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<p>Robotic total knee arthroplasty (TKA) enables repeated intraoperative quantification of preoperative alignment, flexion deformity, and medial and lateral compartment gaps in extension and at 90° flexion before component positioning, but the preoperative patterns guiding functional-alignment planning remain incompletely characterized. This study aimed to derive a pragmatic driver-based classification from preoperative robotic data and evaluate its internal coherence across the surgical workflow. We analyzed 68 consecutive primary functionally aligned robotic TKAs performed by a single surgeon using a CT-based robotic-arm platform. Preoperative variables included hip-knee-ankle angle (HKA), flexion deformity, and independent medial and lateral gaps in extension and at 90° flexion. A 10-case formative series informed concept generation; the finalized hierarchy was then applied to all cases using preoperative variables only. Four phenotypes were derived: bone-driven, ligament-driven, flexion-dominant, and mixed/complex (defined as the co-occurrence of two or more severe deformity drivers). Internal coherence was assessed through release escalation, corrected-state behavior, plan-to-final HKA fidelity, and mechanical and functional-alignment balance. Inter-observer reliability was tested by having five independent surgeons classify all cases blinded, with agreement quantified by Fleiss’ and Cohen’s kappa. All knees were classified: bone-driven, 40/68 (58.8%); ligament-driven, 6/68 (8.8%); flexion-dominant, 10/68 (14.7%); and mixed/complex, 12/68 (17.6%). Release escalation occurred in 1/68 (1.5%), with no posterior capsulotomy. Overall, 58/63 (92.1%) finished within ± 2° of planned HKA; strict mechanical balance was achieved in 58/62 (93.5%) and functional-alignment balance in 61/62 (98.4%). Flexion-dominant knees showed lower coronal fidelity but complete final balance, suggesting a coronal-sagittal trade-off during functional planning. Inter-observer agreement among the five surgeons was almost perfect (Fleiss’ kappa 0.88, 95% CI 0.81–0.93; 92.4% overall agreement). Preoperative HKA, sagittal deformity, and medial-lateral gap asymmetry revealed recurring patterns organized into a four-phenotype driver framework. This classification is best interpreted as an internally coherent derivation framework that showed almost perfect inter-observer reliability (Fleiss’ kappa 0.88) but still requires external, multicenter validation and threshold-sensitivity analysis before its clinical utility can be established.</p>

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Preoperative gap phenotypes in functionally aligned robotic total knee arthroplasty: derivation and internal coherence of a driver-based classification

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年7月20日

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  • Eduardo Frois Temponi,
  • Jared Philip Sachs,
  • Matheus Braga Jacques Gonçalves,
  • Luiz Fernando Machado Soares,
  • Lúcio Honório de Carvalho Júnior

摘要

Robotic total knee arthroplasty (TKA) enables repeated intraoperative quantification of preoperative alignment, flexion deformity, and medial and lateral compartment gaps in extension and at 90° flexion before component positioning, but the preoperative patterns guiding functional-alignment planning remain incompletely characterized. This study aimed to derive a pragmatic driver-based classification from preoperative robotic data and evaluate its internal coherence across the surgical workflow. We analyzed 68 consecutive primary functionally aligned robotic TKAs performed by a single surgeon using a CT-based robotic-arm platform. Preoperative variables included hip-knee-ankle angle (HKA), flexion deformity, and independent medial and lateral gaps in extension and at 90° flexion. A 10-case formative series informed concept generation; the finalized hierarchy was then applied to all cases using preoperative variables only. Four phenotypes were derived: bone-driven, ligament-driven, flexion-dominant, and mixed/complex (defined as the co-occurrence of two or more severe deformity drivers). Internal coherence was assessed through release escalation, corrected-state behavior, plan-to-final HKA fidelity, and mechanical and functional-alignment balance. Inter-observer reliability was tested by having five independent surgeons classify all cases blinded, with agreement quantified by Fleiss’ and Cohen’s kappa. All knees were classified: bone-driven, 40/68 (58.8%); ligament-driven, 6/68 (8.8%); flexion-dominant, 10/68 (14.7%); and mixed/complex, 12/68 (17.6%). Release escalation occurred in 1/68 (1.5%), with no posterior capsulotomy. Overall, 58/63 (92.1%) finished within ± 2° of planned HKA; strict mechanical balance was achieved in 58/62 (93.5%) and functional-alignment balance in 61/62 (98.4%). Flexion-dominant knees showed lower coronal fidelity but complete final balance, suggesting a coronal-sagittal trade-off during functional planning. Inter-observer agreement among the five surgeons was almost perfect (Fleiss’ kappa 0.88, 95% CI 0.81–0.93; 92.4% overall agreement). Preoperative HKA, sagittal deformity, and medial-lateral gap asymmetry revealed recurring patterns organized into a four-phenotype driver framework. This classification is best interpreted as an internally coherent derivation framework that showed almost perfect inter-observer reliability (Fleiss’ kappa 0.88) but still requires external, multicenter validation and threshold-sensitivity analysis before its clinical utility can be established.