Anterior-stabilized TKA is inferior to posterior-stabilized TKA in terms of postoperative posterior stability and knee flexion in osteoarthritic knees: a prospective randomized controlled trial with bilateral TKA



To determine whether knee stability, range of motion (ROM) and clinical scores differ between anterior-stabilized (AS) and posterior-stabilized (PS) total knee arthroplasty (TKA).


This prospective randomized controlled trial included 34 patients with severe bilateral knee osteoarthritis who underwent bilateral TKA between June 2010 and July 2011 using AS and PS designs of a single-implant system. AS TKA with ultracongruent inserts was performed in one knee and PS TKA with a cam-post mechanism was performed in the other knee in each patient. Clinical and radiological data from a mean follow-up period of 5 years, including ROM, clinical scores, peak knee torque determined by isokinetic test, knee joint laxity determined by Telos stress views, tourniquet time and subjects’ preference were analyzed.


The mean postoperative knee flexion angle did not differ between groups until 1 year. Beginning 2 years postoperatively, the knee flexion angle decreased slightly in the AS group and was smaller than that in the PS group (p = 0.004). The mean Knee Society knee score was higher in the PS group than in the AS group after 2 years. The quadriceps strength did not differ between groups. The mean posterior laxity after TKA was 6–8 mm greater in the AS group than in the PS group. No radiological loosening was observed in either group. More subjects preferred PS knees to AS knees. However, this difference was not significant.


AS primary TKA was inferior to PS TKA in terms of posterior knee stability, postoperative knee flexion and clinical scores after 2 years.

Level of evidence

Therapeutic study, Level 1.

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  1. 1.

    Appy Fedida B, Krief E, Havet E, Massin P, Mertl P (2015) Cruciate-sacrificing total knee arthroplasty and insert design: A radiologic study of sagittal laxity. Orthop Traumatol Surg Res 101:941–945

    Article  Google Scholar 

  2. 2.

    Bae JH, Yoon JR, Sung JH, Shin YS (2018) Posterior-stabilized inserts are preferable to cruciate-substituting ultracongruent inserts due to more favourable kinematics and stability. Knee Surg Sports Traumatol Arthrosc 26:3300–3310

    Article  Google Scholar 

  3. 3.

    Berend KR, Lombardi AV Jr, Adams JB (2013) Which total knee replacement implant should I pick? Correcting the pathology: the role of knee bearing designs. Bone Joint J 95-B:129–132

  4. 4.

    Bignozzi S, Zaffagnini S, Akkawi I, Marko T, Bruni D, Neri MP et al (2014) Three different cruciate-sacrificing TKA designs: minor intraoperative kinematic differences and negligible clinical differences. Knee Surg Sports Traumatol Arthrosc 22:3113–3120

    Article  Google Scholar 

  5. 5.

    Borque KA, Gold JE, Incavo SJ, Patel RM, Ismaily SE, Noble PC (2015) Anteroposterior knee stability during stair descent. J Arthroplasty 30:1068–1072

    Article  Google Scholar 

  6. 6.

    Choi WC, Ryu KJ, Lee S, Seong SC, Lee MC (2013) Painful patellar clunk or crepitation of contemporary knee prostheses. Clin Orthop Relat Res 471:1512–1522

    Article  Google Scholar 

  7. 7.

    Churchill DL, Incavo SJ, Johnson CC, Beynnon BD (2001) The influence of femoral rollback on patellofemoral contact loads in total knee arthroplasty. J Arthroplasty 16:909–918

    CAS  Article  Google Scholar 

  8. 8.

    Daniilidis K, Skwara A, Vieth V, Fuchs-Winkelmann S, Heindel W, Stuckmann V et al (2012) Highly conforming polyethylene inlays reduce the in vivo variability of knee joint kinematics after total knee arthroplasty. Knee 19:260–265

    Article  Google Scholar 

  9. 9.

    Fritzsche H, Beyer F, Postler A, Lutzner J (2018) Different intraoperative kinematics, stability, and range of motion between cruciate-substituting ultracongruent and posterior-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 26:1465–1470

    Article  Google Scholar 

  10. 10.

    Heyse TJ, Becher C, Kron N, Ostermeier S, Hurschler C, Schofer MD et al (2010) Patellofemoral pressure after TKA in vitro: highly conforming vs. posterior stabilized inlays. Arch Orthop Trauma Surg 130:191–196

    Article  Google Scholar 

  11. 11.

    Hofmann AA, Tkach TK, Evanich CJ, Camargo MP (2000) Posterior stabilization in total knee arthroplasty with use of an ultracongruent polyethylene insert. J Arthroplasty 15:576–583

    CAS  Article  Google Scholar 

  12. 12.

    Hozack WJ, Rothman RH, Booth RE Jr, Balderston RA (1989) The patellar clunk syndrome. A complication of posterior stabilized total knee arthroplasty. Clin Orthop Relat Res 1989:203–208

  13. 13.

    Ishii Y, Noguchi H, Takeda M, Kiga H, Toyabe SI (2011) Effect of voluntary soft tissue tension and articular conformity after total knee arthroplasty on in vivo anteroposterior displacement. Knee 18:11–14

    CAS  Article  Google Scholar 

  14. 14.

    Ishii Y, Noguchi H, Takeda M, Sato J, Toyabe S (2014) Anteroposterior translation does not correlate with knee flexion after total knee arthroplasty. Clin Orthop Relat Res 472:704–709

    Article  Google Scholar 

  15. 15.

    Kim TW, Lee SM, Seong SC, Lee S, Jang J, Lee MC (2016) Different intraoperative kinematics with comparable clinical outcomes of ultracongruent and posterior stabilized mobile-bearing total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:3036–3043

    Article  Google Scholar 

  16. 16.

    Ko YB, Jang EC, Park SM, Kim SH, Kwak YH, Lee HJ (2015) No difference in clinical and radiologic outcomes after total knee arthroplasty with a new ultra-congruent mobile bearing system and rotating platform mobile bearing systems after minimum 5-year follow-up. J Arthroplasty 30:379–383

    Article  Google Scholar 

  17. 17.

    Laskin RS, Maruyama Y, Villaneuva M, Bourne R (2000) Deep-dish congruent tibial component use in total knee arthroplasty: a randomized prospective study. Clin Orthop Relat Res 380:36–44

    Article  Google Scholar 

  18. 18.

    Lombardi AV Jr, Mallory TH, Vaughn BK, Krugel R, Honkala TK, Sorscher M et al (1993) Dislocation following primary posterior-stabilized total knee arthroplasty. J Arthroplasty 8:633–639

    Article  Google Scholar 

  19. 19.

    Lombardi AV Jr, Mallory TH, Waterman RA, Eberle RW (1995) Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty. J Arthroplasty 10:643–650

    Article  Google Scholar 

  20. 20.

    Louisia S, Siebold R, Canty J, Bartlett RJ (2005) Assessment of posterior stability in total knee replacement by stress radiographs: prospective comparison of two different types of mobile bearing implants. Knee Surg Sports Traumatol Arthrosc 13:476–482

    CAS  Article  Google Scholar 

  21. 21.

    Lutzner J, Beyer F, Dexel J, Fritzsche H, Lutzner C, Kirschner S (2017) No difference in range of motion between ultracongruent and posterior stabilized design in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 25:3515–3521

    Article  Google Scholar 

  22. 22.

    Lutzner J, Firmbach FP, Lutzner C, Dexel J, Kirschner S (2015) Similar stability and range of motion between cruciate-retaining and cruciate-substituting ultracongruent insert total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23:1638–1643

    Article  Google Scholar 

  23. 23.

    Machhindra MV, Kang JY, Kang YG, Chowdhry M, Kim TK (2015) Functional Outcomes of a New Mobile-Bearing Ultra-Congruent TKA System: Comparison With the Posterior Stabilized System. J Arthroplasty 30:2137–2142

    Article  Google Scholar 

  24. 24.

    Marion B, Huten D, Boyer P, Jeanrot C, Massin P (2014) Medium-term osteolysis with the Wallaby I(R) deep-dished total knee prosthesis. Orthop Traumatol Surg Res 100:403–408

    CAS  Article  Google Scholar 

  25. 25.

    Massin P, Boyer P, Sabourin M (2012) Less femorotibial rotation and AP translation in deep-dished total knee arthroplasty. An intraoperative kinematic study using navigation. Knee Surg Sports Traumatol Arthrosc 20:1714–1719

    Article  Google Scholar 

  26. 26.

    Mazzucchelli L, Deledda D, Rosso F, Ratto N, Bruzzone M, Bonasia DE et al (2016) Cruciate retaining and cruciate substituting ultra-congruent insert. Ann Transl Med 4:2

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Parsley BS, Conditt MA, Bertolusso R, Noble PC (2006) Posterior cruciate ligament substitution is not essential for excellent postoperative outcomes in total knee arthroplasty. J Arthroplasty 21:127–131

    Article  Google Scholar 

  28. 28.

    Peters CL, Mulkey P, Erickson J, Anderson MB, Pelt CE (2014) Comparison of total knee arthroplasty with highly congruent anterior-stabilized bearings versus a cruciate-retaining design. Clin Orthop Relat Res 472:175–180

    Article  Google Scholar 

  29. 29.

    Sathappan SS, Wasserman B, Jaffe WL, Bong M, Walsh M, Di Cesare PE (2006) Midterm results of primary total knee arthroplasty using a dished polyethylene insert with a recessed or resected posterior cruciate ligament. J Arthroplasty 21:1012–1016

    Article  Google Scholar 

  30. 30.

    Siebold R, Louisia S, Canty J, Bartlett RJ (2007) Posterior stability in fixed-bearing versus mobile-bearing total knee replacement: a radiological comparison of two implants. Arch Orthop Trauma Surg 127:97–104

    CAS  Article  Google Scholar 

  31. 31.

    Song EK, Seon JK, Yoon TR, Park SJ, Cho SG, Yim JH (2007) Comparative study of stability after total knee arthroplasties between navigation system and conventional techniques. J Arthroplasty 22:1107–1111

    Article  Google Scholar 

  32. 32.

    Sur YJ, Koh IJ, Park SW, Kim HJ, In Y (2015) Condylar-stabilizing tibial inserts do not restore anteroposterior stability after total knee arthroplasty. J Arthroplasty 30:587–591

    Article  Google Scholar 

  33. 33.

    Tang YH, Wong WK, Wong HL (2014) Patellar clunk syndrome in fixed-bearing posterior-stabilised versus cruciate-substituting prostheses. J Orthop Surg (Hong Kong) 22:80–83

    Article  Google Scholar 

  34. 34.

    Tanikawa H, Tada M, Harato K, Okuma K, Nagura T (2017) Influence of total knee arthroplasty on patellar kinematics and patellofemoral pressure. J Arthroplasty 32:280–285

    Article  Google Scholar 

  35. 35.

    Uvehammer J, Karrholm J, Regner L, Carlsson L, Herberts P (2001) Concave versus posterior-stabilized tibial joint surface in total knee arthroplasty: randomized evaluation of 47 knees. J Arthroplasty 16:25–32

    CAS  Article  Google Scholar 

  36. 36.

    Wajsfisz A, Biau D, Boisrenoult P, Beaufils P (2010) Comparative study of intraoperative knee flexion with three different TKR designs. Orthop Traumatol Surg Res 96:242–248

    CAS  Article  Google Scholar 

  37. 37.

    Yoon JR, Yang JH (2018) Satisfactory short-term results of navigation-assisted gap-balancing total knee arthroplasty using ultracongruent insert. J Arthroplasty 33:723–728

    Article  Google Scholar 

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This work was supported by grants from the Seoul National University Boramae Medical Center (06-2010-8) and the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI18C2396).

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Correspondence to Seung-Baik Kang.

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The research study was approved by the ethical committee at SMG-SNU Boramae Medical Center, Seoul, South Korea.

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Han, HS., Kang, SB. Anterior-stabilized TKA is inferior to posterior-stabilized TKA in terms of postoperative posterior stability and knee flexion in osteoarthritic knees: a prospective randomized controlled trial with bilateral TKA. Knee Surg Sports Traumatol Arthrosc 28, 3217–3225 (2020).

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  • Anterior stabilization
  • Posterior stabilization
  • Sagittal stability
  • Range of motion
  • Total knee arthroplasty