Imageless robotic assisted TKA: a systematic review

Background: Imageless robotic-assisted TKA (RATKA) has arisen as a potential technology designed to improve surgical accuracy, advance clinical outcomes, and reduce complications. This systematic review evaluates the clinical efficacy, safety, and radiological accuracy of imageless RATKA. Methods: Review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PROSPERO registered (CRD1161673). A thorough search of PubMed, Scopus, and Web of Science databases was conducted through April 2025. Data were independently withdrawn by reviewers, and study quality was assessed using the Modified Coleman Score and RoB 2 and ROBINS-I tools. Descriptive synthesis and weighted mean analysis were performed. Results: A total of 8 studies involving 612 knees were included. Mean patient age was 67.7 years and mean follow-up was 15.8 months. The overall methodological quality was moderate (mean Modified Coleman Score: 70/100). The preoperative and postoperative functional scores combined demonstrated significant improvement: KSS increased from 34.2 (95% CI, 27.2-41.1) to 88.5 (95% CI, 77.9-91.1), KSS-F increased from 44.5 (95% CI, 38.1-50.9) to 83.1 (95% CI, 74.2-92.1), and KOOS-JR increased from 30.3 (95% CI, 23.4-37.2) to 87.7 (95% CI, 76.8-98.5). Across all studies, the overall complication rate was 2.4%, with the most common adverse event being surgical site infection. Conclusions: Imageless robotic-assisted TKA is distinguished by significant functional and radiologic gains, minimal rate of complications, and acceptable short-term safety. Homogeneity of combined PROMs and alignment data validates accuracy and reliability of imageless systems.