Manual restricted kinematic alignment technique restores postoperative limb alignment in severe knee deformities.

Restricted kinematically aligned total knee arthroplasty (rKA-TKA) for severe deformity in the preoperative hip-knee-ankle angle (HKAA) has gained considerable interest. However, the widespread adoption of rKA-TKA has been limited by its requirement for expensive equipment such as navigation and robotic surgery systems. In this study, we developed manual rKA-TKA with modified soft tissue-respecting technique and investigated its surgical effects on postoperative HKAA. To achieve this, we examined factors affecting postoperative HKAA. Subsequently, the safe zone-related cut-off values of preoperative HKAA were calculated using the receiver operating characteristic curve, and postoperative HKAA was predicted using a linear regression model (LRM) and generalized additive model (GAM). Preoperative HKAA was identified as a factor influencing postoperative HKAA. The cut-off values of preoperative HKAA were -14 and -15° when the safe zones were defined as ± 1-3 and ± 4-5°, respectively. The GAM was more accurate in predicting the postoperative HKAA than the LRM. Additionally, the GAM showed a potential of falling within ± 5° of the postoperative HKAA, even in patients with preoperative HKAA ≤ - 19°. These findings suggest that manual rKA-TKA can be effective even for patients with severe deformities, providing an accessible alternative to conventional TKA for surgeons at resource-limited institutions.