The Surgeon’s Role in Relative Success of PCL-Retaining and PCL-Substituting Total Knee Arthroplasty
The orthopedic literature has not shown a universal and replicated difference, outside of flexion, in clinical results between posterior cruciate ligament retention and posterior cruciate ligament substitution in total knee arthroplasty.
This study was performed to compare the restoration of flexion and knee function in a large series of cruciate-retaining and cruciate-substituting total knee arthroplasties (TKRs). In addition, we aimed to study how other variables, such as those unique to each surgeon, may have affected the results.
Patients and Methods
The current study evaluated 8,607 total knee arthroplasties in 5,594 patients performed by six surgeons, each using one of four prosthesis designs (two posterior cruciate ligament retaining, two posterior cruciate ligament substituting). Knees were compared at the level of cruciate-retaining and cruciate-substituting knees, at the level of the four prostheses, and at the level of surgeon-implant combinations. Least squared means scores were obtained through multiple linear regression, analysis of variance, and the maximum likelihood method.
At the level of posterior cruciate ligament treatment, posterior cruciate ligament substitution as a whole showed 3.2° greater flexion than posterior cruciate ligament retention. At the prosthesis level, cruciate-substituting models provided greater flexion and cruciate-retaining models provided higher function scores. In the surgeon-implant combinations, surgeons provided mixed results that often did not reflect findings from other levels; one surgeon's use of a posterior cruciate ligament retaining prosthesis achieved 14.7° greater flexion than the surgeon's use of a corresponding posterior cruciate ligament substituting design.
Posterior cruciate ligament treatment is confounded by other variables, including the operating surgeon. The arthroplasty surgeon should choose a prosthesis based, not only on outside results, but also on personal experience and comfort.
Level of Evidence
- Abdel MP, Morrey ME, Jensen MR, et al. Increased long-term survival of posterior cruciate-retaining versus posterior cruciate-stabilizing total knee replacements. J Bone Joint Surg Am. 2011; 93(22): 2072-2078. CrossRef
- Becker MW, Insall JN, Faris PM. Bilateral total knee arthroplasty: one cruciate retaining and one cruciate substituting. Clin Orthop Relat Res. 1991; 271: 122-124.
- Berend ME, Ritter MA, Meding JB, et al. Tibial component failure mechanisms total knee arthroplasty. Clin Orthop Relat Res. 2004; 428: 26-34. CrossRef
- Callaghan JJ, Liu SS. Posterior cruciate ligament-substituting total knee arthroplasty. In Scott WN[ed.], Surgery of the Knee, 4th ed. Philadelphia: Churchill Livingstone, 2006. 1531–57.
- Diduch DR, Insall JN, Scott WN, et al. Total knee replacement in young active patients: long-term followup and functional outcome. J Bone Joint Surg Am. 1997; 79: 575-582.
- Engh GA. Is long-term survivorship really significantly better with cruciate-retaining total knee implants? Commentary on an article by Abdel MP et al.: “Increased Long-Term Survival of Posterior Cruciate-Retaining Versus Posterior Cruciate-Stabilizing Total Knee Replacements”. J Bone Joint Surg (Am) 2011; 93(22): e136 1–2.
- Faris PM, Keating EM, Farris A, et al. Hybrid total knee arthroplasty: 13-year survivorship of AGC total knee systems with average 7 years followup. Clin Orthop Relat Res. 2008; 466(5): 1204-1209. CrossRef
- Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res. 1997; 345: 79-86.
- Insall JN, Dorr LD, Scott RD, et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989; 248: 13-14.
- Jacobs WC, Clement DJ, Wymenga AB. Retention versus removal of the posterior cruciate ligament in total knee replacement: a systematic literature review within the Cochrane framework. Acta Orthop. 2005; 76(6): 757-768. CrossRef
- Kelly MA, Clarke HD. Long-term results of posterior cruciate-substituting total knee arthroplasty. Clin Orthop Relat Res. 2002; 404: 51-57. CrossRef
- Rand JA, Trousdale RT, Ilstrup DM, et al. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am. 2003; 85(2): 259-265.
- Rasquinha VJ, Ranawat CS, Cervieri CL, et al. The Press-Fit Condylar modular total knee system with a posterior cruciate-substituting design. J Bone Joint Surg Am. 2006; 88(5): 1006-1010. CrossRef
- Ritter MA. The Anatomical Graduated Component total knee replacement: a long-term evaluation with 20-year survival analysis. J Bone Joint Surg (Br). 2009; 91-B(6): 745-749. CrossRef
- Ritter MA, Davis KE, Davis P, et al. Preoperative malalignment increases risk of failure after total knee arthroplasty. J Bone Joint Surg Am. 2013; 95(2): 126-131. CrossRef
- Ritter MA, Davis KE, Meding JB, et al. The role of the posterior cruciate ligament in total knee replacement. Bone Joint Res. 2012; 1: 64-70. CrossRef
- Ritter MA, Davis KE, Meding JB, et al. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am. 2011; 93(17): 1588-1596. CrossRef
- Robinson RP. The early innovators of today’s resurfacing condylar knees. J Arthroplasty. 2005; 20(Suppl 1): 2-26. CrossRef
- Rosenberg AG, Knapke DM. Posterior cruciate-retaining total knee arthroplasty. In: Scott WN, ed. Surgery of the Knee. 4th ed. Philadelphia: Churchill Livingstone; 2006: 1522-1530.
- Trousdale RT, Pagnano MW. Fixed-bearing cruciate-retaining total knee arthroplasty. Clin Orthop Relat Res. 2002; 404: 58-61. CrossRef
- Vessely MB, Whaley AL, Harmsen WS, et al. The Chitranjan Ranawat Award: long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res. 2006; 452: 28-34. CrossRef
- The Surgeon’s Role in Relative Success of PCL-Retaining and PCL-Substituting Total Knee Arthroplasty
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HSS Journal ®
Volume 10, Issue 2 , pp 107-115
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- posterior cruciate ligament retention
- posterior cruciate ligament substitution
- total knee arthroplasty
- surgeon effect
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