The groups were comparable in demographic and clinical characteristics, grip strength, and all other static and dynamic gait and posture parameters evaluated preoperatively. Although both groups showed notable improvement by the third postoperative month, a trend indicated better clinical and gait outcomes for the raTKA group, though none reached statistical significance. The tibialis anterior MVIS, balanced body weight distribution between the left and right legs, the ROM, TUG, and patient satisfaction demonstrated better outcomes for the raTKA group, however the only statistically significant difference was higher patient satisfaction in the raTKA group. Although the differences did not reach significance, the short follow-up period, small sample size, and lack of randomisation indicate promising signs of potential enhancements for the raTKA group. Overall, the hypothesis that raTKA would provide improved metrics in functional gait analysis compared to mTKA in the early postoperative period remains valid yet unproven. Nevertheless, exploring this relationship establishes a foundation for future research and advancements in surgical practice techniques.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePrevious studies\u003c/h2\u003e \u003cp\u003eVarious studies on different types of raTKAs have reported that the raTKA enhances the precision of implant alignment compared to the mTKA [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The relationship between implant precision accuracy and improved long-term functional outcomes and gait parameters requires further investigation. Few studies evaluated gait parameters for patients undergoing raTKA [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A recent randomised controlled trial with a limited sample size comparing MAKO-assisted raTKA to mTKA found benefits for both groups [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. After 12 months, there were no significant differences in cadence, walking velocity, or plantar pressure ratios between the mTKA and raTKA groups. However, the raTKA group experienced less propulsion time and lateral sway, while the mTKA group showed reductions in foot flat and mid-stance durations. A separate non-comparative study evaluated 31 patients undergoing raTKA via the SkyWalker\u0026trade; system (Suzhou MicroPort Changxing Robot Co., Ltd., China) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Improvements in gait parameters for the operated leg were notable by the third month after surgery and persisted for six months post-TKA. Nonetheless, the operated leg still demonstrated considerable functional deficits compared to the contralateral knee. This study supported that 3D gait analysis is more sensitive than the WOMAC score in evaluating clinical effectiveness. Studies on ROSA raTKA suggest improved implantation accuracy and superior early functional outcomes compared to mTKA [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], yet no ROSA gait analysis study has been conducted thus far. Our study is the first to compare muscle strength, TUG test, static balance and other gait analysis parameters between mTKA and a ROSA raTKA group. We view patient satisfaction as a multifaceted measure that does not always indicate substantial improvements in gait and posture. However, we believe that the improved gait and posture outcomes of the raTKA group contributed to the enhancement of patient satisfaction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMVIS\u003c/h2\u003e \u003cp\u003eOur research shows that the raTKA group had better MVIS of the tibialis anterior muscle in the early postoperative phase, indicating potential benefits of the raTKA method for recovery. Patients with advanced knee osteoarthritis face challenges like knee stiffness and muscle atrophy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], hindering mobility and causing a decline in muscular strength [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Articular muscle depression impairs quadriceps activation, causing knee swelling, pain, and stiffness [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patients with knee osteoarthritis often experience greater thigh muscle weakness than normal adults [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. TKA recovery emphasises muscle strength and joint function restoration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. By the third month, Wang et al. observed improvements in muscle strength and joint mobility, but differences remained compared to non-arthritic individuals. By six months, knee function improved significantly [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, both quadriceps and tibialis anterior muscle strength significantly increased by the end of the third postoperative month for both groups. Although the anterior tibialis and quadriceps muscle strength were higher for the raTKA group at three months postoperatively, and although no significant differences were noted between the groups, there is a strong indication that raTKA leads to better measurable gait and postural results. The results of our study warrant further investigation with an extended follow-up and an alternative design for a randomised study that could reveal statistical differences between robotic and manual TKA techniques.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBody weight distribution between legs\u003c/h2\u003e \u003cp\u003eOur research revealed a trend, though not significant, toward better body weight distribution between the left and right legs during stance in the raTKA group. Postural stability difficulties contribute to falls in older adults, creating a public health challenge for osteoarthritis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In osteoarthritis patients, impaired stability arises from proprioceptive deficits, muscle weakness, and knee pain [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Knee osteoarthritis patients exhibit increased postural sway, greater anterior-posterior sway in sit-stand transitions, and reduced control when shifting from double to single-leg positions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although functional scores improve after TKA, posture and balance issues tied to fall risks may remain [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our study found that the raTKA group displayed a smaller average difference in body weight distribution between the left and right legs while standing, along with a potential trend indicating reduced sway postoperatively, compared to the mTKA group. A follow-up study with improved methods might yield different insights. Understanding this relationship could enhance stability and patient outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eCOM and TUG\u003c/h2\u003e \u003cp\u003eMeasuring COM trajectories in natural settings shows how gait and balance change with diseases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This method enhances understanding their impact on daily life, leading to improved management and interventions. Naili et al. found COM trajectory to be a sensitive indicator of functional compensations after TKA in knee osteoarthritis patients during a sit-to-stand test [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our study introduced an innovative technique for accurately determining the displacement during unperturbed posture by using a single IMU attached to the sacrum, significantly enhancing the analysis of posture dynamics. Our results showed a notable enhancement in COM trajectory following surgery for both groups, with no differences, indicating similar posture dynamics for both techniques. We suggest a longer investigation than three months post-surgery to adequately capture and compare posture dynamics across groups.\u003c/p\u003e \u003cp\u003eOur study showed improved TUG test scores for both groups at three months postoperatively, with a trend favoring better dynamic balance restoration in the raTKA group. Other TKA studies have shown a similar improvement in the TUG test \u003csup\u003e8\u003c/sup\u003e. Healthy individuals aged 60\u0026ndash;80 usually complete the TUG test in 10 seconds. Older males and females may take 1\u0026ndash;2 seconds longer [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The TUG test reliably assesses knee osteoarthritis patients' function, balance, and walking ability. It's a widely used performance measure for TKA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], showing excellent test-retest reliability [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A 2.27-second change in the TUG signals a significant shift in post-TKA rehabilitation, indicating that patients not showing this progress may require additional rehabilitation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The average improvement in the TUG test was over 2.2 seconds for both groups in our study, although it was greater for the raTKA group. Research shows that the TUG test improves notably three months post-TKA, with no further advancements [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; however, a longer follow-up and randomized study may yield different results.\u003c/p\u003e \u003cp\u003eSeveral limitations in our study should be considered when interpreting the findings. Firstly, this study focuses on short-term follow-ups. Longer follow-ups could yield different clinical outcomes. Therefore, it's essential to consider the implications of follow-up duration when evaluating results. Secondly, it is necessary to note that this study is not a randomised, blinded investigation; therefore, there exists the possibility of bias in the allocation of patients to the two groups. Nonetheless, the allocation was based on the patient's preference for raTKA and mTKA. Third, not all gait parameters were evaluated in this study. Fourth, the patients in the raTKA group knew that they would be undergoing surgery with robotic assistance, a factor that could influence their overall experience assessments. Fifth, and most importantly, this study may be underpowered to detect clinically meaningful differences in the primary gait and strength outcomes. The sample size calculation was based on a single parameter (COM kinematics). Consequently, the non-significant findings across multiple metrics should be interpreted as inconclusive rather than definitive evidence of equivalence. Although these limitations exist, a single surgeon conducted all procedures in this prospective case-control study using a consistent surgical approach, implant design, pain management, and rehabilitation protocol for both groups. Besides, the two groups were comparable in demographic and other clinical and gait posture characteristics.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is the first to evaluate gait and posture between a group receiving mTKA and another receiving ROSA raTKA. At three months, patient satisfaction was significantly higher in the raTKa group. Most of the gait and posture results are better for the raTKA group. Although they do not reach statistical significance in the early 3-month follow-up, they indicate a better functional outcome that aligns with improved patient satisfaction in the raTKA group. While the follow-up period is short, the sample size is limited, and there is no randomisation, this is a comparative series conducted by a single surgeon, employing the same gap balancing technique along with consistent perioperative protocols, anaesthetics, chemoprophylaxis, and anticoagulation, as well as the same physiotherapy schedule and implants in both groups, which is unique in the literature. We discovered differences that may not reach significance; however, they suggest consistent directional trends favoring the raTKA group across multiple gait analysis parameters compared to mTKA. Further well powered, randomised studies with longer follow-up and improved design, are necessary to confirm if the higher satisfaction translates into measurable advantages over time.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eraTKA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erobotically assisted total knee arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emTKA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emanual total knee arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRobotic Surgical Assistant (Zimmer-Biomet system) ) Knee System (Zimmer-Biomet, Warsaw, IN, USA)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody center-of-mass\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMVIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emaximum voluntary isometric strength\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTUG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTimed Up and Go (test)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erange of motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKOOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnee Injury and Osteoarthritis Outcome Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual Analogue Scale (for pain)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einertial measurement unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eactivities of daily living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003equality of life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all the individual participants included in the study. The study was approved by the Bioethics Committee of the Medical University of A.U.Th.\u0026nbsp;(6.237-29/07/2020).\u003c/p\u003e\n\u003cp\u003eClinical trial registration number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organisation for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study\u0026rsquo;s conception and design. D. Koukoulias, P. Tsaklis, E. Kenanidis and E. Tsiridis performed material preparation, data collection, and analysis. E. Kenanidis wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRajgor HD, Mayne A, Munasinghe C, Pagkalos J, Agrawal Y, Davis ET, Sharma AD. Mako versus ROSA: comparing surgical accuracy in robotic total knee arthroplasty. J Robot Surg. 2024;18:33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s11701-023-01786-6\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s11701-023-01786-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenanidis E, Paparoidamis G, Milonakis N, Potoupnis M, Tsiridis E. Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study. Eur J Orthop Surg Traumatol. 2023;33:1231\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00590-022-03274-3\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00590-022-03274-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVermue H, Batailler C, Monk P, Haddad F, Luyckx T, Lustig S. The evolution of robotic systems for total knee arthroplasty, each system must be assessed for its own value: a systematic review of clinical evidence and meta-analysis. Arch Orthop Trauma Surg. 2023;143:3369\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00402-022-04632-w\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00402-022-04632-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamie Z, Paparoidamis G, Milonakis N, Kenanidis E, Tsiridis E. The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case-control study. Eur J Orthop Surg Traumatol. 2024;34:2449\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00590-024-03942-6\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00590-024-03942-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjekigbe B, Ramaskandhan J, Clement N, Galloway S, Gabrov N, Smith K, Weir D, Deehan D. Robotic-arm assisted versus manual total knee arthroplasty: Functional gait analysis from a randomised controlled trial. J Biomech. 2024;169:112112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.jbiomech.2024.112112\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.jbiomech.2024.112112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe R, Xiong R, Sun ML, Yang JJ, Chen H, Yang PF, Yang L. Study on the correlation between early three-dimensional gait analysis and clinical efficacy after robot-assisted total knee arthroplasty. Chin J Traumatol. 2023;26:8393. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.cjtee.2022.05.003\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.cjtee.2022.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeo JH, Seon JK, Lee DH, Song EK. No difference in outcomes and gait analysis between mechanical and kinematic knee alignment methods using robotic total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2019;27:1142\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00167-018-5133-x\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00167-018-5133-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsubosaka M, Muratsu H, Nakano N, Kamenaga T, Kuroda Y, Miya H, Kuroda R, Matsumoto T. Sequential changes in lower extremity function after total knee arthroplasty. J Orthop Surg (Hong Kong). 2020;28:2309499020965645. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1177/2309499020965645\u003c/span\u003e\u003cspan address=\"https://doi:10.1177/2309499020965645\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang XF, Ma ZH, Teng XR. Isokinetic Strength Test of Muscle Strength and Motor Function in Total Knee Arthroplasty. Orthop Surg. 2020;12:878\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1111/os.12699\u003c/span\u003e\u003cspan address=\"https://doi:10.1111/os.12699\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Athritis Rheum. 2010;40:250\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.semarthrit.2009.10.001\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.semarthrit.2009.10.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith JW, Marcus RL, Peters CL, Pelt CE, Tracy BL, LaStayo PC. Muscle force steadiness in older adults before and after total knee arthroplasty. J Arthroplasty. 2014;29:1143\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.arth.2013.11.023\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.arth.2013.11.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuc-Harkey BA, Safran-Norton CE, Mandl LA, Katz JN, Losina E. Associations among knee muscle strength, structural damage, and pain and mobility in individuals with osteoarthritis and symptomatic meniscal tear. BMC Musculoskelet Disord. 2018;19:258. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1186/s12891-018-2182-8\u003c/span\u003e\u003cspan address=\"https://doi:10.1186/s12891-018-2182-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavut S, Huzmeli I, Hallaceli H, Kalacı A. Does Total Knee Arthroplasty positively affect body static-dynamic balance and fall risk parameters in patients with satisfactory functional scores? Cureus. 2022;14:e30207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.7759/cureus.30207\u003c/span\u003e\u003cspan address=\"https://doi:10.7759/cureus.30207\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunsky A. The effect of balance and coordination exercises on quality of life in older adults: a mini-review. Front Aging Neurosci. 2019;11:318. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.3389/fnagi.2019.00318\u003c/span\u003e\u003cspan address=\"https://doi:10.3389/fnagi.2019.00318\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwartz I, Kandel L, Sajina A, Litinezki D, Herman A, Mattan Y. Balance is an important predictive factor for quality of life and function after primary total knee replacement. J Bone Joint Surg Br. 2012;94:782\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1302/0301-620X.94B6.27874\u003c/span\u003e\u003cspan address=\"https://doi:10.1302/0301-620X.94B6.27874\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu S, Duan T, Hou M, Yang F, Chai Y, Chen Y, Liu B, Ma Y, Liu A, Wang X, Chen L. (2021) Postural balance in individuals with knee osteoarthritis during stand-to-sit task. Front Hum Neurosci 15: 760960. https://doi:0.3389/fnhum.2021.760960.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBragonzoni L, Rovini E, Barone G, Cavallo F, Zaffagnini S, Benedetti MG. How proprioception changes before and after total knee arthroplasty: A systematic review. Gait Posture. 2019;72:1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.gaitpost.2019.05.005\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.gaitpost.2019.05.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuong TTH, Uher D, Young SD, Farooquee R, Druffner A, Pasternak A, Kanner C, Fragala-Pinkham M, Montes J, Zanotto D. Accurate COM Trajectory Estimation in Healthy and Pathological Gait Using Multimodal Instrumented Insoles and Deep Learning Models. IEEE Trans Neural Syst Rehabil Eng. 2023;31:4801\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1109/TNSRE.2023.3338519\u003c/span\u003e\u003cspan address=\"https://doi:10.1109/TNSRE.2023.3338519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaili JE, Brostr\u0026ouml;m EW, Gutierrez-Farewik EM, Schwartz MH. The centre of mass trajectory is a sensitive and responsive measure of functional compensations in individuals with knee osteoarthritis performing the five times sit-to-stand test. Gait Posture. 2018;62:140\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.gaitpost.2018.03.016\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.gaitpost.2018.03.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteffen TM, Hacker TA, Mollinger L, Up T. \u0026amp; Go Test, and gait speeds. Phys Ther 82:128\u0026thinsp;\u0026ndash;\u0026thinsp;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1093/ptj/82.2.128\u003c/span\u003e\u003cspan address=\"https://doi:10.1093/ptj/82.2.128\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDobson F, Hinman RS, Roos EM, Abbott JH, Stratford P, Davis AM, Buchbinder R, Snyder-Mackler L, Henrotin Y, Thumboo J, Hansen P, Bennell KL. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1042. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.joca.2013.05.002\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.joca.2013.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImada A, Nelms N, Halsey D, Blankstein M. Physical therapists collect different outcome measures after total joint arthroplasty as compared to most orthopaedic surgeons: a New England study. Arthroplast Today. 2018;4:113\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.artd.2017.08.003\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.artd.2017.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuksel E, Kalkan S, Cekmece S, Unver B, Karatosun V. Assessing minimal detectable changes and test-retest reliability of the timed up and go test and the 2-minute walk test in patients with total knee arthroplasty. J Arthroplasty. 2017;32:426\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.arth.2016.07.031\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.arth.2016.07.031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ROSA, robotically assisted TKA, raTKA, total knee arthroplasty, gait, posture","lastPublishedDoi":"10.21203/rs.3.rs-8419899/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8419899/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eFew studies assess gait in robotically assisted total knee arthroplasty (raTKA); none in ROSA raTKA patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMaximum voluntary isometric strength (MVIS), body centre-of-mass (COM) walking kinematics, body-weight distribution, time-up-and-go (TUG) test, quality of life, and range of motion (ROM) were evaluated in three postoperative months between manually TKA (mTKA) and raTKAs. A surgeon performed all procedures using the same technique.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eForty-six uncomplicated primary raTKAs and 24 mTKAs were included, showing similar demographics, grip strength, and preoperative KOOS scores. At three months, there were no significant differences in quadriceps (p\u0026thinsp;=\u0026thinsp;0.869), tibialis MVIS (p\u0026thinsp;=\u0026thinsp;0.327), COM kinematics (p\u0026thinsp;=\u0026thinsp;0.801), body-weight distribution (p\u0026thinsp;=\u0026thinsp;0.189), TUG (p\u0026thinsp;=\u0026thinsp;0.59), and ROM (p\u0026thinsp;=\u0026thinsp;0.165). Patient satisfaction was significantly higher in the raTKA group (p\u0026thinsp;=\u0026thinsp;0,048) and furthermore numerical differences favoring the raTKA group were observed in tibialis anterior MVIS, weight distribution, TUG, and ROM, even though there were no statistically significant differences.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAt three months post-operation, ROSA raTKA resulted in significantly higher patient satisfaction but did not yield statistically differences in gait, posture, or strength outcomes compared to mTKA. The observed non-significant numerical differences in favor of the raTKA grpoup, should be explored in larger, long-term, randomized controlled trials.\u003c/p\u003e","manuscriptTitle":"Robotic-Arm Assisted vs Manual Total Knee Arthroplasty: A Comparative Analysis of Pre and Post-operative Gait and Posture in a Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 11:55:15","doi":"10.21203/rs.3.rs-8419899/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08c265bc-9667-421c-b0ca-e7c0e6ca5738","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T12:10:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 11:55:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8419899","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8419899","identity":"rs-8419899","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}