Preservation of the PCL when performing cruciate-retaining TKA: Is the tibial tuberosity a reliable predictor of the PCL footprint location?

  • A. JawharEmail author
  • A. S. Kadavkolan
  • S. Wasnik
  • H. P. Scharf
  • H. RoehlEmail author



Reconstruction of the joint line is crucial in total knee arthroplasty (TKA). A routine height of tibial cut to maintain the natural joint line may compromise the preservation of the PCL. Since the PCL footprint is not accessible prior to tibial osteotomy, it seems beneficial to identify a reliable extraarticular anatomic landmark for predicting the PCL footprint and being visible within standard TKA approach. The fibula head predicts reliably the location of PCL footprint; however, it is not accessible during TKA. The aim of this study now was to analyze whether the tibial tuberosity can serve as a reliable referencing landmark to estimate the PCL footprint height prior to tibial cut.


The first consecutive case series included 216 CR TKA. Standing postoperative lateral view radiographs were utilized to measure the vertical distance between tibial tuberosity and tibial osteotomy plane. In the second case series, 223 knee MRIs were consecutively analyzed to measure the vertical distance between tibial tuberosity and PCL footprint. The probability of partial or total PCL removal was calculated for different vertical distances between tibial tuberosity and tibial cutting surface.


The vertical distance between the tibial tuberosity and tibial cut averaged 24.7 ± 4 mm. The average vertical distance from tibial tuberosity to proximal and to distal PCL footprint was found to be 22 ± 4.4 and 16 ± 4.4 mm, respectively. Five knees were considered at 50 % risk of an entire PCL removal after CR TKA.


Current surgical techniques of tibial preparation may result in partial or total PCL damage. Tibial tuberosity is a useful anatomical landmark to locate the PCL footprint and to predict the probability of its detachment pre-, intra-, and postoperatively. This knowledge might be useful to predict and avoid instability, consecutive pain, and dissatisfaction after TKA related to PCL insufficiency.

Level of evidence



Cruciate-retaining total knee arthroplasty Posterior cruciate ligament Tibial cut Tibial tuberosity 


Conflict of interest

All authors declare that there are no conflicts of interest.


  1. 1.
    Amis AA, Gupte CM, Bull AM, Edwards A (2006) Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 14(3):257–263PubMedCrossRefGoogle Scholar
  2. 2.
    Chaudhary R, Beaupre LA, Johnston DW (2008) Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses a randomized clinical trial. J Bone Joint Surg Am 90(12):2579–2586PubMedCrossRefGoogle Scholar
  3. 3.
    Feyen H, Van Opstal N, Bellemans J (2013) Partial resection of the PCL insertion site during tibial preparation in cruciate-retaining TKA. Knee Surg Sports Traumatol Arthrosc 21(12):2674–2679PubMedCrossRefGoogle Scholar
  4. 4.
    Freeman MA, Pinskerova V (2005) The movement of the normal tibio-femoral joint. J Biomech 38(2):197–208PubMedCrossRefGoogle Scholar
  5. 5.
    Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231PubMedCrossRefGoogle Scholar
  6. 6.
    Greiner P, Magnussen RA, Lustig S, Demey G, Neyret P, Servien E (2011) Computed tomography evaluation of the femoral and tibial attachments of the posterior cruciate ligament in vitro. Knee Surg Sports Traumatol Arthrosc 19(11):1876–1883PubMedCrossRefGoogle Scholar
  7. 7.
    Heesterbeek PJ, Labey L, Wong P, Innocenti B, Wymenga AB (2014) A new spacer-guided, PCL balancing technique for cruciate-retaining total knee replacement. Knee Surg Sports Traumatol Arthrosc 22(3):650–659PubMedCrossRefGoogle Scholar
  8. 8.
    Jacobs WC, Clement DJ, Wymenga AB (2005) Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for treatment of osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev 4:CD004803PubMedGoogle Scholar
  9. 9.
    Jawhar A, Wasnik S, Scharf HP, Roehl H (2014) Fibula head is a useful landmark to predict the location of posterior cruciate ligament footprint prior to total knee arthroplasty. Int Orthop 38(2):267–272PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Kim YH, Choi Y, Kim JS (2009) Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. J Bone Joint Surg Am 91(8):1874–1881PubMedCrossRefGoogle Scholar
  11. 11.
    Matsuzaki T, Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kawakami Y, Ishida K, Oka S, Kuroda R, Kurosaka M (2013) Kinematic factors affecting postoperative knee flexion after cruciate-retaining total knee arthroplasty. Int Orthop 37(5):803–808PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Matziolis G, Mehlhorn S, Schattat N, Diederichs G, Hube R, Perka C, Matziolis D (2012) How much of the PCL is really preserved during the tibial cut? Knee Surg Sports Traumatol Arthrosc 20(6):1083–1086PubMedCrossRefGoogle Scholar
  13. 13.
    Mihalko WM, Creek AT, Mary MN, Williams JL, Komatsu DE (2011) Mechanoreceptors found in a posterior cruciate ligament from a well-functioning total knee arthroplasty retrieval. J Arthroplasty 26(3):504 e509–504 e512CrossRefGoogle Scholar
  14. 14.
    Ochsner JL Jr, McFarland G, Baffes GC, Cook SD (1993) Posterior cruciate ligament avulsion in total knee arthroplasty. Orthop Rev 22(10):1121–1124PubMedGoogle Scholar
  15. 15.
    Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ (1998) Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res 356:39–46PubMedCrossRefGoogle Scholar
  16. 16.
    Shannon FJ, Cronin JJ, Cleary MS, Eustace SJ, O’Byrne JM (2007) The posterior cruciate ligament-preserving total knee replacement: do we ‘preserve’ it? A radiological study. J Bone Joint Surg Br 89(6):766–771PubMedCrossRefGoogle Scholar
  17. 17.
    Takahashi M, Matsubara T, Doi M, Suzuki D, Nagano A (2006) Anatomical study of the femoral and tibial insertions of the anterolateral and posteromedial bundles of human posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14(11):1055–1059PubMedCrossRefGoogle Scholar
  18. 18.
    van den Boom LG, Brouwer RW, van den Akker-Scheek I, Bulstra SK, van Raaij JJ (2009) Retention of the posterior cruciate ligament versus the posterior stabilized design in total knee arthroplasty: a prospective randomized controlled clinical trial. BMC Musculoskelet Disord 10:119PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Van Dommelen BA, Fowler PJ (1989) Anatomy of the posterior cruciate ligament. A review. Am J Sports Med 17(1):24–29PubMedCrossRefGoogle Scholar
  20. 20.
    Waslewski GL, Marson BM, Benjamin JB (1998) Early, incapacitating instability of posterior cruciate ligament-retaining total knee arthroplasty. J Arthroplasty 13(7):763–767PubMedCrossRefGoogle Scholar
  21. 21.
    Yue B, Varadarajan KM, Rubash HE, Li G (2012) In vivo function of posterior cruciate ligament before and after posterior cruciate ligament-retaining total knee arthroplasty. Int Orthop 36(7):1387–1392PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  1. 1.Orthopaedic and Trauma Surgery CenterUniversity Medical Center Mannheim of University HeidelbergMannheimGermany
  2. 2.Department of OrthopaedicsHiranandani Orthopaedic Medical EducationMumbaiIndia

Personalised recommendations