Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

It was my pleasure to assess this clear, up-to-date, and clinically useful overview of MA, AA, KA, rKA, iKA, aMA, and FA. The narrative balances historical context with present-day robotic enablement and appropriately calls for nomenclature standardization in FA.

Standardize usage for terms and abbreviations at first mention: LDFA, MPTA, HKA, PCA, CPAK, FA, and ensure consistent dash style in hip–knee–ankle (HKA) across text and captions.

Correct minor issues such as “polyethelene” → “polyethylene”, “longevty” → “longevity”, “philosphopy” → “philosophy”, “are also remains” → “also remains”, and the extra parenthesis in “iKA concept)”. These appear sporadically in Sections 3–4 and the Future Directions figure text.

Where you list rKA/iKA boundaries, consider one concise table summarizing each philosophy, coronal/sagittal targets/boundaries, tools (conventional, navigation, robotic), and anticipated soft-tissue strategy. This would complement Figures 5–7 and aid quick comparison.

Author Response

It was my pleasure to assess this clear, up-to-date, and clinically useful overview of MA, AA, KA, rKA, iKA, aMA, and FA. The narrative balances historical context with present-day robotic enablement and appropriately calls for nomenclature standardization in FA.

Standardize usage for terms and abbreviations at first mention: LDFA, MPTA, HKA, PCA, CPAK, FA, and ensure consistent dash style in hip–knee–ankle (HKA) across text and captions.

Thank you for your insightful comments, we have gone through the manuscript again and clarified the abbreviations

Correct minor issues such as “polyethelene” → “polyethylene”, “longevty” → “longevity”, “philosphopy” → “philosophy”, “are also remains” → “also remains”, and the extra parenthesis in “iKA concept)”. These appear sporadically in Sections 3–4 and the Future Directions figure text.

Thank you for the comments, the errors have been corrected.

Where you list rKA/iKA boundaries, consider one concise table summarizing each philosophy, coronal/sagittal targets/boundaries, tools (conventional, navigation, robotic), and anticipated soft-tissue strategy. This would complement Figures 5–7 and aid quick comparison.

We appreciate your criticism, we have contructed two tables summarising each philosophy. We would like to welcome any comments which would make the table more informative.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a timely and relevant review on the evolving paradigm of alignment strategies in total knee arthroplasty (TKA). The topic is of significant clinical interest, addressing a well-known problem (patient dissatisfaction) and surveying modern solutions. The structure is logical, and the writing is generally clear. However, the review in its current form is more of a concise summary or "current concepts" outline than a substantive, critical review. It lacks depth, methodological rigor in its review process, and sufficient critical analysis of the evidence it cites. Significant revisions are required to elevate it to the standard of a publishable review article.

1. The introduction section should build on the evidence gaps clearly and should end with clearly stating the aims and objectives for undertaking this study.
2. The current review looks narrative. But, in the methods, it is critical to state how were the literature search carried out for each elements and how was the completeness of literature ensured? This is very important so that the views and expressions stated by the authors are valid and less prone for errors.
3. Is 'Philosophies' an appropriate term or should it be 'principles'? 
4. Please try to incorporate some tables where ever possible.
5. Critically assess each study that you have considered including and provide strengths of evidence for all the included studies so that the readers could identify the significance for their practice.
6. The way forward section is nice but it lacks appropriate citations. Consider doing the same.
7. Please explicitly state the limitations and how they can be addressed in future studies.

Author Response

This manuscript presents a timely and relevant review on the evolving paradigm of alignment strategies in total knee arthroplasty (TKA). The topic is of significant clinical interest, addressing a well-known problem (patient dissatisfaction) and surveying modern solutions. The structure is logical, and the writing is generally clear. However, the review in its current form is more of a concise summary or "current concepts" outline than a substantive, critical review. It lacks depth, methodological rigor in its review process, and sufficient critical analysis of the evidence it cites. Significant revisions are required to elevate it to the standard of a publishable review article.

1. The introduction section should build on the evidence gaps clearly and should end with clearly stating the aims and objectives for undertaking this study.

Thank you for the constructive comments, the introduction has been modified, and the aim of the review is now more evidently discussed.

2. The current review looks narrative. But, in the methods, it is critical to state how were the literature search carried out for each elements and how was the completeness of literature ensured? This is very important so that the views and expressions stated by the authors are valid and less prone for errors.

We thank the reviewer for this important comment and agree that greater methodological clarity is required. This manuscript was designed as a structured narrative review rather than a formal systematic review.

In response, we have revised the Methods section to clarify the literature identification approach for each alignment philosophy and have added an explicit statement in the Limitations section acknowledging the inherent constraints of a narrative review.

3. Is 'Philosophies' an appropriate term or should it be 'principles'? 

We appreciate the reviewer’s thoughtful comment. The phrase philosophy was intentionally used as the approaches described extend beyond fixed technical rules or prescriptive steps. Each description of an alignment strategy represents a broader conceptual framework that considers native anatomy, load distribution and soft tissue behaviour. Consequently, these frameworks allow for variability in execution, depending on the initial deformity and intraoperative feedback from surgical “feel” or enabling technologies.

The term “principles” we feel implies a more rigid and systematically applicable set of rules, which neglects the heterogeneity, adaptability and evolution of these strategies.

For clarity, we have ensured that within each section, the key priciples and boundaries underpinning each philosophy are explicitly defined.

4. Please try to incorporate some tables where ever possible.

As requested a table summarising the academic evidences for each philosophy and the general surgical principles has been incorporated to the manuscript. We would like to welcome any comments which would make the table more informative.

5. Critically assess each study that you have considered including and provide strengths of evidence for all the included studies so that the readers could identify the significance for their practice.

Thank you for the comment. The description of the studies included has been expanded to include strengths of evidence and critical analysis of the studies.

6. The way forward section is nice but it lacks appropriate citations. Consider doing the same.

References for the statements in the Future Directions section has been included. Thank you for pointing this out.

7. Please explicitly state the limitations and how they can be addressed in future studies.

A section discussing the limitations of our review has been included, to make readers aware of the possible biases of the review, the knowledge gaps which needs to be filled in the future and the differences in data from different philosophies.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the revision.