Comparison of Radiographic Accuracy and Clinical Outcomes Between Velys-assisted total knee arthroplasty and conventional total knee arthroplasty: A Meta-Analysis

Comparison of Radiographic Accuracy and Clinical Outcomes Between Velys-assisted total knee arthroplasty and conventional total knee arthroplasty: A Meta-Analysis | 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 Comparison of Radiographic Accuracy and Clinical Outcomes Between Velys-assisted total knee arthroplasty and conventional total knee arthroplasty: A Meta-Analysis Changjiao Sun, Qi Ma, Xijiu Zhao, Xiaofei Zhang, Huimin Li, Xu Cai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8628486/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background The goal of the image-free VELYS Robotic-Assisted total knee arthroplasty is to maximize soft tissue kinematics and surgical precision during total knee arthroplasty (TKA). However, clinical evidence regarding its superiority over manual techniques remains equivocal. This is the first meta-analysis to synthesize the perioperative, functional, and radiographic performance of VELYS-assisted TKA (VELYS-TKA) compared with conventional TKA (C-TKA). Methods A comprehensive literature search was performed in PubMed, Embase, and the Cochrane Library, as well as major Chinese databases including CNKI and Wanfang, to identify relevant comparative studies published up to January 2026. Our analysis focused primarily on patient-reported outcomes, including the KSS and VAS. Surgical factors and safety outcomes were also examined, covering range of motion, length of hospital stay, operative time, and the occurrence of complications, MUA, and revision surgery. Statistical computations were performed using STATA MP software (v18.0) Results Nine qualifying studies were incorporated, involving 138,441 patients undergoing primary total knee arthroplasty (TKA). The meta-analysis indicated no significant differences between VELYS-assisted TKA and conventional TKA regarding KSS knee score (P = 0.43), dynamic VAS score (P = 0.38), flexion-extension range of motion (P > 0.05), or operative time (P = 0.29). The revision rate, the rate of manual reduction under anesthesia (MUA), and the overall complication rate were all similar for the two surgical methods. In contrast, patients undergoing VELYS-assisted TKA experienced faster early functional recovery, as evidenced by higher KSS functional scores (P < 0.001), lower static VAS scores (P = 0.04), and shorter hospital stays (P < 0.001). Conclusion The VELYS robotic system is safe and feasible alternative to standard TKA without increasing operative time or risk with real benefits in promoting early functional recovery and shorter hospital stay. Although these early results are promising, long-term durability and cost-effectiveness of the platform should be validated in high-quality multicenter randomized trials with extended longitudinal follow-up. Velys Robotic-assisted Total knee arthroplasty Meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Total knee arthroplasty (TKA) is considered the gold standard for end-stage knee osteoarthritis, with confirmed effects of pain relief and joint function restoration [ 1 ]. Although clinical treatment has been successful, there was still 15%–20% patients who were left with residual pain or functional deficits after surgery [ 2 – 4 ]. Conventional TKA (C-TKA) is performed using manual instrumentation and the surgeon’s judgment, which have been reported to cause diversity in limb alignment and soft-tissue balance [ 5 , 6 ], especially in the case of complex deformities [ 7 ]. This variable has been linked to reduced satisfaction and could be accounting for sustained dissatisfaction in some patients [ 8 ]. There is a promising technology to address these problems that has been developed over the last decade: robotic-assisted TKA (RATKA)[ 9 – 12 ]. Through intraoperative immediate feedback and highly accurate cutting templates, RATKA seeks to reduce human error and increase the reliability of component positioning. Previously developed robotic systems often required a preoperative CT scan to plan procedures, which would increase costs and radiation exposure [ 13 ]. To maximize efficiency and expedite access, imageless robotic systems have been designed to provide intraoperative guidance without preoperative imaging [ 14 – 16 ]. The VELYS Robotic-Assisted Solution (DePuy Synthes, Warsaw, IN, USA) is a new table-mounted, imageless robotic system [ 17 , 18 ]. Unlike large autonomous robotic platforms, the VELYS system employs a surgeon-controlled handheld robotic saw that integrates dynamic feedback from soft tissues. This enables real-time adjustments to femoral and tibial resections based on patient-specific ligament tension across the full range of motion. Preliminary clinical studies suggest that VELYS-assisted TKA may improve the accuracy of planned versus achieved component alignment and support enhanced early postoperative recovery compared with conventional TKA[ 19 , 20 ]. However, some studies have shown that postoperative pain scores, functional outcomes, operative time, and length of hospital stay are similar between VELYS-TKA and C-TKA [ 17 ]. These conflicting results call for a systematic assessment of the clinical importance and limitations of VELYS-TKA in comparison with C-TKA. To our knowledge, no meta-analysis has yet focused on this system. In this context, the present study aims to systematically evaluate perioperative, functional, and radiological outcomes of VELYS-TKA compared with C-TKA, providing clinicians with an updated, evidence-based perspective on its clinical performance. Methods To ensure methodological transparency, the protocol for this systematic review was formally documented in the PROSPERO international registry before its commencement (ID: CRD420261279483; URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261279483 ). Furthermore, the execution and subsequent reporting of this investigation strictly adhered to the PRISMA framework[ 21 ]. Search strategy Relevant literature on VELYS-TKA versus conventional TKA was identified by an extensive search of the major electronic databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library) as well as regional Chinese ones (CNKI, Wanfang and CBM). This search included all entries until the beginning of January 2026. The precise query logic using Boolean operators and the relevant platform-specific MeSH terms are described in Supplementary Data 1. Two investigators (X.J.Z. and Q.M.) reviewed the titles, abstracts and full text independently after identifying the studies through search. When there was disagreement, a third senior investigator (C.J.S.) acted as an arbiter and the final decision was by consensus. Inclusion and exclusion criteria This selection process was based on predetermined criteria used in the retrieval of suitable studies. We selected studies from randomized controlled trials (RCTs) or observational studies (cohort and case-control) that compared individuals with advanced degenerative knee osteoarthritis. The primary comparison was between VELYS robotic-assisted and manual TKA. Studies were eligible only if they presented at least 1 clinical or surgical endpoint, including functional scores (KSS knee and function subscales), pain metrics (static/dynamic VAS), or perioperative indicators (flexion/extension ROM, operative duration, and length of stay). Also, the safety information was needed (complication rate, MUA and revision surgery). In addition, inclusion was contingent on the availability of adequate raw data to calculate effect sizes (i.e., MD or RR). “Narrative reviews, letters, editorials and case series as well as conference abstract or reports that did not provide granular extractable data were excluded. Data extraction process Two researchers (X.J.Z. and Q.M.) co-registered datasets on the same day. In cases of disagreement, a third investigator (C.J.S.) served as an arbiter to reach a final consensus. The data extracted from each of the studies consisted of three primary sources: publication-level characteristics (eg, lead author, year at entry, country and methodology), patient baseline characteristics (eg, sex, age at surgery or enrollment date into a study, BMI and follow-up duration) and all prespecified surgical or functional outcomes. In order to avoid a potential bias, missing/unclear information was clarified by contacting the corresponding authors by email. Data Transformation To ensure data consistency across the pooled analysis, trials reporting non-parametric summaries (medians with ranges or interquartile ranges) were converted to mean and standard deviation (SD) formats. This mathematical harmonization was performed using the validated algorithms developed by Luo et al.[ 22 ] and Wan et al[ 23 ], which are widely recognized for yielding high-fidelity estimates [ 24 – 27 ]. Furthermore, as our statistical analysis in Stata initially generated log-transformed risk ratios, we performed an anti-log transformation (exponentiation) on the resulting coefficients to derive the final clinical risk ratios (RRs). Quality Assessment Methodological quality of the non-randomized studies was evaluated using the Newcastle–Ottawa Scale (NOS))[ 28 ], which focuses on how the study group was selected, comparability, and outcome tracking. This evaluation was independently scored by two authors (Q.M. and X.J.Z.). In cases where there were divergent ratings, a final consensus was achieved through a consultative process with a third senior investigator (C.J.S.). Data Analyses Statistical computations were performed using Stata MP (version 18.0; StataCorp, College Station, TX, USA). We summarized continuous variables using means and standard deviations (SD). To quantify inter-study heterogeneity, both the Cochran’s Q test and the I² index were utilized. Recognizing the inherent clinical and methodological diversity across the included trials, all synthesis procedures employed a random-effects framework based on the Restricted Maximum Likelihood (REML) estimator [ 29 ]. ໿ Effect sizes were documented alongside their 95% confidence intervals (CIs). For dichotomous endpoints (e.g., complication, MUA, and revision rates), we calculated risk ratios (RRs). [ 18 ]. Risk ratios (RRs) were calculated for dichotomous study endpoints (e.g. complication, MUA, and revision rates). Continuous parameters, including KSS subscales, VAS scores (static and dynamic), ROM (degrees), operative time (minutes), and hospital stay were statistically analyzed using the means difference (MD). A two-tailed alpha of 0.05 was chosen for statistical significance. Lastly, to evaluate the stability of our summary results we performed a leave-one-out sensitivity analysis in which one study at a time was removed and the rest were re-analysed to check whether any single study excessively influenced the pooled estimates. Search results The stages of our systematic selection process are represented in the PRISMA flow diagram (Fig. 1 ), and the search string s used for each index is provided in Supplementary Data 1. We identified 138 citations and removed 23 duplicates using Zotero. This yielded 115 unique papers for an initial title and abstract screening. At this stage, 105 papers were excluded because they did not meet our previous inclusion criteria on population, intervention or study outcomes. Ten full-text articles were then read for a final evaluation; one paper was excluded because of incomplete data. There were 9 eligible studies[ 16 , 17 , 19 , 20 , 31 – 35 ] included in this meta-analysis. Sample Characteristics A comprehensive summary of the study cohorts’ demographics and the specific endpoints used in this analysis is presented in Tables 1 and 2 . Chronologically, the evidence base for this synthesis is highly contemporary, with all qualifying trials published during 2023–2025. Results Quality assessment The evidence base consisted entirely of non-randomized cohorts, with Newcastle–Ottawa Scale (NOS) scores ranging from 7 to 8. These results signify a robust-to-moderate methodological standard across the included trials (Table 3 ). Recurrent flaws identified during the appraisal included attrition bias and non-blinded outcome assessment—constraints that are often unavoidable in observational research. Despite these limitations, the aggregate quality of the included studies was deemed sufficiently rigorous for our synthesis. Sensitivity Analysis Leave-one-out analyses confirmed the robustness of our findings, as the pooled outcomes were largely unaffected by removing any single trial (Supplementary Data 2). Outcome measurement Radiological Implant Position and Alignment Regarding radiological implant position and alignment, a formal meta-analysis could not be conducted because one of the two included studies did not report the mean and standard deviation (SD). Consequently, the findings were synthesized descriptively. Moreover, the two studies used different definitions for limb alignment: one assessed deviation from the surgical plan using the root mean square error (RMSE), while the other evaluated the proportion of outliers exceeding ± 3° from neutral alignment. Alton et al.[ 19 ] reported radiological accuracy outcomes from a prospective multicenter study, using root mean square error (RMSE) to quantify deviations from the preoperative plan. Their analysis demonstrated significantly lower RMSE values in the Velys-TKA group compared with C-TKA across several key alignment parameters, including the mechanical medial distal femoral angle (mMDFA: 1.3 vs. 1.9, p = 0.0026), mechanical medial proximal tibial angle (mMPTA: 1.2 vs. 1.5, p = 0.026), tibial posterior slope (TPS: 1.7 vs. 2.8, p < 0.0001), and femoral flexion (1.9 vs. 2.8, p = 0.0002). Similarly, Rajasekaran et al.[ 20 ] evaluated radiological performance by examining the proportion of alignment outliers, defined as deviations greater than ± 3° from the neutral axis. The Velys-TKA group exhibited a significantly lower outlier rate for the hip–knee–ankle (HKA) angle (13% vs. 31%, p = 0.001), lateral distal femoral angle (LDFA) (23% vs. 29%, p = 0.001), and tibial slope (17% vs. 37%, p = 0.001) when compared with the manual technique. Overall, although quantitative pooling was not possible, the radiological data suggest that Velys-TKA enables more accurate execution of the planned component alignment and reduces variability in coronal and sagittal alignment when compared with C-TKA. Function outcome results The functional indicators evaluated in these trials included the Knee Society Score (KSS) for both the knee and functional subscores, along with pain measurements using static and dynamic VAS ratings. Quantitative synthesis revealed that VELYS-TKA and conventional methods performed similarly regarding KSS Knee scores (MD = − 1.06; 95% CI, − 3.20 to 7.52; p = 0.43; Fig. 2.1) and dynamic pain intensity (MD = 0.20; 95% CI, − 0.65 to 0.25; p = 0.38; Fig. 2.4). However, the robotic cohort demonstrated superior functional performance, as indicated by a markedly higher KSS Function score (MD = 2.98; 95% CI, 2.02 to 3.94; p < 0.001; Fig. 2.2). Furthermore, static VAS ratings favored the VELYS group, which exhibited a subtle but statistically significant reduction in resting pain (MD = − 0.40; 95% CI, − 0.79 to − 0.01; p = 0.04; Fig. 2.3). Perioperative Metrics results The perioperative variables synthesized in this study encompassed joint kinematics (flexion and extension ROM), surgical efficiency (operative time and LOS), and safety indicators (complications, MUA, and revision rates). Quantitative analysis revealed no statistically significant difference between VELYS-TKA and conventional methods across most of these domains. Specifically, joint mobility remained comparable in terms of flexion ROM (MD = 0.85; 95% CI, − 2.67 to 4.39; p = 0.63; Fig. 3.1) and extension ROM (MD = − 0.73; 95% CI, − 1.52 to 0.06; p = 0.07; Fig. 3.2). Similarly, there were no statistically significant differences in operation time (MD = 3.73; 95% CI, − 3.19 to 10.66; p = 0.29; Fig. 3.4) or postoperative safety profiles, including complications (RR = 0.92; 95% CI, 0.68 to 1.25; p = 0.93; Fig. 4.1), MUA (RR = 0.80; 95% CI, 0.35 to 1.82; p = 0.59; Fig. 4.2), and revision rate (RR = 0.53; 95% CI, 0.10 to 2.86; p = 0.46; Fig. 4.3). However, VELYS assistance provided a advantage in hospital throughput, as evidenced by a significantly shorter LOS compared to the manual cohort (MD = − 0.45 days; 95% CI, − 0.58 to − 0.33; p < 0.001; Fig. 3.3). Discussion As the initial meta-analysis regarding VELYS robotic-assisted total knee arthroplasty, our study represents an up-to-date and versatile formulation of large-sample evidence, including over 130,000 cases. The meta-analysis shows that VELYS-guided TKA is linked to better performance in the early time period, as demonstrated by improvements in the KSS Function score, a decrease in bone at rest pain, and a shorter length of hospital stay. Crucially, these advantages were not attained at the expense of increased operative time or elevated rates of postoperative complications, manipulation under anesthesia, or early revision. A noteworthy finding in our study is that KSS Function scores significantly increased while the static VAS pain score significantly decreased in the VELYS-TKA group. One possible reason for this finding could be the image-free tracing technique of the devices, coupled with their potential to evaluate soft tissue in a dynamic manner. In contrast to conventional instrumentation, which uses static bony landmarks as reference points, the VELYS system permits dynamic assessment and modification of both flexion and extension gaps intraoperatively, at every position in the ROM. Better ligament balancing obtained in this way might lead to more physiologic knee kinematics, which are possibly better reflected in functional outcome scores that express activities of daily life. Radiographic results add more evidence that VELYS- TKA is accurate. A formal meta-analysis was not possible due to heterogeneity of the methods used to measure alignment in the included studies; however both papers agreed generally that VELYS-TKA leads toward better alignment with plan and fewer extreme outliers. Such an improved component location accuracy may contribute to the observed increase in functional scores, and reduction in resting pain, suggesting that accurate cup position could be important for early postoperative recovery. Operative time efficiencies are often questioned with robotic surgery, which are predominantly raised by setup and registration issues. However, the current study revealed no significant difference in operative time between VELYS-assisted and conventional total knee arthroplasty. This observation is the inverse of first-generation robotic platforms, which often had increased operative times and learning curves[ 36 , 37 ]. The higher overall maintained efficiency for the VELYS system may be due to its imageless workflow and the use of a table-mounted design, both of which facilitate intraoperative work. Moreover, the decrease in hospital length of stay (LOS) observed provides further evidence for potential benefits in postoperative recovery and resource costs and could be the result of less surgical insult and earlier mobilization of the patients. Safety continues to be an important factor with the introduction of new surgical technologies. VELYS-assisted TKA was not associated with complication, MUA, or revision rates in this meta-analysis compared to conventional TKA. The lack of difference in MUA rates is important, as it indicates that the robotic systems gap-balancing algorithm does not result in patients being overtightened and developing postoperative arthrofibrosis[ 38 ]. Moreover, similar early revision rates suggest that implementation of this robotic technology will not negatively affect short-term implant survival, adding confidence in its clinical safety profile. Limitations Although a large pooled sample size has been accumulated, several methodological limitations on this study need to be considered. First, the number of included studies was relatively small (n = 9), and thereby the statistical power might be decreased for some secondary outcomes and become more vulnerable to publication bias. Second, a significant amount of our included data were obtained from big registries and retrospective cohort studies. While these sources of evidence are rich, they do suffer from natural selection bias and inter-study heterogeneity that may be important to take into account associated with interpreting the pooled result. Third, the follow-up time from most of the eligible studies was short-term to a great extent. As a result, the long-term influence of VELYS-assisted TKA on polyethylene wear, late implant loosening and total implant survival could not be sufficiently evaluated. Nevertheless, the methodological approach was pre-specified and systematically implemented, and the results represent best available evidence on the clinical outcomes of VELYS-assisted TKA to date. Conclusion In summary, VELYS-aided TKA is safe and effective and can be used as an alternative to conventional TKA. There is evidence that the benefits may include better early functional recovery and a shorter hospital stay, with no apparent increase in operating time. However, in view of the relatively small number of independent comparisons available, these results should be considered promising yet tentative. More high-quality, multicenter randomized controlled trials with mid- to long-term follow-up are necessary to clarify whether these early gains will translate into better clinical outcomes and greater cost-effectiveness in the future. Declarations Ethics approval and consent to participate As this is secondary analysis of a previously published literature, in which there will be no interaction with human subjects, it was granted a formal exemption from institutional ethical clearance. Competing interests All contributing authors explicitly state that no relevant financial or personal conflicts of interest exist concerning the publication of this manuscript. Funding The "14th Five-Year Plan" National Key Research and Development Program: Key Special Project on Additive Manufacturing and Laser Manufacturing Data availability statement To ensure research transparency, the analytical datasets and harvesting templates underpinning this study's results are available from the corresponding author upon request. CRediT authorship contribution statement Changjiao Sun: Conceptualization, Writing — original draft, Visualization, Validation, Resources, Methodology, Investigation, Data curation, Formal analysis, Conceptualization, Writing — review & editing. Xijiu Zhao: Investigation, Data curation. Qi Ma: Investigation, Data curation. Xiaofei Zhang: Formal analysis, Software. Huimin Li: Resources,Project administration. Xu Cai: Supervision. References Hassan SMT, Hussain S, Wasim S et al (2025) Etiology of total knee arthroplasty failure and functional outcome of revision knee arthroplasty. 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Arthroplast Today 31:101588. https://doi.org/10.1016/j.artd.2024.101588 Severson E, Tan Z, English A et al (2025) Healthcare resource utilization for VELYS ™ robotic-assisted solution compared to manual surgery for total knee arthroplasty. J Robot Surg 19:539. https://doi.org/10.1007/s11701-025-02510-2 Spitzer A, Barrett W, Nassif N et al Use of Image Free Robotic-Assisted System for Total Knee Arthroplasty Associated with Improved Knee Society Function Score Compared to Manual Instrumentation, A Retrospective Multi-center Study. pp 207–202 Calderon D, Chumacero B, Ordinola F (2026) Robotic assisted versus conventional total knee arthroplasty in obese patients: A systematic review and meta-analysis. J Orthop 72:312–318. https://doi.org/10.1016/j.jor.2025.11.046 Pujol O, Minguell J, Pijoan J et al (2025) Learning curve of robotic-assisted total knee arthroplasty: a literature review. J Robot Surg 19:411. https://doi.org/10.1007/s11701-025-02597-7 Zhang J, Matzko CN, Sawires A et al (2022) Adoption of Robotic-Arm-Assisted Total Knee Arthroplasty Is Associated with Decreased Use of Articular Constraint and Manipulation under Anesthesia Compared to a Manual Approach. J Knee Surg 35:849–857. https://doi.org/10.1055/s-0040-1721123 Tables Table 1. Description of studies including publication year, country, study design and characteristics of participants The detailed baseline characteristics information Author/year Country Study type Velys-TKA/C-TKA Patients TKAs Mean age(years) Womenr( ％ ) BMI Follow-up time(month) Alton 2024 USA PCS 100/100` 100/100` 66.6/64.4 48/53 31.7/33.5 12 Chen 2025 Singapore RCS 65/65/ 65/65/ 70.5/70.2 75.4/75.4 28.1/27.8 6 Huang 2024 Indiana RCS 866/128643 866/128643 NA NA NA NA Le Guen 2025 France RCS 149/218 149/218 73.4/74.2 26/52 28/27.5 NA Morrisey 2023 USA RCS 66/99 66/99 68.21/69.52 53/56.6 30.27/30.88 12/12 Pagan 2024 USA PCS 80/80 80/80 64.2/63.2 51/45 30/31.5 NA Rajasekaran 2024 India RCS 77/81 100/100 62.58/63.32 78/83 29.68/29.48 6 Severson 2025 USA RCS 215/237 215/237 67.9/66.9 44.3/54 34.1/34 NA Spitzer 2024 USA RCS 553/6705 553/6705 69.37/66.37 55.22/56.53 29.9/30.79 3 Table 1 legend: Description of studies including publication year, country, study design and characteristics of participants (e.g. sample size, age, sex, BMI, monitoring duration). Abbreviations: BMI: body mass index; TKA: total knee arthroplasty; RCT: Randomized control trial; RCS: Retrospective cohort study; PCS: Prospective cohort study; Velys-TKA): Velys assisted- KTA ; C-TKA: Conventional total knee arthroplasty. Table 2: Detailed rendering of synthetic clinical and image findings Author/year Outcome Alton 2024 Operation time, complication rates, MUA rates, PTS, VAS Static, VAS Dynamic, ROM Chen 2025 Range of motion flexion, Range of motion extension, KSS function, KSS knee, Operation time, VAS Static, VAS Dynamic, LOS Huang 2024 Operation time.LOS,revision rate Le Guen 2025 Operation time Morrisey 2023 Operation time, Range of motion flexion, Range of motion extension, VAS, MUA rates Pagan 2024 Operation time Rajasekaran 2024 KSS knee, KSS function, complication rates Severson 2025 LOS Spitzer 2024 KSS function Table 2 legend: Detailed rendering of synthetic clinical and image findings Abbreviations: OKS, Oxford Knee Score; AKSS, American Knee Society Score; FJS, Forgotten Joint score; PCS, Pain Catastrophizing Scale; VAS, Visual analog scale; ROM, range of motion; PJI, periprosthetic joint infection; FCCA, Femoral component Coronal alignment; TCCA,Tibial component Sagittal alignment; SF-12, 12-Item Short Form Health Survey; LFCFEA, Lateral femoral component flexion-extension angle; TCPT, Tibial component posterior tilt; MFTA, mechanical femorotibial axis. Table 3 Methodological assessment of the evidence found Risk-of-bias assessment for the studies included in the meta-analysis (NOS) (nRCT) Study = 15 Selection Comparability Outcome/Exposure Score Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Alton 2024 * * * ** * * * 8 Chen 2025 * * * ** * * 7 Huang 2024 * * * ** * * 7 Le Guen 2025 * * * ** * * 7 Morrisey 2023 * * * ** * * * 8 Pagan 2024 * * * ** * * 7 Rajasekaran 2024 * * * ** * * 7 Severson 2025 * * * ** * * 7 Spitzer 2024 * * * ** * * 7 Table 3 legend: Methodological assessment of the evidence found, with quality scores ranging between 7 and 8. Item 1, Is the case definition adequate / Representativeness of the exposed cohort. Item 2, Representativeness of the case / Selection of the non-exposed cohort. Item 3, Selection of controls / Ascertainment of exposure to implants. Item 4, Definition of controls / Demonstration that outcome of interest was not present at start of study. Item 5, Comparability of cases and controls on the basis of design or analysis / Comparability of cohorts on the basis of the design or analysis. Item 6, Ascertainment of exposure / Assessment of outcome. Item 7, Same method of ascertainment for cases and controls / Was follow up long enough for outcomes to occur. Item 8, Non-response rate / Adequacy of follow up of cohorts. Additional Declarations No competing interests reported. Supplementary Files SupplementaryAppendix.zip Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 17 Mar, 2026 Reviews received at journal 17 Mar, 2026 Reviews received at journal 15 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor assigned by journal 20 Jan, 2026 Submission checks completed at journal 20 Jan, 2026 First submitted to journal 17 Jan, 2026 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-8628486","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578384048,"identity":"ef4c6523-6039-4809-a4d1-d721ee0bf7a1","order_by":0,"name":"Changjiao Sun","email":"","orcid":"","institution":"Orthopaedics and Sports Medicine Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua Medicine， Tsinghua 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1","display":"","copyAsset":false,"role":"figure","size":765945,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart depicting systematic identification, screening, and inclusion of eligible trials.\u003c/p\u003e","description":"","filename":"fig1PRISMA2020flowdiagramnew.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/6e2ac7fde7b6ee9c4f723a04.jpg"},{"id":101019057,"identity":"f965f4c3-383d-495a-84f4-4442adca6661","added_by":"auto","created_at":"2026-01-24 00:35:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1297637,"visible":true,"origin":"","legend":"\u003cp\u003eQuantitative synthesis of functional recovery and pain relief: Forest plots for KSS subscales and VAS scores\u003c/p\u003e","description":"","filename":"fig2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/09b1b82f6349ccba55ae0495.jpg"},{"id":101204271,"identity":"beedb933-f19a-4f14-94fa-6ebbc2b63c21","added_by":"auto","created_at":"2026-01-27 09:42:22","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1416988,"visible":true,"origin":"","legend":"\u003cp\u003eMeta-analysis of perioperative efficiency and joint kinematics: Forest plots for ROM, LOS, and operative duration.\u003c/p\u003e","description":"","filename":"fig3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/bc2aa822be231a7d3a8abeba.jpg"},{"id":101204608,"identity":"a61d74c0-eead-42be-b3d7-01144c1c8e31","added_by":"auto","created_at":"2026-01-27 09:43:34","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":933856,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of clinical safety profiles: Forest plots for overall complications, MUA, and revision incidences.\u003c/p\u003e","description":"","filename":"fig4.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/69847dfee2b4c512c6e25520.jpg"},{"id":106344332,"identity":"f5f42f0b-7977-4009-a64a-a2e6db646373","added_by":"auto","created_at":"2026-04-07 16:13:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5528641,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/5d61e10e-2c40-41cc-9e94-6c8ecfeaa575.pdf"},{"id":101296893,"identity":"f7d826d2-95e4-407b-9ecb-7ec532f949b6","added_by":"auto","created_at":"2026-01-28 09:22:43","extension":"zip","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":420550,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendix.zip","url":"https://assets-eu.researchsquare.com/files/rs-8628486/v1/c728e20a91d9e8f81bcf446d.zip"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparison of Radiographic Accuracy and Clinical Outcomes Between Velys-assisted total knee arthroplasty and conventional total knee arthroplasty: A Meta-Analysis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA) is considered the gold standard for end-stage knee\u0026ensp;osteoarthritis, with confirmed effects of pain relief and joint function restoration [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although clinical treatment has been successful, there was still 15%\u0026ndash;20% patients who were left with residual pain or\u0026ensp;functional deficits after surgery [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Conventional TKA (C-TKA)\u0026ensp;is performed using manual instrumentation and the surgeon\u0026rsquo;s judgment, which have been reported to cause diversity in limb alignment and soft-tissue balance [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], especially in the case of complex deformities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This variable has been linked to reduced\u0026ensp;satisfaction and could be accounting for sustained dissatisfaction in some patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a promising technology to address these problems that has been developed over the last decade: robotic-assisted TKA (RATKA)[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Through intraoperative immediate feedback and highly accurate cutting templates, RATKA seeks to reduce human error and increase the reliability of component positioning. Previously developed robotic systems often required a preoperative CT scan to plan procedures, which would increase costs and radiation exposure [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To maximize efficiency and expedite access, imageless robotic systems have been designed to provide intraoperative guidance without preoperative imaging [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe VELYS Robotic-Assisted Solution (DePuy Synthes, Warsaw, IN, USA) is a new table-mounted, imageless robotic system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Unlike large autonomous robotic platforms, the VELYS system employs a surgeon-controlled handheld robotic saw that integrates dynamic feedback from soft tissues. This enables real-time adjustments to femoral and tibial resections based on patient-specific ligament tension across the full range of motion. Preliminary clinical studies suggest that VELYS-assisted TKA may improve the accuracy of planned versus achieved component alignment and support enhanced early postoperative recovery compared with conventional TKA[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, some studies have shown that postoperative pain scores, functional outcomes, operative time, and length of hospital stay are similar between VELYS-TKA and C-TKA [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These conflicting results call for a systematic assessment of the clinical importance and limitations of VELYS-TKA in comparison\u0026ensp;with C-TKA.\u003c/p\u003e \u003cp\u003eTo our knowledge, no meta-analysis has yet focused on this system. In this context, the present study aims to systematically evaluate perioperative, functional, and radiological outcomes of VELYS-TKA compared with C-TKA, providing clinicians with an updated, evidence-based perspective on its clinical performance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo ensure methodological transparency, the protocol for this systematic review was formally documented in the PROSPERO international registry before its commencement (ID: CRD420261279483; URL: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261279483\u003c/span\u003e\u003cspan address=\"https://www.crd.york.ac.uk/PROSPERO/view/CRD420261279483\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Furthermore, the execution and subsequent reporting of this investigation strictly adhered to the PRISMA framework[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy\u003c/h2\u003e \u003cp\u003e Relevant literature on VELYS-TKA versus conventional TKA was\u0026ensp;identified by an extensive search of the major electronic databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library) as well as regional Chinese ones (CNKI, Wanfang and CBM). This search included all entries until the beginning of January\u0026ensp;2026. The precise query logic using Boolean operators and the relevant platform-specific MeSH terms are described in\u0026ensp;Supplementary Data 1. Two investigators (X.J.Z. and\u0026ensp;Q.M.) reviewed the titles, abstracts and full text independently after identifying the studies through search. When there was\u0026ensp;disagreement, a third senior investigator (C.J.S.) acted as an arbiter and the final decision was by consensus.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThis selection process was based on predetermined criteria used in the retrieval of suitable studies. We selected studies from randomized controlled trials (RCTs) or observational studies (cohort and case-control) that compared individuals with advanced degenerative knee osteoarthritis. The primary comparison was between VELYS robotic-assisted and manual TKA. Studies\u0026ensp;were eligible only if they presented at least 1 clinical or surgical endpoint, including functional scores (KSS knee and function subscales), pain metrics (static/dynamic VAS), or perioperative indicators (flexion/extension ROM, operative duration, and length of stay). Also, the\u0026ensp;safety information was needed (complication rate, MUA and revision surgery). In addition, inclusion was contingent on the availability of adequate\u0026ensp;raw data to calculate effect sizes (i.e., MD or RR). \u0026ldquo;Narrative reviews, letters, editorials and case series as well as conference abstract or reports that did not provide\u0026ensp;granular extractable data were excluded.\u003c/p\u003e\n\u003ch3\u003eData extraction process\u003c/h3\u003e\n\u003cp\u003eTwo researchers (X.J.Z. and Q.M.) co-registered datasets on the same day. In cases of disagreement, a third investigator (C.J.S.) served as an arbiter to reach a final consensus. The data extracted from each of the studies consisted of three primary sources: publication-level characteristics (eg, lead author, year at entry, country and methodology), patient baseline characteristics\u0026ensp;(eg, sex, age at surgery or enrollment date into a study, BMI and follow-up duration) and all prespecified surgical or functional outcomes. In order to avoid a potential bias, missing/unclear information was\u0026ensp;clarified by contacting the corresponding authors by email.\u003c/p\u003e\n\u003ch3\u003eData Transformation\u003c/h3\u003e\n\u003cp\u003eTo ensure data consistency across the pooled analysis, trials reporting non-parametric summaries (medians with ranges or interquartile ranges) were converted to mean and standard deviation (SD) formats. This mathematical harmonization was performed using the validated algorithms developed by Luo et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Wan et al[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which are widely recognized for yielding high-fidelity estimates [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, as our statistical analysis in Stata initially generated log-transformed risk ratios, we performed an anti-log transformation (exponentiation) on the resulting coefficients to derive the final clinical risk ratios (RRs).\u003c/p\u003e\n\u003ch3\u003eQuality Assessment\u003c/h3\u003e\n\u003cp\u003eMethodological quality of the non-randomized studies was evaluated using the Newcastle\u0026ndash;Ottawa Scale (NOS))[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which focuses on how the study group was selected, comparability, and outcome tracking. This evaluation was independently scored by two\u0026ensp;authors (Q.M. and X.J.Z.). In cases\u0026ensp;where there were divergent ratings, a final consensus was achieved through a consultative process with a third senior investigator (C.J.S.).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analyses\u003c/h2\u003e \u003cp\u003eStatistical computations were performed using Stata MP (version 18.0; StataCorp, College Station, TX, USA). We summarized continuous variables using means and standard deviations (SD). To quantify inter-study heterogeneity, both the Cochran\u0026rsquo;s Q test and the I\u0026sup2; index were utilized. Recognizing the inherent clinical and methodological diversity across the included trials, all synthesis procedures employed a random-effects framework based on the Restricted Maximum Likelihood (REML) estimator [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e໿ Effect sizes were documented alongside their 95% confidence intervals (CIs). For dichotomous endpoints (e.g., complication, MUA, and revision rates), we calculated risk ratios (RRs). [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Risk ratios (RRs) were calculated for dichotomous study\u0026ensp;endpoints (e.g. complication, MUA, and revision rates). Continuous parameters, including KSS subscales, VAS\u0026ensp;scores (static and dynamic), ROM (degrees), operative time (minutes), and hospital stay were statistically analyzed using the means difference (MD). A two-tailed alpha of 0.05 was chosen for\u0026ensp;statistical significance. Lastly, to evaluate the stability of our\u0026ensp;summary results we performed a leave-one-out sensitivity analysis in which one study at a time was removed and the rest were re-analysed to check whether any single study excessively influenced the pooled estimates.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch results\u003c/h3\u003e\n\u003cp\u003eThe stages of our\u0026ensp;systematic selection process are represented in the PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and the search string s used for each index is provided in Supplementary Data\u0026ensp;1. We identified 138 citations and removed 23 duplicates using Zotero. This yielded 115 unique papers for an initial title and abstract screening. At this stage, 105 papers were excluded because they did not meet our\u0026ensp;previous inclusion criteria on population, intervention or study outcomes. Ten full-text articles were then read for a final evaluation; one paper was excluded\u0026ensp;because of incomplete data. There were 9 eligible studies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] included in this meta-analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSample Characteristics\u003c/h3\u003e\n\u003cp\u003eA comprehensive summary of the study cohorts\u0026rsquo; demographics and the specific endpoints used in this analysis is presented in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Chronologically, the evidence base for this synthesis is highly contemporary, with all qualifying trials published during 2023\u0026ndash;2025.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eQuality assessment\u003c/h2\u003e \u003cp\u003eThe evidence base consisted entirely of non-randomized cohorts, with Newcastle\u0026ndash;Ottawa Scale (NOS) scores ranging from 7 to 8. These results signify a robust-to-moderate methodological standard across the included trials (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Recurrent flaws identified during the appraisal included attrition bias and non-blinded outcome assessment\u0026mdash;constraints that are often unavoidable in observational research. Despite these limitations, the aggregate quality of the included studies was deemed sufficiently rigorous for our synthesis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity Analysis\u003c/h2\u003e \u003cp\u003eLeave-one-out analyses confirmed the robustness of our findings, as the pooled outcomes were largely unaffected by removing any single trial (Supplementary Data 2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measurement\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eRadiological Implant Position and Alignment\u003c/h2\u003e \u003cp\u003eRegarding radiological implant position and alignment, a formal meta-analysis could not be conducted because one of the two included studies did not report the mean and standard deviation (SD). Consequently, the findings were synthesized descriptively. Moreover, the two studies used different definitions for limb alignment: one assessed deviation from the surgical plan using the root mean square error (RMSE), while the other evaluated the proportion of outliers exceeding\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u0026deg; from neutral alignment. Alton et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported radiological accuracy outcomes from a prospective multicenter study, using root mean square error (RMSE) to quantify deviations from the preoperative plan. Their analysis demonstrated significantly lower RMSE values in the Velys-TKA group compared with C-TKA across several key alignment parameters, including the mechanical medial distal femoral angle (mMDFA: 1.3 vs. 1.9, p\u0026thinsp;=\u0026thinsp;0.0026), mechanical medial proximal tibial angle (mMPTA: 1.2 vs. 1.5, p\u0026thinsp;=\u0026thinsp;0.026), tibial posterior slope (TPS: 1.7 vs. 2.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and femoral flexion (1.9 vs. 2.8, p\u0026thinsp;=\u0026thinsp;0.0002). Similarly, Rajasekaran et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] evaluated radiological performance by examining the proportion of alignment outliers, defined as deviations greater than \u0026plusmn;\u0026thinsp;3\u0026deg; from the neutral axis. The Velys-TKA group exhibited a significantly lower outlier rate for the hip\u0026ndash;knee\u0026ndash;ankle (HKA) angle (13% vs. 31%, p\u0026thinsp;=\u0026thinsp;0.001), lateral distal femoral angle (LDFA) (23% vs. 29%, p\u0026thinsp;=\u0026thinsp;0.001), and tibial slope (17% vs. 37%, p\u0026thinsp;=\u0026thinsp;0.001) when compared with the manual technique. Overall, although quantitative pooling was not possible, the radiological data suggest that Velys-TKA enables more accurate execution of the planned component alignment and reduces variability in coronal and sagittal alignment when compared with C-TKA.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFunction outcome results\u003c/h2\u003e \u003cp\u003eThe functional indicators evaluated in these trials included the Knee Society Score (KSS) for both the knee and functional subscores, along with pain measurements using static and dynamic VAS ratings. Quantitative synthesis revealed that VELYS-TKA and conventional methods performed similarly regarding KSS Knee scores (MD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.06; 95% CI, \u0026minus;\u0026thinsp;3.20 to 7.52; p\u0026thinsp;=\u0026thinsp;0.43; Fig.\u0026nbsp;2.1) and dynamic pain intensity (MD\u0026thinsp;=\u0026thinsp;0.20; 95% CI, \u0026minus;\u0026thinsp;0.65 to 0.25; p\u0026thinsp;=\u0026thinsp;0.38; Fig.\u0026nbsp;2.4). However, the robotic cohort demonstrated superior functional performance, as indicated by a markedly higher KSS Function score (MD\u0026thinsp;=\u0026thinsp;2.98; 95% CI, 2.02 to 3.94; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;2.2). Furthermore, static VAS ratings favored the VELYS group, which exhibited a subtle but statistically significant reduction in resting pain (MD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.40; 95% CI, \u0026minus;\u0026thinsp;0.79 to \u0026minus;\u0026thinsp;0.01; p\u0026thinsp;=\u0026thinsp;0.04; Fig.\u0026nbsp;2.3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative Metrics results\u003c/h2\u003e \u003cp\u003eThe perioperative variables synthesized in this study encompassed joint kinematics (flexion and extension ROM), surgical efficiency (operative time and LOS), and safety indicators (complications, MUA, and revision rates). Quantitative analysis revealed no statistically significant difference between VELYS-TKA and conventional methods across most of these domains. Specifically, joint mobility remained comparable in terms of flexion ROM (MD\u0026thinsp;=\u0026thinsp;0.85; 95% CI, \u0026minus;\u0026thinsp;2.67 to 4.39; p\u0026thinsp;=\u0026thinsp;0.63; Fig.\u0026nbsp;3.1) and extension ROM (MD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.73; 95% CI, \u0026minus;\u0026thinsp;1.52 to 0.06; p\u0026thinsp;=\u0026thinsp;0.07; Fig.\u0026nbsp;3.2). Similarly, there were no statistically significant differences in operation time (MD\u0026thinsp;=\u0026thinsp;3.73; 95% CI, \u0026minus;\u0026thinsp;3.19 to 10.66; p\u0026thinsp;=\u0026thinsp;0.29; Fig.\u0026nbsp;3.4) or postoperative safety profiles, including complications (RR\u0026thinsp;=\u0026thinsp;0.92; 95% CI, 0.68 to 1.25; p\u0026thinsp;=\u0026thinsp;0.93; Fig.\u0026nbsp;4.1), MUA (RR\u0026thinsp;=\u0026thinsp;0.80; 95% CI, 0.35 to 1.82; p\u0026thinsp;=\u0026thinsp;0.59; Fig.\u0026nbsp;4.2), and revision rate (RR\u0026thinsp;=\u0026thinsp;0.53; 95% CI, 0.10 to 2.86; p\u0026thinsp;=\u0026thinsp;0.46; Fig.\u0026nbsp;4.3). However, VELYS assistance provided a advantage in hospital throughput, as evidenced by a significantly shorter LOS compared to the manual cohort (MD\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.45 days; 95% CI, \u0026minus;\u0026thinsp;0.58 to \u0026minus;\u0026thinsp;0.33; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;3.3).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the initial meta-analysis regarding VELYS robotic-assisted total knee arthroplasty, our study represents an up-to-date and versatile formulation of large-sample evidence, including over 130,000 cases. The meta-analysis shows that VELYS-guided TKA is linked to better performance in the early time period, as demonstrated by improvements in the KSS Function score, a decrease in bone at rest pain, and a shorter length of hospital stay. Crucially, these advantages were not attained at the expense of increased operative time or elevated rates of postoperative complications, manipulation under anesthesia, or early revision.\u003c/p\u003e \u003cp\u003eA noteworthy finding in our study is that KSS Function scores significantly increased while the static VAS pain score significantly decreased in the VELYS-TKA group. One possible reason for this finding could be the image-free tracing technique of the devices, coupled with their potential to evaluate soft tissue in a dynamic manner. In contrast to conventional instrumentation, which uses static bony landmarks as reference points, the VELYS system permits dynamic assessment and modification of both flexion and extension gaps intraoperatively, at every position in the ROM. Better ligament balancing obtained in this way might lead to more physiologic knee kinematics, which are possibly better reflected in functional outcome scores that express activities of daily life.\u003c/p\u003e \u003cp\u003eRadiographic results add more evidence that\u0026ensp;VELYS- TKA is accurate. A formal meta-analysis was not possible due to heterogeneity of\u0026ensp;the methods used to measure alignment in the included studies; however both papers agreed generally that VELYS-TKA leads toward better alignment with plan and fewer extreme outliers. Such an improved component location accuracy may\u0026ensp;contribute to the observed increase in functional scores, and reduction in resting pain, suggesting that accurate cup position could be important for early postoperative recovery.\u003c/p\u003e \u003cp\u003eOperative time efficiencies are often questioned with robotic surgery, which are predominantly raised by setup and registration issues. However, the current study revealed no significant difference in operative time between VELYS-assisted and conventional total knee arthroplasty. This observation is the inverse of first-generation robotic platforms, which often had increased operative times and learning curves[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The higher overall maintained efficiency for the VELYS system may be due to its imageless workflow and the use of a table-mounted design, both of which facilitate intraoperative work. Moreover, the decrease in hospital length of stay (LOS) observed provides further evidence for potential benefits in postoperative recovery and resource costs and could be the result of less surgical insult and earlier mobilization of the patients.\u003c/p\u003e \u003cp\u003eSafety continues to be an important factor with the introduction of\u0026ensp;new surgical technologies. VELYS-assisted TKA was not associated with complication, MUA, or\u0026ensp;revision rates in this meta-analysis compared to conventional TKA. The lack of difference in MUA rates\u0026ensp;is important, as it indicates that the robotic systems gap-balancing algorithm does not result in patients being overtightened and developing postoperative arthrofibrosis[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Moreover, similar early revision rates suggest\u0026ensp;that implementation of this robotic technology will not negatively affect short-term implant survival, adding confidence in its clinical safety profile.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAlthough a large pooled sample size has been accumulated, several methodological limitations on\u0026ensp;this study need to be considered. First, the number of included studies was relatively small (n\u0026thinsp;=\u0026thinsp;9), and thereby the statistical power might be decreased for some\u0026ensp;secondary outcomes and become more vulnerable to publication bias. Second, a significant amount of our included data were obtained from big registries and\u0026ensp;retrospective cohort studies. While these\u0026ensp;sources of evidence are rich, they do suffer from natural selection bias and inter-study heterogeneity that may be important to take into account associated with interpreting the pooled result. Third, the follow-up time from\u0026ensp;most of the eligible studies was short-term to a great extent. As a result, the long-term influence of VELYS-assisted TKA\u0026ensp;on polyethylene wear, late implant loosening and total implant survival could not be sufficiently evaluated. Nevertheless, the methodological approach was pre-specified and systematically implemented, and the results represent best available evidence on the clinical outcomes of VELYS-assisted TKA to date.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, VELYS-aided TKA is safe and effective and can be used as an alternative to conventional TKA. There is evidence that the benefits may include better early functional recovery and a shorter hospital stay, with no apparent increase in operating time. However, in view of the relatively small number of independent comparisons available, these results should be considered promising yet tentative. More high-quality, multicenter randomized controlled trials with mid- to long-term follow-up are necessary to clarify whether these early gains will translate into better clinical outcomes and greater cost-effectiveness in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003cbr\u003e\u003c/strong\u003eAs this is secondary analysis of a previously published literature, in which there will be no interaction with human subjects, it was granted a formal exemption from institutional ethical clearance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll contributing authors explicitly state that no relevant financial or personal conflicts of interest exist concerning the publication of this manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \"14th Five-Year Plan\" National Key Research and Development Program: Key Special Project on Additive Manufacturing and Laser Manufacturing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure research transparency, the analytical datasets and harvesting templates underpinning this study's results are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChangjiao Sun:\u0026nbsp;\u003c/strong\u003eConceptualization, Writing — original draft, Visualization, Validation, Resources, Methodology, Investigation, Data curation, Formal analysis, Conceptualization, Writing — review \u0026amp; editing.\u003cstrong\u003eXijiu Zhao:\u0026nbsp;\u003c/strong\u003eInvestigation, Data curation.\u0026nbsp;\u003cstrong\u003eQi Ma:\u0026nbsp;\u003c/strong\u003eInvestigation, Data curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eXiaofei Zhang:\u003c/strong\u003e Formal analysis, Software.\u0026nbsp;\u003cstrong\u003eHuimin Li:\u0026nbsp;\u003c/strong\u003eResources,Project administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eXu Cai:\u003c/strong\u003eSupervision.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHassan SMT, Hussain S, Wasim S et al (2025) Etiology of total knee arthroplasty failure and functional outcome of revision knee arthroplasty. 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J Knee Surg 35:849\u0026ndash;857. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0040-1721123\u003c/span\u003e\u003cspan address=\"10.1055/s-0040-1721123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDescription of\u0026ensp;studies including publication year, country, study design and characteristics of participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 553px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe detailed baseline characteristics information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor/year\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVelys-TKA/C-TKA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTKAs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWomenr(\u003c/strong\u003e\u003cstrong\u003e％\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up time(month)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlton 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003ePCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e100/100`\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e100/100`\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e66.6/64.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e48/53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e31.7/33.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eSingapore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65/65/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e65/65/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e70.5/70.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e75.4/75.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e28.1/27.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuang 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eIndiana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e866/128643\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e866/128643\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLe Guen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e149/218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e149/218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e73.4/74.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e26/52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e28/27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorrisey 2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e66/99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e66/99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e68.21/69.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e53/56.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e30.27/30.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e12/12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePagan 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003ePCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e80/80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e80/80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e64.2/63.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e51/45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e30/31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRajasekaran 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e77/81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e100/100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e62.58/63.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e78/83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e29.68/29.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverson 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e215/237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e215/237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e67.9/66.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e44.3/54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34.1/34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpitzer 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eRCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e553/6705\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e553/6705\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e69.37/66.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e55.22/56.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e29.9/30.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 legend:\u0026nbsp;Description of\u0026ensp;studies including publication year, country, study design and characteristics of participants (e.g. sample size, age, sex, BMI, monitoring duration).\u003c/p\u003e\n\u003cp\u003eAbbreviations: BMI: body mass index; TKA: total knee arthroplasty; RCT: \u0026nbsp;Randomized control trial; RCS: \u0026nbsp;Retrospective cohort study; PCS: \u0026nbsp;Prospective cohort study; Velys-TKA): Velys assisted- KTA ; C-TKA: Conventional total knee arthroplasty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eDetailed rendering of\u0026ensp;synthetic clinical and image findings\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor/year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlton 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOperation time, complication rates, MUA rates, PTS, VAS Static, VAS Dynamic, ROM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eRange of motion flexion,\u0026nbsp;Range of motion extension, KSS function, KSS knee, Operation time, VAS Static, VAS Dynamic, LOS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuang 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOperation time.LOS,revision rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLe Guen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOperation time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorrisey 2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOperation time, Range of motion flexion,\u0026nbsp;Range of motion extension, VAS,\u0026nbsp;MUA rates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePagan 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOperation time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRajasekaran 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eKSS knee, KSS function, complication rates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverson 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eLOS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpitzer 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eKSS function\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 legend:\u003c/strong\u003e Detailed rendering of\u0026ensp;synthetic clinical and image findings\u003c/p\u003e\n\u003cp\u003eAbbreviations: OKS, Oxford Knee Score; AKSS, American Knee Society Score; FJS, Forgotten Joint score; PCS, Pain Catastrophizing Scale; VAS, Visual analog scale; ROM, range of motion; PJI, periprosthetic joint infection; FCCA, Femoral component Coronal alignment; TCCA,Tibial component Sagittal alignment; SF-12, 12-Item Short Form Health Survey; LFCFEA, Lateral femoral component flexion-extension angle; TCPT, Tibial component posterior tilt; MFTA, mechanical femorotibial axis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eMethodological\u0026ensp;assessment of the evidence found\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 636px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk-of-bias assessment for the studies included in the meta-analysis (NOS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(nRCT) Study = 15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome/Exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem 8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlton 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuang 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLe Guen 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorrisey 2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePagan 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRajasekaran 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n 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valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverson 2025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpitzer 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 legend:\u0026nbsp;Methodological\u0026ensp;assessment of the evidence found, with quality scores ranging between 7 and 8.\u003c/p\u003e\n\u003cp\u003eItem 1, Is the case definition adequate / Representativeness of the exposed cohort.\u003c/p\u003e\n\u003cp\u003eItem 2, Representativeness of the case / Selection of the non-exposed cohort.\u003c/p\u003e\n\u003cp\u003eItem 3, Selection of controls / Ascertainment of exposure to implants.\u003c/p\u003e\n\u003cp\u003eItem 4, Definition of controls / Demonstration that outcome of interest was not present at start of study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eItem 5, Comparability of cases and controls on the basis of design or analysis / Comparability of cohorts on the basis of the design or analysis.\u003c/p\u003e\n\u003cp\u003eItem 6, Ascertainment of exposure / Assessment of outcome.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eItem 7, Same method of ascertainment for cases and controls / Was follow up long enough for outcomes to occur. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eItem 8, Non-response rate / Adequacy of follow up of cohorts. \u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Velys, Robotic-assisted, Total knee arthroplasty, Meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-8628486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8628486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe goal of the image-free VELYS Robotic-Assisted total knee arthroplasty is to maximize soft tissue kinematics and surgical precision during total knee arthroplasty (TKA). However, clinical evidence regarding its superiority over manual techniques remains equivocal. This is the first meta-analysis to synthesize the perioperative, functional, and radiographic performance of VELYS-assisted TKA (VELYS-TKA) compared with conventional TKA (C-TKA).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA comprehensive literature search was performed in PubMed, Embase, and the Cochrane Library, as well as major Chinese databases including CNKI and Wanfang, to identify relevant comparative studies published up to January 2026. Our analysis focused primarily on patient-reported outcomes, including the KSS and VAS. Surgical factors and safety outcomes were also examined, covering range of motion, length of hospital stay, operative time, and the occurrence of complications, MUA, and revision surgery. Statistical computations were performed using STATA MP software (v18.0)\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNine qualifying studies were incorporated, involving 138,441 patients undergoing primary total knee arthroplasty (TKA). The meta-analysis indicated no significant differences between VELYS-assisted TKA and conventional TKA regarding KSS knee score (P\u0026thinsp;=\u0026thinsp;0.43), dynamic VAS score (P\u0026thinsp;=\u0026thinsp;0.38), flexion-extension range of motion (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), or operative time (P\u0026thinsp;=\u0026thinsp;0.29). The revision rate, the rate of manual reduction under anesthesia (MUA), and the overall complication rate were all similar for the two surgical methods. In contrast, patients undergoing VELYS-assisted TKA experienced faster early functional recovery, as evidenced by higher KSS functional scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower static VAS scores (P\u0026thinsp;=\u0026thinsp;0.04), and shorter hospital stays (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe VELYS robotic system is safe and feasible alternative to standard TKA without increasing operative time or risk with real benefits in promoting early functional\u0026ensp;recovery and shorter hospital stay. Although these early results are\u0026ensp;promising, long-term durability and cost-effectiveness of the platform should be validated in high-quality multicenter randomized trials with extended longitudinal follow-up.\u003c/p\u003e","manuscriptTitle":"Comparison of Radiographic Accuracy and Clinical Outcomes Between Velys-assisted total knee arthroplasty and conventional total knee arthroplasty: A Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-24 00:35:03","doi":"10.21203/rs.3.rs-8628486/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-17T10:22:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T07:26:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T14:39:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72803795591240553438394304593164291917","date":"2026-03-15T14:30:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249542994275061926296509534714872744306","date":"2026-02-13T06:32:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165837996988643313552344233491942886823","date":"2026-01-21T16:02:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T12:43:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T01:16:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T11:03:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2026-01-17T22:59:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a8d28185-a625-425a-b30e-deff88af48a8","owner":[],"postedDate":"January 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:07:37+00:00","versionOfRecord":{"articleIdentity":"rs-8628486","link":"https://doi.org/10.1007/s11701-026-03370-0","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-04-03 16:00:13","publishedOnDateReadable":"April 3rd, 2026"},"versionCreatedAt":"2026-01-24 00:35:03","video":"","vorDoi":"10.1007/s11701-026-03370-0","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03370-0","workflowStages":[]},"version":"v1","identity":"rs-8628486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8628486","identity":"rs-8628486","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}