Total Knee Arthroplasty and the Evolution of Coronal Alignment: From Mechanical to Personalized Strategies

Total knee arthroplasty (TKA) remains a cornerstone of orthopedic surgery, with optimal coronal alignment playing a pivotal role in determining both clinical outcomes and implant longevity. Traditionally, mechanical alignment has been regarded as the gold standard. However, the emergence of alternative philosophies—such as kinematic alignment and hybrid techniques—has shifted the focus toward individualized approaches. Recent advancements in robotic and computer-assisted systems have significantly enhanced the precision of implant positioning, allowing surgeons to better replicate native knee biomechanics and improve patient satisfaction. This narrative review examines current alignment philosophies in TKA, including mechanical, kinematic, and hybrid methods. It analyzes each technique’s principles, functionalities, benefits, and limitations while highlighting ongoing debates regarding their clinical application. Special attention is given to the role of technology in enabling more accurate, patient-specific surgical execution. Despite promising developments, challenges remain in standardizing these techniques and validating their long-term efficacy. To ensure a comprehensive evaluation relevant literature was reviewed, focusing on studies that explore alignment strategies, biomechanical outcomes, and the integration of technology in TKA. This review aims to synthesize current evidence, identify gaps in knowledge, and outline directions for future research needed to optimize alignment strategies in modern knee arthroplasty.