The 100 Most Cited Publications on Alignment in Total Knee Arthroplasty: A Bibliometric Analysis Revealing a Paradigm Shift Toward Personalized Alignment Strategies.

Abstract

Alignment strategies in total knee arthroplasty (TKA) have undergone a major conceptual evolution over the past decades, shifting from mechanically driven paradigms toward more personalized approaches. Despite the growing volume of literature, there is currently no comprehensive overview identifying the publications that have most strongly influenced the development and dissemination of alignment concepts in TKA. The aim of this study was to identify and analyse the 100 most-cited publications related to total knee arthroplasty and alignment. A bibliometric analysis was conducted using the Web of Science Core Collection to identify the 100 most-cited articles addressing alignment concepts in TKA. Articles were ranked according to total citation count. Extracted data included publication year, journal, country of origin, study design, level of evidence, and citation density. Bibliometric network analyses were performed to assess international collaborations and keyword co-occurrence, allowing exploration of thematic clusters and temporal trends. The 100 most-cited articles accumulated a total of 17,550 citations, with a mean of 175.5 citations per article. Publications increased markedly from the early 2000s, with a peak around 2017, followed by relative stabilization. Nearly 70% of the articles were published in six major orthopaedic journals. Europe and North America were the predominant contributors, with strong representation from the United States, United Kingdom, and Australia. Thematically, early most cited studies focused primarily on implant survivorship and mechanically driven alignment, whereas more recent publications emphasized functional outcomes, kinematic alignment, and alignment phenotyping. Most studies were based on level III to V evidence. The most-cited literature on TKA alignment reflects a progressive shift from survival-oriented mechanical concepts toward phenotype-based and function-oriented alignment strategies. For clinicians, this evolution supports a move away from a uniform mechanical alignment target and toward routine preoperative consideration of individual knee phenotype when planning TKA. However, as most-cited studies remain at level III to V evidence, these concepts should currently be applied with clinical judgment rather than as definitive standards, pending validation through prospective comparative studies. IV - Bibliometric analysis.