Precision vs. paradox: A systematic review and meta-analysis of clinical outcomes, radiographic accuracy and cost-effectiveness in robotic-assisted total knee arthroplasty (2015-2025).

Robotic-assisted total knee arthroplasty (RA-TKA) was designed to reduce the “dissatisfaction gap” seen in manual TKA (m-TKA) because it allows surgery to be more precise. However, its long-term clinical superiority and cost-utility remain the subjects of intense debate. This systematic review and meta-analysis aimed to compare RA-TKA and m-TKA with respect to radiographic alignment accuracy, patient-reported outcome measures (PROMs), complications and economic impact. Based on the methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020), PubMed, Embase and Scopus were searched for studies on composts published in the years 2015 and up to 2025. Data from 24 studies (n = 4,678 knees) were synthesised. Methodological quality was analysed by Cochrane RoB 2.0 and the Newcastle-Ottawa scales. RA-TKA had significantly improved KSS scores at 6 months (mean difference − 4.15; 95% CI, 2.85 to 5.45; p = 0.002); however, this improvement was not near thresholds established as Minimal Clinically Important Difference (MCID). Then at 24 months, functional outcomes were the same between the groups (p = 0.42). Robotic procedures required significantly longer operative costs (MD: +22.4 min; p < 0.001) and experienced increased direct costs (2,500–4,000 USD). There was no difference in complication rates between groups (OR: 0.94; p = 0.82). RA-TKA has increased technical precision and a statistically significant performance gain early. Nonetheless, the early clinical benefit may not be detected by patients because it is still below the MCID threshold. Long-term value is always dependent on future data on survivorship. Economic justification for robotics is therefore dependent on long-term survivorship data acquired in the future.