{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T16:53:22Z","timestamp":1791910402816,"version":"4.3.4"},"reference-count":27,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:00:00Z","timestamp":1791849600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:00:00Z","timestamp":1791849600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["esskajournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Knee surg. sports traumatol. arthrosc."],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To determine how preoperative coronal phenotype and structural remodelling relate to initial and final intraoperative balance in robot\u2010assisted total knee arthroplasty.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Initial analyses included 429 knees; final\/change analyses included 389. Preoperative phenotype was characterised by hip\u2010knee\u2010ankle angle (HKA), arithmetic HKA (aHKA), functional knee phenotype (FKP), and categorical aHKA\u2013joint\u2010line obliquity (JLO) components. Structural factors included medial and lateral osteophyte burden and coronal tibiofemoral subluxation. Medial and lateral gaps and coronal laxity ranges were recorded in extension and flexion before and after balancing. Signed mediolateral gap difference was defined as lateral minus medial, and change as final minus initial. Initial extension signed gap difference was the primary outcome; corresponding initial flexion, final, and change outcomes were secondary. Compartment\u2010specific gaps, laxity ranges, and varus\u2013valgus analyses were exploratory. Multivariable linear regression adjusted for age, sex, and body mass index, with patient\u2010level cluster\u2010robust standard errors and Benjamini\u2013Hochberg false discovery rate correction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The FKP model incorporating all structural factors yielded adjusted\n                      <jats:italic>R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      values of 0.201 for the primary outcome and 0.125 for initial flexion, leaving approximately 80% of primary\u2010outcome variability unexplained. In the overall cohort, the maximum adjusted\n                      <jats:italic>R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      across final outcomes was 0.064. For extension and flexion changes, FKP alone and HKA alone yielded adjusted\n                      <jats:italic>R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      values of 0.234 and 0.122, respectively. In exploratory comparisons, valgus knees had greater initial extension and flexion signed gap differences than varus knees (adjusted mean differences, 3.10\u2009mm [95% confidence interval, 2.39\u20133.81] and 2.98\u2009mm [2.23\u20133.74], respectively; both false discovery rate\u2010adjusted\n                      <jats:italic>p<\/jats:italic>\n                      values were\u2009&lt;\u20090.001).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Preoperative coronal phenotype and structural remodelling explained only modest variability in the initial intraoperative balance state and changes between assessments, and little variability in final balance, particularly in flexion. These findings support direct intraoperative assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level III, retrospective cohort study.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ksa.70648","type":"journal-article","created":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T16:26:06Z","timestamp":1791908766000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Preoperative coronal phenotype is associated with the initial balance state but only weakly with final balance in robot\u2010assisted TKA"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8642-6613","authenticated-orcid":false,"given":"Yugo","family":"Morita","sequence":"first","affiliation":[{"name":"Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikolaos","family":"Mylonakis","sequence":"additional","affiliation":[{"name":"Academic Orthopaedic Department Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki Thessaloniki Greece"},{"name":"ICAROS Orthopaedic Center Thessaloniki Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonggu","family":"Shin","sequence":"additional","affiliation":[{"name":"Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"El\u2010Hassan","sequence":"additional","affiliation":[{"name":"Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ittai","family":"Shichman","sequence":"additional","affiliation":[{"name":"Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eustathios","family":"Kenanidis","sequence":"additional","affiliation":[{"name":"Academic Orthopaedic Department Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki Thessaloniki Greece"},{"name":"ICAROS Orthopaedic Center Thessaloniki Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eleftherios","family":"Tsiridis","sequence":"additional","affiliation":[{"name":"Academic Orthopaedic Department Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki Thessaloniki Greece"},{"name":"ICAROS Orthopaedic Center Thessaloniki Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7050-5571","authenticated-orcid":false,"given":"Peter K.","family":"Sculco","sequence":"additional","affiliation":[{"name":"Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,13]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"crossref","first-page":"A1","DOI":"10.1016\/j.joca.2006.11.009","article-title":"Atlas of individual radiographic features in osteoarthritis, revised","volume":"15","author":"Altman RD","year":"2007","journal-title":"Osteoarthritis Cartilage"},{"key":"e_1_2_12_3_1","doi-asserted-by":"crossref","first-page":"1773","DOI":"10.1002\/ksa.12561","article-title":"Change of CPAK class does not affect functional outcomes in robotic arm\u2010assisted total knee arthroplasty performed with functional alignment","volume":"33","author":"Bertugli E","year":"2025","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_4_1","doi-asserted-by":"crossref","first-page":"2505","DOI":"10.1002\/ksa.12082","article-title":"Gender\u2010based differences exist in the functional knee phenotypes classification of the osteoarthritic knee","volume":"32","author":"Chelli S","year":"2024","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_5_1","doi-asserted-by":"crossref","first-page":"1398","DOI":"10.1007\/s00167-022-07088-y","article-title":"Dynamic gap analysis of valgus knees shows large inter\u2010individual variability of gaps","volume":"31","author":"Eller K","year":"2023","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_6_1","doi-asserted-by":"crossref","DOI":"10.1002\/ksa.70502","article-title":"Laxity phenotyping in total knee arthroplasty: a current concept 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OA","volume":"30","author":"Graichen H","year":"2022","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_10_1","doi-asserted-by":"crossref","first-page":"1183","DOI":"10.2214\/AJR.20.23503","article-title":"Current measurement strategies of coronal tibiofemoral subluxation: a systematic review of literature","volume":"216","author":"Greif DN","year":"2021","journal-title":"Am J Roentgenol"},{"key":"e_1_2_12_11_1","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1016\/j.artd.2020.12.022","article-title":"Improved compartment balancing using robot\u2010assisted total knee arthroplasty","volume":"7","author":"Held MB","year":"2021","journal-title":"Arthroplast Today"},{"key":"e_1_2_12_12_1","doi-asserted-by":"crossref","first-page":"2873","DOI":"10.1007\/s00167-018-4973-8","article-title":"Functional knee phenotypes: a call for a more personalised and individualised approach to total knee arthroplasty?","volume":"26","author":"Hirschmann MT","year":"2018","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_13_1","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1007\/s00167-019-05509-z","article-title":"Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non\u2010osteoarthritic patients","volume":"27","author":"Hirschmann MT","year":"2019","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_14_1","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.artd.2021.08.007","article-title":"What is the effect of posterior osteophytes on flexion and extension gaps in total knee arthroplasty? A cadaveric study","volume":"11","author":"Holst DC","year":"2021","journal-title":"Arthroplast Today"},{"key":"e_1_2_12_15_1","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1007\/s00256-015-2244-z","article-title":"Coronal tibiofemoral subluxation in knee osteoarthritis","volume":"45","author":"Khamaisy S","year":"2016","journal-title":"Skeletal Radiol"},{"key":"e_1_2_12_16_1","doi-asserted-by":"crossref","first-page":"2858","DOI":"10.1002\/ksa.70178","article-title":"Pre\u2010resection ligament balance more frequently reproduces joint line orientation compared to inverse\u2010kinematic workflow in robotic total knee arthroplasty","volume":"34","author":"Lee GC","year":"2026","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_17_1","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1302\/0301-620X.103B2.BJJ-2020-1050.R1","article-title":"Coronal Plane Alignment of the Knee (CPAK) classification: a new system for describing knee 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kinematic alignment in primary total knee arthroplasty: a systematic review of radiographic and clinical data","volume":"33","author":"Risitano S","year":"2022","journal-title":"J Orthop"},{"key":"e_1_2_12_22_1","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1016\/j.artd.2019.07.003","article-title":"Imageless, robotic\u2010assisted total knee arthroplasty combined with a robotic tensioning system can help predict and achieve accurate postoperative ligament balance","volume":"5","author":"Shalhoub S","year":"2019","journal-title":"Arthroplast Today"},{"key":"e_1_2_12_23_1","doi-asserted-by":"crossref","first-page":"963","DOI":"10.1007\/s00167-022-07107-y","article-title":"Joint gap produced by manual stress is dependent on the surgeon's experience and is smaller in flexion in robotic\u2010assisted total knee arthroplasty","volume":"31","author":"Sohmiya K","year":"2023","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_24_1","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1007\/s00590-017-2118-2","article-title":"Effects of posterior condylar osteophytes on gap balancing in computer\u2010assisted total knee arthroplasty with posterior cruciate ligament sacrifice","volume":"28","author":"Sriphirom P","year":"2018","journal-title":"Eur J Orthop Surg Traumatol"},{"key":"e_1_2_12_25_1","doi-asserted-by":"crossref","first-page":"5118","DOI":"10.1007\/s00167-023-07567-w","article-title":"Functional alignment in total knee arthroplasty best achieves balanced gaps and minimal bone resections: an analysis comparing mechanical, kinematic and functional alignment strategies","volume":"31","author":"Van de Graaf VA","year":"2023","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"e_1_2_12_26_1","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1186\/s42836-025-00338-7","article-title":"Impact of preoperative and constitutional alignment on soft tissue stiffness in robot\u2010assisted total knee arthroplasty","volume":"7","author":"Wang Z","year":"2025","journal-title":"Arthroplasty"},{"key":"e_1_2_12_27_1","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1186\/s42836-024-00268-w","article-title":"Soft tissue laxity is highly variable in patients undergoing total knee arthroplasty","volume":"6","author":"Weiner TR","year":"2024","journal-title":"Arthroplasty"},{"key":"e_1_2_12_28_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.artd.2023.101196"}],"container-title":["Knee Surgery, Sports Traumatology, Arthroscopy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/ksa.70648","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/ksa.70648","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/ksa.70648","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T16:26:11Z","timestamp":1791908771000},"score":1,"resource":{"primary":{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/10.1002\/ksa.70648"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,13]]},"references-count":27,"alternative-id":["10.1002\/ksa.70648"],"URL":"https:\/\/doi.org\/10.1002\/ksa.70648","archive":["Portico"],"relation":{},"ISSN":["0942-2056","1433-7347"],"issn-type":[{"value":"0942-2056","type":"print"},{"value":"1433-7347","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,13]]},"assertion":[{"value":"2026-08-06","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication 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