Cemented Total Knee Arthroplasty (TKA) fixation is considered less technically challenging than cementless TKA because it is more forgiving of small defects in the bone cuts, which can be filled with cement.1 “Arguably the principle cause of poor outcomes in cementless TKA is poor surgical technique due to the finer margins relative to cemented knee arthroplasty.”2

Robotic-assisted TKA has been shown to improve the accuracy and reproducibility of surgery, which should lend itself to cementless TKA.3 Advancements in surgery-assisting technologies have also allowed the evolution of new alignment philosophies, like Functional Alignment (FA). This approach “manipulates alignment, bone resections, soft tissue releases, and/or implant positioning with a robotic-assisted system to optimize TKR function for a patient’s specific alignment, bone morphology, and soft tissue envelope.”4

Recently, it has been suggested that FA may also “improve cortico-cancellous contact of the tibial component, and so reduce subsidence of the tibial component.”2 This failure mode has been reported in several studies of cementless TKA, with some authors reporting a failure rate as high as 19% at ~5 years. To address this failure mode, it has been suggested that “surgeons need to maximise the tibial cortico-cancellous contact with the tibial component to reduce micromotion and subsidence, and increase the area of ingrowth.”2 It may be that robotic-assisted FA can help to achieve that goal, and lower the technical barriers to cementless TKA by increasing the accuracy and reproducibility of the surgery.