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Bicruciate-Retaining Total Knee Arthroplasty: A Review Jeffrey J. Cherian, DO1 Bhaveen H. Kapadia, MD1 Samik Banerjee, MS (Orth), MRCS (Glasg)1 Julio J. Jauregui, MD1 Steven F. Harwin, MD2 Michael A. Mont, MD1 1 Center for Joint Preservation and Replacement, Rubin Institute for
Advanced Orthopedics, Baltimore, Maryland 2 Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York
Address for correspondence Michael A. Mont, MD, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD 21215 (e-mail: [email protected]).
Abstract
Keywords
► bicruciate retaining ► total knee arthroplasty ► ACL-sparing
Total knee arthroplasty (TKA) has been shown to have excellent long-term outcomes and survivorship in numerous studies, however, with changes in patient demographics, questions have arisen about the use of conventional arthroplasties and their functionality in highly active, young patients. The recent interest in bicruciate-retaining prostheses is aimed to address the need for an implant that can mimic a natural knee during high activity levels. Although there are currently few of these prostheses which are being utilized, results from prior studies have demonstrated similar results to that of anterior cruciate ligament–sacrificing TKA in terms of function and survivorship. In this review, we will describe the history, kinematics, clinical outcomes, concerns, and future outlook of bicruciate-retaining arthroplasty.
The majority of total knee arthroplasties (TKAs) are performed in the elderly population, however, as the indication and population demographics continue to change, younger patients are undergoing this procedure.1 In conjunction with this demographic shift, numerous reports have demonstrated that approximately 20% of patients who undergo these procedures are unsatisfied.2 One large series published in 2000 by Robertson et al using a questionnaire asking, “How satisfied are you with your knee replacement.” They found that 17% of 25,275 unrevised patients were either dissatisfied or uncertain regarding their satisfaction, with this number rising to 41% for revision cases.3,4 In addition, patients may potentially have suboptimal functional outcomes after TKA, with a recent study by Clement et al reported that less than 25% of patients were satisfied with their ability to squat or kneel.5 This dissatisfaction may potentially be explained by the abnormal kinematics affecting the muscle movement arms and proprioceptive instability when sacrificing the anterior cruciate ligament (ACL) during TKA.
Therefore, surgeons are aiming to develop prostheses that can allow patients to have a more natural knee feeling, improve return to high activity levels, and allow for better satisfaction. It has been theorized that retention of the ACL may generate superior knee mechanics and proprioception, thus leading to improved patient function, particularly by improving maximum knee flexion movements. In addition, bicruciate-retaining TKA theoretically has the potential of improved implant longevity, by lessening the stress transmitted through the prosthesis by using a less constrained polyethylene tibial component. However, due to multiple reasons including the technical difficulty of obtaining good visualization with both cruciates intact, questionable evidence of the ACL benefit in TKA, and the unpredictably of tensioning of retained ligaments, this prosthesis design has not gained widespread popularity. In addition, surgeons have questioned its use due to the potential inability to correct the deformity of the knee, as well as the future potential for instability from ligament failure. This
received February 19, 2014 accepted March 16, 2014 published online April 24, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1374812. ISSN 1538-8506.
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report summarizes the recent evidence concerning bicruciate-retaining TKA. We will specifically focus on the following: (1) Historical contents; (2) Kinematics; (3) Outcomes; (4) Concerns; and (5) The future outlook of these prostheses.
History The bicruciate-retaining knee prosthesis was originally designed to allow for more physiological movement of the knee. Bicruciate-retaining TKA was originally developed in the mid1960s by Gunston, who developed the polycentric knee (Winnipeg, Canada).6 This design was constructed using two semicircular runners for the femoral condyles which articulated with two separate tibial components fixed with acrylic cement. In the mid-1970s, the development of another anterior cruciate-retaining design, the geometric knee prosthesis occurred at the Mayo Clinic.7 This prosthesis differed from the original prosthesis being composed of a single femoral component. These earlier designs were followed by numerous ACLsparing prostheses including the following: UCI Knee, Leeds Knee, Ewald Knee, Kodama-Yamamoto Mark I, Duopatella Knee (DePuy Orthopaedics, Warsaw, IN), LCS Bicruciate Knee (DePuy Orthopaedics, Warsaw IN), Geomedic, and Anametric Knee.2 However, these implants ultimately fell out of favor due to clinical successes seen with ACL-sacrificing prostheses.8 In 1972, Townley created the anatomic total knee (Port Huron, Michigan), which is one of the first modern ACLsparing prosthetic designs. This prosthesis was designed to minimize bone and ligamentous resection, and aimed to resurface the joint allowing for the anatomical motion of the knee.9 The femoral implant was bilobed, horseshoe shaped, and made as thin as possible to allow for retention of all ligaments.9 Similarly, in 1975, Cloutier designed a nonconstrained total anatomic resurfacing prosthesis at St. Luc Hospital in Montreal after positive results seen with compartmental prostheses.10–12 These prostheses were two-part, unlinked, metal-on plastic implants, with chromium–cobalt femoral components which replaced the articular surface. The patellar flange geometry replicated the normal anatomy, and the asymmetrical femoral condyles were divergent with their radii of curvature in the sagittal plane decreasing posteriorly. The tibial component consisted of two nearly flat articular surfaces composed of carbon-reinforced polyethylene placed into a U-shaped chromium cobalt alloy retainer.
Kinematics of Bicruciate-Retaining Knee Prostheses It is believed that the cruciate ligaments play a pivotal role in normal knee function and kinematics. Since the advent of TKA, controversies have surrounded the influence of the cruciate ligaments, however, a majority of the discussion has been solely on the posterior cruciate ligament (PCL).8 It is surprising that much of the debate has been centered around the PCL, because the ACL is believed to play a more The Journal of Knee Surgery
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crucial role in normal knee kinematics than the PCL. Despite this belief, the ACL is routinely resected during TKA. The ACL is the predominant restraint to anterior tibial displacement. When the knee is placed in extension, the posterolateral bundle of the ACL in under tension, and the anteromedial bundle of the ACL is tight in flexion.13 The ACL accepts 75% of anterior force at full extension and approximately 85% at 30 and 90 degrees of flexion. In normal knee kinematics, ACL is taut in full knee extension, and tends to externally rotate the tibia; then as the knee moves from a flexed position to extension, the shorter, more highly convex lateral femoral condyle finishes its articular surface and is resisted by the ACL. The larger and less curved medial condyle continues its forward roll and slides backward and is assisted by tightening of the PCL. Toward full extension, there is lateral rotation of the tibia and joint in relation to the femur, which is termed the “screw home” mechanism.14 As the knee flexes, the femoral condyle rolls posteriorly (roll back), and due to the different condyle sizes the tibia is internally rotated.15 This posterior movement increases the motion arm of the quadriceps muscle, and causes medialization of the tibial tubercle through greater external rotation, which ultimately aids in proper patellar tracking.16 ACL sacrificing PCL-retaining TKAs (cruciate retaining) has been shown to behave similar to an ACL-deficient knee, where there is paradoxical motion.17,18 Normally, the tibia translates posteriorly and the femur subluxes anteriorly; however, this motion is reversed without the ACL and potentially results in posterior femoral impingement leading to limitations in deep flexion. This can be prevented by releasing the PCL or undersizing the femoral component, however, this can result in flexion instability, pain, and joint swelling. In bicruciate-sacrificing (posterior-stabilizing) TKAs, a cam-post mechanism is used to mimic the function of the PCL, and similar to cruciate-retaining prostheses, the ACL is deficient, which results in anterior subluxation of the tibia. One potential consequence of this mechanism is when the tibia is brought into extension it creates an impingement of the anterior cam on the posterior-stabilizing box.19 This may ultimately lead to excessive wear of the anterior post, and possible failure.20 In addition, this prosthesis limits anterior translation of the femur. These altered mechanics after TKA can result in abnormal quadriceps muscle movement arms, diminishing their mechanism. Furthermore, in both types of ACL-sacrificing prostheses, there is a loss of tibial rotation control during knee flexion, which can result in lateral patellar tilt and subluxation from excess external rotation.21 Numerous studies support the notion that preservation of both cruciate ligaments in TKA preserves more normal knee kinematics.22–28 A study by Stiehl et al examined the kinematics of bicruciate TKA to a posterior cruciate-retaining prosthesis using in vivo weight-bearing fluoroscopy.23 The authors reported that PCL-retaining TKAs medial and lateral contact points were significantly posterior at 0 degrees (p < 0.01, p < 0.001, respectively), and at 60 degrees of flexion the lateral femoral condyle was significantly posterior (p < 0.05) compared with the bicruciate design. The authors stated that this posterior contact point in extension and
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anterior translation in deep flexion could potentially lead to increased posterior wear of the prosthesis. Similarly, Morooka et al analyzed the in vivo kinematics (treadmill gait, stair stepping, and maximum flexion activities) using dynamic fluoroscopy and shape matching in bicruciate retaining compared with posterior cruciate-retaining TKA.24 The authors noted that both condyles in the bicruciate-retaining TKA demonstrated significantly greater posterior translation in the stance and swing phases of gait than in the posterior cruciate–retaining prosthesis (p < 0.05). Furthermore, the authors reported that with maximum flexion activities (6 mm more) and stair stepping from 30 to 70 degrees there were significantly more posterior translation of the lateral condyle bicruciate prosthesis when compared with the cruciate-retaining knees (p < 0.05). In addition to the abnormal kinematics seen with resection of ACL in TKA, reports have purported that its removal adds to abnormal proprioception.17 Reports have shown that ACL and capsular mechanoreceptors respond mostly when the knee is place in terminal extension where these receptors have the greatest proprioception sensitivity.29 A study by Jerosch et al evaluated proprioceptive capabilities of the knee joint with balance testing in 8 conservatively treated patients, 12 surgically treated patients with ACL-deficient knee joints, and 12 healthy control patients.30 The authors demonstrated that healthy patients had higher proprioceptive capabilities compared with ACL-deficient knees, and with those who underwent ACL reconstruction. Moreover, Fuchs et al31 evaluated the proprioception in 15 patients who underwent bicondylar Sledge Prosthesis (Endo, Link, Hamburg, Germany) which retains both cruciate ligaments, compared with their contralateral native knee, as well as healthy individuals. Through sway measurements during single-leg stance on a force platform, the authors demonstrated that there were no significant differences in balance measurements between the patients who received bicondylar prostheses and their contralateral leg, as well as the healthy individuals. These findings help support the theory that the ACL plays a crucial role in knee stability and proprioception.
Clinical Outcomes In 1979, Cracchiolo et al analyzed the first generation bicruciate-retaining TKAs (119 polycentric and 92 geometric), and found that at a mean follow-up of 3.5 years (range, 2–6 years), failure occurred in 11 and 16% of the polycentric and geometric knees, respectively.7 Despite their less than optimal failure rates, these two prostheses were reported to provide excellent pain relief. Townley examined the long-term results in 426 patients who underwent cemented anatomic TKA.9 They reported that the overall 11-year result in relation to pain relief, motion, and level of activity were excellent or good in 89%, fair in 7%, and poor of failed in 4% of patients. Patients were considered to have excellent outcomes if their motion was greater than 90 degrees, and pain and activity restriction was mild or none. Buechel and Pappas evaluated the long-term survivorship of their low-contact-stress, mobile-bearing knee prosthesis
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system.32 Their system consisted of the same femoral and patellar components with bicruciate-retaining meniscal bearing (n ¼ 46), posterior-cruciate meniscal bearing (n ¼ 57), or a cruciate sacrificing, rotating-platform tibial component (n ¼ 108). At 6- and 12-year follow-up the authors reported that overall survivorship for bicruciate prostheses was 100 and 90.9%, respectively. In comparison, the 6-year survivorship of the posterior cruciate-retaining prosthesis was 97.9%, and the 10-year rate for rotating-platform design was 97.5%. The authors stated that this study indicated the predictable long-term survivorship of these bicruciate-retaining prostheses. Since Cloutier’s development of a bicruciate-retaining TKA in the 1970s, there have been numerous reports on this type of prostheses. The authors have published two reports on a series of 130 patients (163 knees) who received bicruciateretaining prosthesis (Hermes 2C total knees arthroplasty; Ceraver-Osteal, Roissy, France) between 1986 and 1988. Patients in this series were noted to undergo bicruciateretaining prosthesis despite ACL degeneration. The authors used functional diagnosis by normal anterior drawer as the inclusion criteria. In their first report in 1999, which evaluated the 9- to 11-year survivorship, the authors found that in 104 of the 107 patients available for follow-up had good-toexcellent results.12 They noted that 91% of patient had adequate pain relief, a mean range of motion of 107 degrees, 89% had normal anteroposterior translation, 90% had normal mediolateral stability, the mean Knee Score was 91 points (range, 54–100 points), the mean functional score was 82 points (range, 10–100 points), and the survivorship (with revision as an end point) rate was 95%. A recent 22-year follow-up of these patient by Sabouret et al33 found that the overall survivorship rate with revision as an end point was 82%. After revision, lost to follow-up, and death, a total of 32 knees were available from the initial cohort. The authors reported that the mean flexion achieved was 103 degrees (range, 80–120 degrees), mean American Knee Society Knee and functional scores were 87 points (range, 27–100 points) and 68 points (range, 0–100 points), respectively. In addition, patients were noted to have mean mediolateral laxity of 0.14 degree (range, 0–4 degrees), and mean anteroposterior translation of 1.03 mm (range, 0–7 mm). The authors concluded that even when the ACL was not perfect at the time of index arthroplasty, good clinical results could be demonstrated in bicruciate-retaining prostheses at greater than 20-year follow-up. In 1996 and 2011 Pritchett examined patient preference of knee in a series of patients who underwent staged-bilateral TKA using different prostheses on each side.34,35 The first series consisted of 50 patients who received a bicruciate prosthesis on one knee type and a posterior cruciate retaining on the other. The authors noted that 70% of patients stated that the bicruciate-retaining TKA was their preferred knee. In the author’s more recent study, they evaluated 440 patients who received either bicruciate-retaining, posterior cruciateretaining, medial pivot, posterior-stabilizing, or mobile bearing TKA in one knee and another prosthesis in the other. At 2year evaluation, he reported that 89.1% of patients preferred The Journal of Knee Surgery
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their bicruciate retaining TKA to their posterior-stabilizing TKA. He concluded that patients might obtain a better subjective “feel” from bicruciate-retaining TKA. However, not all studies have shown such positive results.8,36 A prospective study by Jenny and Jenny8 evaluated
the short-term outcomes of 32 ACL-retaining compared with 93 ACL-sacrificing TKAs at 2- to 3-year follow-up. The authors found that the Knee Society scores were not significantly different in the ACL-sparing cohort than the ACL-sacrificing cohort, 89 versus 90 points, respectively. Similarly, they were
Table 1 Outcomes of bicruciate-retaining prostheses Study, year
Number of knees
Implant design
Mean follow-up (y)
Brief summary of results
Cracchiolo et al, 19797
211
Polycentric and geometric
3.5
In these early prostheses, failure occurred in 11 and 16% of the polycentric and geometric knees, respectively
Townley, 19859
426
Anatomic total knee
11
The author found excellent or good outcomes in 89%, fair in 7%, and poor of failed in 4% of patients
Buechel and Pappas, 199030
46
Low-contact-stress, mobile-bearing knee prosthesis
6
The overall survivorship for bicruciate prosthesis was 100%, and the PCLretaining prosthesis was 97.9%
Cloutier et al, 199912
104
Hermes 2C total knees arthroplasty
10
The survivorship (with revision as an end point) rate was 95%
Sabouret et al, 201333
32
Hermes 2C total knees arthroplasty
22
The overall survivorship rate with revision as an end point was 82%, after long-term follow-up
Pritchett, 199634
50
Biopro Total Knee Prosthesis
Minimum of 5
70% of patients stated that the bicruciate-retaining TKA was their preferred knee
Pritchett, 201135
201
Biopro Total Knee Prosthesis and Wright Medical ACL-PCL retaining
2
89.1% of patients preferred their bicruciateretaining to posteriorstabilizing TKA
Jenny and Jenny, 19988
93
Search Total Knee prosthesis (Aesculap, Germany)
3
Knee Society scores, postoperative flexion angle, functional scores, and radiographic outcomes were not significantly different in the ACL-sparing cohort than the ACL-sacrificing cohort
Migaud et al, 199637
38
Cloutier Prosthesis
5.5
No statistical differences in range of motion, HSS knee scores, and function between the two prostheses cohorts; however, posterior tibial slope was the only significant factor influencing the anterior tibial translation
Abbreviations: ACL, anterior cruciate ligament; HSS, Hospital for Special Surgery score; PCL, posterior cruciate ligament; TKA, total knee arthroplasty. The Journal of Knee Surgery
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Concerns with Bicruciate-Retaining Designs, Technique, and ACL Viability Design There have been several concerns over the years with bicruciate-retaining TKA designs, as well as with the surgical technique in which it is performed. Tibial component fixation has been one of the major concerns of bicruciate-retaining prostheses because of the limited contact surface available for implant stability with the retention of both cruciate ligaments. When the ACL is retained, this results in an inability of central standard stabilization, and thus must be supported by smaller fins or pegs, which may expose the implant to fixation failure. Similarly, another challenge with the tibial component was the threat of fracture of the tibial bar (bridge connecting the two tibial plateaus). This bar could be placed under severe stress causing it to break, however, to correct this problem, the implant would have had to be made thicker, potentially endangering the valuable bone or may even cause disruption of the ACL. In addition, developers and surgeons are faced with the difficultly of the differences in tibial plateau’s slope and restoration of the natural 3 degree varus slope of the joint line. Surgeons may have difficulty in reproducing natural knee anatomy and joint kinematics.
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Technique Similar to design problems, there are several surgical technique challenges that present themselves when performing bicruciate-retaining TKA. One of the major challenges is the difficult exposure when the ACL remains intact. The retention of both cruciate ligaments and their insertion on the tibial eminence is technically more demanding, which could lead to poorer quality of implantation.8 In addition, Bellemans38 stated that mediolateral positioning of the tibial component must be handled with care to avoid component overhang; joint line restoration to ensure optimal ACL and PCL functionality and knee kinematics; and surgeons must avoid impingement of the femoral component on the central bone block. In addition, Amiri and Wilson stressed the importance of ligamentous balancing, and consequences of abnormal tensioning in bicruciate-retaining prostheses.39
Anterior Cruciate Ligament Viability A study by Johnson et al evaluated 200 patients for ACL integrity at the time of TKA.40 All patient underwent Lachman tests under anesthesia, ACL characterization intraoperatively as intact, frayed, disrupted, or absent, and 100 patients had magnetic resonance imaging (MRI) scans to evaluate ACL integrity. The authors demonstrated 78% of patients (n ¼ 155) had intact ACLs intraoperatively, whereas, on MRI scan 69% were graded as intact, 14% were indeterminate, and 17% were ruptured. A study by Cushner et al41 found that only 26% of ACLs were still intact in osteoarthritic patients who had a mean age of 63 years, while another 26% of patients had slight degeneration of the ACL. Their findings were similar to pathologic findings noted in the PCL at the time of TKA. However, Sabouret et al33 found that a partially degenerated ACL can remain functional even after 22-year follow-up in bicruciate-retaining TKA. In addition, they noted that patients might do well with these prostheses even if they have a degeneration of the ligament, as long as there is a negative anterior drawer test at the time of index surgery. Refer to ►Table 2 for summary of concerns surrounding bicruciate-retaining TKA.
Future Outlook At this time, we are uncertain whether bicruciate-retaining TKA will become the current standard of care, however, they are clearly an attractive option for development based on the well-documented shortcomings of cruciate-retaining and posterior-stabilizing prostheses. With the numerous recent reports demonstrated excellent outcomes with unicompartmental arthroplasty, the use of bicompartmental knee arthroplasty has made a reemergence. The use of bicompartmental prostheses must be the solution to the current ACL-sacrificing prostheses by allowing retention of both cruciate ligaments without the complications seen with the tibial bar prior bicruciate-retaining designs. Furthermore, as researchers, surgeons, and developers study the natural kinematic and function of the knee and promote the introduction of new designs and surgical techniques, the use of
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unable to demonstrate any statistical differences in flexion angle (102 vs. 101 degrees), functional scores (80 vs. 79 points), and radiographic outcomes between patient who received ACL-sparing compared with the ACL-sacrificing prosthesis. They concluded that there was no advantage in retaining the ACL in TKA according to the short and midterm seen with the posterior cruciate-retaining prosthesis. In addition, Migaud et al evaluated the influence of posterior tibial slope and ACL sparing on anterior tibial translation in 68 Cloutier total knee prostheses (38 ACL sparing; 30 ACL sacrificing) after a mean follow-up period of 5.5 years (range, 2–15 years).37 The authors were unable to demonstrate statistical differences in range of motion, HSS knee scores, and function between the two prostheses cohorts. However, they demonstrated that the posterior tibial slope (mean, 6.2 degrees) was the only significant factor influencing the anterior tibial translation (mean, 3.9 mm) (p ¼ 0.0007). They reported that a 10 degree increase in the posterior tibial slope would result in a rise of anterior tibial translation by 5.6 mm during weight bearing. When the ACL was preserved, the anterior tibial translation was lower, but not significant. The authors concluded the posterior tibial slope had a higher impact than ACL-sparing on anterior tibial translation. Controversy surround ACL preservation in TKA is still a topic of discussion, with some studies demonstrating superiority with ACL-retaining prostheses, while others showing no difference with cruciate-sacrificing designs. However, given the positive results seen in some of these studies, we believe that with improved designs and techniques, ACL-sparing prostheses may make a reemergence in the future. Refer to ►Table 1 for a brief summary of outcomes of bicruciateretaining TKA.
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Table 2 Concerns surrounding bicruciate-retaining prostheses Design • • • •
Tibial component fixation with limited contact surface available after retention of cruciate ligaments Thicker components can endanger valuable bone-stock or even cause disruption of the ACL Variation in differences between tibial plateau’s slope Implant designed to replicate the natural 3 degrees varus slope of the joint line
Technique • • • • •
Difficult exposure to the joint when the ACL remains intact Careful three-dimensional positioning of the tibial component to avoid component overhang Appropriate ligamentous balancing to avoid abnormal tensioning of cruciate ligaments Joint line restoration to ensure optimal ACL and PCL functionality and knee kinematics Potential for femoral component impingement on remaining central bone block
ACL viability • Numerous studies have demonstrated that there is degeneration of the ACL in a majority of patients who are undergoing TKA • If functionally present with anterior drawer testing, studies have demonstrated good long-term outcomes
Abbreviations: ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; TKA, total knee arthroplasty.
current posterior cruciate-retaining or posterior-stabilizing arthroplasties may potentially lose popularity.
Conclusion
5 Clement ND, Macdonald D, Patton JT, Burnett R. Post-operative
6
As the population in which TKA is being performed changes, questions have arisen about the use of posterior-stabilizing and posterior cruciate-retaining arthroplasty and their functionality in highly active, young patients. The recent development of bicruciate-retaining prostheses is aimed at addressing the need for an implant that can mimic a natural knee during high activity levels. Currently, the use of bicruciate-retaining knee arthroplasty has fallen out of favor due to concerns with prosthesis design and fixation, as well as the potentially difficult surgical technique. However, the results from some prior studies have demonstrated similar results to that of ACL-sacrificing TKA in terms of function and survivorship outcomes. Furthermore, developments of these designs and techniques may lead to an increase in usage in the future.
7
8
9 10 11 12
13
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knee-extension exercise. Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am 1984;66(5):725–734 Puloski SK, McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB. Tibial post wear in posterior stabilized total knee arthroplasty. An unrecognized source of polyethylene debris. J Bone Joint Surg Am 2001;83-A(3):390–397 Li G, Papannagari R, Most E, et al. Anterior tibial post impingement in a posterior stabilized total knee arthroplasty. J Orthop Res 2005; 23(3):536–541 Lee KY, Slavinsky JP, Ries MD, Blumenkrantz G, Majumdar S. Magnetic resonance imaging of in vivo kinematics after total knee arthroplasty. J Magn Reson Imaging 2005;21(2):172–178 Stiehl JB, Dennis DA, Komistek RD, Keblish PA. In vivo kinematic comparison of posterior cruciate ligament retention or sacrifice with a mobile bearing total knee arthroplasty. Am J Knee Surg 2000;13(1):13–18 Stiehl JB, Komistek RD, Cloutier JM, Dennis DA. The cruciate ligaments in total knee arthroplasty: a kinematic analysis of 2 total knee arthroplasties. J Arthroplasty 2000;15(5):545–550 Moro-oka TA, Muenchinger M, Canciani JP, Banks SA. Comparing in vivo kinematics of anterior cruciate-retaining and posterior cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2007;15(1):93–99 Banks SA, Markovich GD, Hodge WA. In vivo kinematics of cruciate-retaining and -substituting knee arthroplasties. J Arthroplasty 1997;12(3):297–304 Komistek RD, Allain J, Anderson DT, Dennis DA, Goutallier D. In vivo kinematics for subjects with and without an anterior cruciate ligament. Clin Orthop Relat Res 2002;(404):315–325 Andriacchi TP, Stanwyck TS, Galante JO. Knee biomechanics and total knee replacement. J Arthroplasty 1986;1(3):211–219 Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br 2002;84(1):50–53 Hogervorst T, Brand RA. Mechanoreceptors in joint function. J Bone Joint Surg Am 1998;80(9):1365–1378
surgically and conservatively treated knee joints with injuries of the cruciate ligament [in German]. Unfallchirurg 1998;101(1): 26–31 Fuchs S, Tibesku CO, Genkinger M, Laass H, Rosenbaum D. Proprioception with bicondylar sledge prostheses retaining cruciate ligaments. Clin Orthop Relat Res 2003;(406):148–154 Buechel FF, Pappas MJ. Long-term survivorship analysis of cruciate-sparing versus cruciate-sacrificing knee prostheses using meniscal bearings. Clin Orthop Relat Res 1990;(260):162–169 Sabouret P, Lavoie F, Cloutier JM. Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study. Bone Joint J 2013;95-B(7):917–922 Pritchett JW. Anterior cruciate-retaining total knee arthroplasty. J Arthroplasty 1996;11(2):194–197 Pritchett JW. Patients prefer a bicruciate-retaining or the medial pivot total knee prosthesis. J Arthroplasty 2011;26(2):224–228 Goutallier D, Manicom O, Van Driessche S. Total knee arthroplasty with bicruciate preservation: Comparison versus the same posterostabilized design at eight years follow-up [in French]. Rev Chir Orthop Reparatrice Appar Mot 2008;94(6):585–595 Migaud H, De Ladoucette A, Dohin B, Cloutier JM, Gougeon F, Duquennoy A. [Influence of the tibial slope on tibial translation and mobility of non-constrained total knee prosthesis]. Rev Chir Orthop Reparatrice Appar Mot 1996;82(1):7–13 Bellemans J. Bicruciate-substituting and bicruciate-replacing arthroplasty of the knee: technique and results. In: Scuderi GR, Tria AJ, eds. The Knee: A Comprehensive Review. Hackensack, NJ: World Scientific; 2010 Amiri S, Wilson DR. A computational modeling approach for investigating soft tissue balancing in bicruciate retaining knee arthroplasty. Comput Math Methods Med 2012;2012:652865 Johnson AJ, Howell SM, Costa CR, Mont MA. The ACL in the arthritic knee: how often is it present and can preoperative tests predict its presence? Clin Orthop Relat Res 2013;471(1):181–188 Cushner FD, La Rosa DF, Vigorita VJ, Scuderi GR, Scott WN, Insall JN. A quantitative histologic comparison: ACL degeneration in the osteoarthritic knee. J Arthroplasty 2003;18(6):687–692
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Bicruciate-Retaining Total Knee Arthroplasty: A Review Jeffrey J. Cherian, DO1 Bhaveen H. Kapadia, MD1 Samik Banerjee, MS (Orth), MRCS (Glasg)1 Julio J. Jauregui, MD1 Steven F. Harwin, MD2 Michael A. Mont, MD1 1 Center for Joint Preservation and Replacement, Rubin Institute for
Advanced Orthopedics, Baltimore, Maryland 2 Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York
Address for correspondence Michael A. Mont, MD, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD 21215 (e-mail: [email protected]).
Abstract
Keywords
► bicruciate retaining ► total knee arthroplasty ► ACL-sparing
Total knee arthroplasty (TKA) has been shown to have excellent long-term outcomes and survivorship in numerous studies, however, with changes in patient demographics, questions have arisen about the use of conventional arthroplasties and their functionality in highly active, young patients. The recent interest in bicruciate-retaining prostheses is aimed to address the need for an implant that can mimic a natural knee during high activity levels. Although there are currently few of these prostheses which are being utilized, results from prior studies have demonstrated similar results to that of anterior cruciate ligament–sacrificing TKA in terms of function and survivorship. In this review, we will describe the history, kinematics, clinical outcomes, concerns, and future outlook of bicruciate-retaining arthroplasty.
The majority of total knee arthroplasties (TKAs) are performed in the elderly population, however, as the indication and population demographics continue to change, younger patients are undergoing this procedure.1 In conjunction with this demographic shift, numerous reports have demonstrated that approximately 20% of patients who undergo these procedures are unsatisfied.2 One large series published in 2000 by Robertson et al using a questionnaire asking, “How satisfied are you with your knee replacement.” They found that 17% of 25,275 unrevised patients were either dissatisfied or uncertain regarding their satisfaction, with this number rising to 41% for revision cases.3,4 In addition, patients may potentially have suboptimal functional outcomes after TKA, with a recent study by Clement et al reported that less than 25% of patients were satisfied with their ability to squat or kneel.5 This dissatisfaction may potentially be explained by the abnormal kinematics affecting the muscle movement arms and proprioceptive instability when sacrificing the anterior cruciate ligament (ACL) during TKA.
Therefore, surgeons are aiming to develop prostheses that can allow patients to have a more natural knee feeling, improve return to high activity levels, and allow for better satisfaction. It has been theorized that retention of the ACL may generate superior knee mechanics and proprioception, thus leading to improved patient function, particularly by improving maximum knee flexion movements. In addition, bicruciate-retaining TKA theoretically has the potential of improved implant longevity, by lessening the stress transmitted through the prosthesis by using a less constrained polyethylene tibial component. However, due to multiple reasons including the technical difficulty of obtaining good visualization with both cruciates intact, questionable evidence of the ACL benefit in TKA, and the unpredictably of tensioning of retained ligaments, this prosthesis design has not gained widespread popularity. In addition, surgeons have questioned its use due to the potential inability to correct the deformity of the knee, as well as the future potential for instability from ligament failure. This
received February 19, 2014 accepted March 16, 2014 published online April 24, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1374812. ISSN 1538-8506.
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report summarizes the recent evidence concerning bicruciate-retaining TKA. We will specifically focus on the following: (1) Historical contents; (2) Kinematics; (3) Outcomes; (4) Concerns; and (5) The future outlook of these prostheses.
History The bicruciate-retaining knee prosthesis was originally designed to allow for more physiological movement of the knee. Bicruciate-retaining TKA was originally developed in the mid1960s by Gunston, who developed the polycentric knee (Winnipeg, Canada).6 This design was constructed using two semicircular runners for the femoral condyles which articulated with two separate tibial components fixed with acrylic cement. In the mid-1970s, the development of another anterior cruciate-retaining design, the geometric knee prosthesis occurred at the Mayo Clinic.7 This prosthesis differed from the original prosthesis being composed of a single femoral component. These earlier designs were followed by numerous ACLsparing prostheses including the following: UCI Knee, Leeds Knee, Ewald Knee, Kodama-Yamamoto Mark I, Duopatella Knee (DePuy Orthopaedics, Warsaw, IN), LCS Bicruciate Knee (DePuy Orthopaedics, Warsaw IN), Geomedic, and Anametric Knee.2 However, these implants ultimately fell out of favor due to clinical successes seen with ACL-sacrificing prostheses.8 In 1972, Townley created the anatomic total knee (Port Huron, Michigan), which is one of the first modern ACLsparing prosthetic designs. This prosthesis was designed to minimize bone and ligamentous resection, and aimed to resurface the joint allowing for the anatomical motion of the knee.9 The femoral implant was bilobed, horseshoe shaped, and made as thin as possible to allow for retention of all ligaments.9 Similarly, in 1975, Cloutier designed a nonconstrained total anatomic resurfacing prosthesis at St. Luc Hospital in Montreal after positive results seen with compartmental prostheses.10–12 These prostheses were two-part, unlinked, metal-on plastic implants, with chromium–cobalt femoral components which replaced the articular surface. The patellar flange geometry replicated the normal anatomy, and the asymmetrical femoral condyles were divergent with their radii of curvature in the sagittal plane decreasing posteriorly. The tibial component consisted of two nearly flat articular surfaces composed of carbon-reinforced polyethylene placed into a U-shaped chromium cobalt alloy retainer.
Kinematics of Bicruciate-Retaining Knee Prostheses It is believed that the cruciate ligaments play a pivotal role in normal knee function and kinematics. Since the advent of TKA, controversies have surrounded the influence of the cruciate ligaments, however, a majority of the discussion has been solely on the posterior cruciate ligament (PCL).8 It is surprising that much of the debate has been centered around the PCL, because the ACL is believed to play a more The Journal of Knee Surgery
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crucial role in normal knee kinematics than the PCL. Despite this belief, the ACL is routinely resected during TKA. The ACL is the predominant restraint to anterior tibial displacement. When the knee is placed in extension, the posterolateral bundle of the ACL in under tension, and the anteromedial bundle of the ACL is tight in flexion.13 The ACL accepts 75% of anterior force at full extension and approximately 85% at 30 and 90 degrees of flexion. In normal knee kinematics, ACL is taut in full knee extension, and tends to externally rotate the tibia; then as the knee moves from a flexed position to extension, the shorter, more highly convex lateral femoral condyle finishes its articular surface and is resisted by the ACL. The larger and less curved medial condyle continues its forward roll and slides backward and is assisted by tightening of the PCL. Toward full extension, there is lateral rotation of the tibia and joint in relation to the femur, which is termed the “screw home” mechanism.14 As the knee flexes, the femoral condyle rolls posteriorly (roll back), and due to the different condyle sizes the tibia is internally rotated.15 This posterior movement increases the motion arm of the quadriceps muscle, and causes medialization of the tibial tubercle through greater external rotation, which ultimately aids in proper patellar tracking.16 ACL sacrificing PCL-retaining TKAs (cruciate retaining) has been shown to behave similar to an ACL-deficient knee, where there is paradoxical motion.17,18 Normally, the tibia translates posteriorly and the femur subluxes anteriorly; however, this motion is reversed without the ACL and potentially results in posterior femoral impingement leading to limitations in deep flexion. This can be prevented by releasing the PCL or undersizing the femoral component, however, this can result in flexion instability, pain, and joint swelling. In bicruciate-sacrificing (posterior-stabilizing) TKAs, a cam-post mechanism is used to mimic the function of the PCL, and similar to cruciate-retaining prostheses, the ACL is deficient, which results in anterior subluxation of the tibia. One potential consequence of this mechanism is when the tibia is brought into extension it creates an impingement of the anterior cam on the posterior-stabilizing box.19 This may ultimately lead to excessive wear of the anterior post, and possible failure.20 In addition, this prosthesis limits anterior translation of the femur. These altered mechanics after TKA can result in abnormal quadriceps muscle movement arms, diminishing their mechanism. Furthermore, in both types of ACL-sacrificing prostheses, there is a loss of tibial rotation control during knee flexion, which can result in lateral patellar tilt and subluxation from excess external rotation.21 Numerous studies support the notion that preservation of both cruciate ligaments in TKA preserves more normal knee kinematics.22–28 A study by Stiehl et al examined the kinematics of bicruciate TKA to a posterior cruciate-retaining prosthesis using in vivo weight-bearing fluoroscopy.23 The authors reported that PCL-retaining TKAs medial and lateral contact points were significantly posterior at 0 degrees (p < 0.01, p < 0.001, respectively), and at 60 degrees of flexion the lateral femoral condyle was significantly posterior (p < 0.05) compared with the bicruciate design. The authors stated that this posterior contact point in extension and
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anterior translation in deep flexion could potentially lead to increased posterior wear of the prosthesis. Similarly, Morooka et al analyzed the in vivo kinematics (treadmill gait, stair stepping, and maximum flexion activities) using dynamic fluoroscopy and shape matching in bicruciate retaining compared with posterior cruciate-retaining TKA.24 The authors noted that both condyles in the bicruciate-retaining TKA demonstrated significantly greater posterior translation in the stance and swing phases of gait than in the posterior cruciate–retaining prosthesis (p < 0.05). Furthermore, the authors reported that with maximum flexion activities (6 mm more) and stair stepping from 30 to 70 degrees there were significantly more posterior translation of the lateral condyle bicruciate prosthesis when compared with the cruciate-retaining knees (p < 0.05). In addition to the abnormal kinematics seen with resection of ACL in TKA, reports have purported that its removal adds to abnormal proprioception.17 Reports have shown that ACL and capsular mechanoreceptors respond mostly when the knee is place in terminal extension where these receptors have the greatest proprioception sensitivity.29 A study by Jerosch et al evaluated proprioceptive capabilities of the knee joint with balance testing in 8 conservatively treated patients, 12 surgically treated patients with ACL-deficient knee joints, and 12 healthy control patients.30 The authors demonstrated that healthy patients had higher proprioceptive capabilities compared with ACL-deficient knees, and with those who underwent ACL reconstruction. Moreover, Fuchs et al31 evaluated the proprioception in 15 patients who underwent bicondylar Sledge Prosthesis (Endo, Link, Hamburg, Germany) which retains both cruciate ligaments, compared with their contralateral native knee, as well as healthy individuals. Through sway measurements during single-leg stance on a force platform, the authors demonstrated that there were no significant differences in balance measurements between the patients who received bicondylar prostheses and their contralateral leg, as well as the healthy individuals. These findings help support the theory that the ACL plays a crucial role in knee stability and proprioception.
Clinical Outcomes In 1979, Cracchiolo et al analyzed the first generation bicruciate-retaining TKAs (119 polycentric and 92 geometric), and found that at a mean follow-up of 3.5 years (range, 2–6 years), failure occurred in 11 and 16% of the polycentric and geometric knees, respectively.7 Despite their less than optimal failure rates, these two prostheses were reported to provide excellent pain relief. Townley examined the long-term results in 426 patients who underwent cemented anatomic TKA.9 They reported that the overall 11-year result in relation to pain relief, motion, and level of activity were excellent or good in 89%, fair in 7%, and poor of failed in 4% of patients. Patients were considered to have excellent outcomes if their motion was greater than 90 degrees, and pain and activity restriction was mild or none. Buechel and Pappas evaluated the long-term survivorship of their low-contact-stress, mobile-bearing knee prosthesis
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system.32 Their system consisted of the same femoral and patellar components with bicruciate-retaining meniscal bearing (n ¼ 46), posterior-cruciate meniscal bearing (n ¼ 57), or a cruciate sacrificing, rotating-platform tibial component (n ¼ 108). At 6- and 12-year follow-up the authors reported that overall survivorship for bicruciate prostheses was 100 and 90.9%, respectively. In comparison, the 6-year survivorship of the posterior cruciate-retaining prosthesis was 97.9%, and the 10-year rate for rotating-platform design was 97.5%. The authors stated that this study indicated the predictable long-term survivorship of these bicruciate-retaining prostheses. Since Cloutier’s development of a bicruciate-retaining TKA in the 1970s, there have been numerous reports on this type of prostheses. The authors have published two reports on a series of 130 patients (163 knees) who received bicruciateretaining prosthesis (Hermes 2C total knees arthroplasty; Ceraver-Osteal, Roissy, France) between 1986 and 1988. Patients in this series were noted to undergo bicruciateretaining prosthesis despite ACL degeneration. The authors used functional diagnosis by normal anterior drawer as the inclusion criteria. In their first report in 1999, which evaluated the 9- to 11-year survivorship, the authors found that in 104 of the 107 patients available for follow-up had good-toexcellent results.12 They noted that 91% of patient had adequate pain relief, a mean range of motion of 107 degrees, 89% had normal anteroposterior translation, 90% had normal mediolateral stability, the mean Knee Score was 91 points (range, 54–100 points), the mean functional score was 82 points (range, 10–100 points), and the survivorship (with revision as an end point) rate was 95%. A recent 22-year follow-up of these patient by Sabouret et al33 found that the overall survivorship rate with revision as an end point was 82%. After revision, lost to follow-up, and death, a total of 32 knees were available from the initial cohort. The authors reported that the mean flexion achieved was 103 degrees (range, 80–120 degrees), mean American Knee Society Knee and functional scores were 87 points (range, 27–100 points) and 68 points (range, 0–100 points), respectively. In addition, patients were noted to have mean mediolateral laxity of 0.14 degree (range, 0–4 degrees), and mean anteroposterior translation of 1.03 mm (range, 0–7 mm). The authors concluded that even when the ACL was not perfect at the time of index arthroplasty, good clinical results could be demonstrated in bicruciate-retaining prostheses at greater than 20-year follow-up. In 1996 and 2011 Pritchett examined patient preference of knee in a series of patients who underwent staged-bilateral TKA using different prostheses on each side.34,35 The first series consisted of 50 patients who received a bicruciate prosthesis on one knee type and a posterior cruciate retaining on the other. The authors noted that 70% of patients stated that the bicruciate-retaining TKA was their preferred knee. In the author’s more recent study, they evaluated 440 patients who received either bicruciate-retaining, posterior cruciateretaining, medial pivot, posterior-stabilizing, or mobile bearing TKA in one knee and another prosthesis in the other. At 2year evaluation, he reported that 89.1% of patients preferred The Journal of Knee Surgery
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their bicruciate retaining TKA to their posterior-stabilizing TKA. He concluded that patients might obtain a better subjective “feel” from bicruciate-retaining TKA. However, not all studies have shown such positive results.8,36 A prospective study by Jenny and Jenny8 evaluated
the short-term outcomes of 32 ACL-retaining compared with 93 ACL-sacrificing TKAs at 2- to 3-year follow-up. The authors found that the Knee Society scores were not significantly different in the ACL-sparing cohort than the ACL-sacrificing cohort, 89 versus 90 points, respectively. Similarly, they were
Table 1 Outcomes of bicruciate-retaining prostheses Study, year
Number of knees
Implant design
Mean follow-up (y)
Brief summary of results
Cracchiolo et al, 19797
211
Polycentric and geometric
3.5
In these early prostheses, failure occurred in 11 and 16% of the polycentric and geometric knees, respectively
Townley, 19859
426
Anatomic total knee
11
The author found excellent or good outcomes in 89%, fair in 7%, and poor of failed in 4% of patients
Buechel and Pappas, 199030
46
Low-contact-stress, mobile-bearing knee prosthesis
6
The overall survivorship for bicruciate prosthesis was 100%, and the PCLretaining prosthesis was 97.9%
Cloutier et al, 199912
104
Hermes 2C total knees arthroplasty
10
The survivorship (with revision as an end point) rate was 95%
Sabouret et al, 201333
32
Hermes 2C total knees arthroplasty
22
The overall survivorship rate with revision as an end point was 82%, after long-term follow-up
Pritchett, 199634
50
Biopro Total Knee Prosthesis
Minimum of 5
70% of patients stated that the bicruciate-retaining TKA was their preferred knee
Pritchett, 201135
201
Biopro Total Knee Prosthesis and Wright Medical ACL-PCL retaining
2
89.1% of patients preferred their bicruciateretaining to posteriorstabilizing TKA
Jenny and Jenny, 19988
93
Search Total Knee prosthesis (Aesculap, Germany)
3
Knee Society scores, postoperative flexion angle, functional scores, and radiographic outcomes were not significantly different in the ACL-sparing cohort than the ACL-sacrificing cohort
Migaud et al, 199637
38
Cloutier Prosthesis
5.5
No statistical differences in range of motion, HSS knee scores, and function between the two prostheses cohorts; however, posterior tibial slope was the only significant factor influencing the anterior tibial translation
Abbreviations: ACL, anterior cruciate ligament; HSS, Hospital for Special Surgery score; PCL, posterior cruciate ligament; TKA, total knee arthroplasty. The Journal of Knee Surgery
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Concerns with Bicruciate-Retaining Designs, Technique, and ACL Viability Design There have been several concerns over the years with bicruciate-retaining TKA designs, as well as with the surgical technique in which it is performed. Tibial component fixation has been one of the major concerns of bicruciate-retaining prostheses because of the limited contact surface available for implant stability with the retention of both cruciate ligaments. When the ACL is retained, this results in an inability of central standard stabilization, and thus must be supported by smaller fins or pegs, which may expose the implant to fixation failure. Similarly, another challenge with the tibial component was the threat of fracture of the tibial bar (bridge connecting the two tibial plateaus). This bar could be placed under severe stress causing it to break, however, to correct this problem, the implant would have had to be made thicker, potentially endangering the valuable bone or may even cause disruption of the ACL. In addition, developers and surgeons are faced with the difficultly of the differences in tibial plateau’s slope and restoration of the natural 3 degree varus slope of the joint line. Surgeons may have difficulty in reproducing natural knee anatomy and joint kinematics.
203
Technique Similar to design problems, there are several surgical technique challenges that present themselves when performing bicruciate-retaining TKA. One of the major challenges is the difficult exposure when the ACL remains intact. The retention of both cruciate ligaments and their insertion on the tibial eminence is technically more demanding, which could lead to poorer quality of implantation.8 In addition, Bellemans38 stated that mediolateral positioning of the tibial component must be handled with care to avoid component overhang; joint line restoration to ensure optimal ACL and PCL functionality and knee kinematics; and surgeons must avoid impingement of the femoral component on the central bone block. In addition, Amiri and Wilson stressed the importance of ligamentous balancing, and consequences of abnormal tensioning in bicruciate-retaining prostheses.39
Anterior Cruciate Ligament Viability A study by Johnson et al evaluated 200 patients for ACL integrity at the time of TKA.40 All patient underwent Lachman tests under anesthesia, ACL characterization intraoperatively as intact, frayed, disrupted, or absent, and 100 patients had magnetic resonance imaging (MRI) scans to evaluate ACL integrity. The authors demonstrated 78% of patients (n ¼ 155) had intact ACLs intraoperatively, whereas, on MRI scan 69% were graded as intact, 14% were indeterminate, and 17% were ruptured. A study by Cushner et al41 found that only 26% of ACLs were still intact in osteoarthritic patients who had a mean age of 63 years, while another 26% of patients had slight degeneration of the ACL. Their findings were similar to pathologic findings noted in the PCL at the time of TKA. However, Sabouret et al33 found that a partially degenerated ACL can remain functional even after 22-year follow-up in bicruciate-retaining TKA. In addition, they noted that patients might do well with these prostheses even if they have a degeneration of the ligament, as long as there is a negative anterior drawer test at the time of index surgery. Refer to ►Table 2 for summary of concerns surrounding bicruciate-retaining TKA.
Future Outlook At this time, we are uncertain whether bicruciate-retaining TKA will become the current standard of care, however, they are clearly an attractive option for development based on the well-documented shortcomings of cruciate-retaining and posterior-stabilizing prostheses. With the numerous recent reports demonstrated excellent outcomes with unicompartmental arthroplasty, the use of bicompartmental knee arthroplasty has made a reemergence. The use of bicompartmental prostheses must be the solution to the current ACL-sacrificing prostheses by allowing retention of both cruciate ligaments without the complications seen with the tibial bar prior bicruciate-retaining designs. Furthermore, as researchers, surgeons, and developers study the natural kinematic and function of the knee and promote the introduction of new designs and surgical techniques, the use of
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unable to demonstrate any statistical differences in flexion angle (102 vs. 101 degrees), functional scores (80 vs. 79 points), and radiographic outcomes between patient who received ACL-sparing compared with the ACL-sacrificing prosthesis. They concluded that there was no advantage in retaining the ACL in TKA according to the short and midterm seen with the posterior cruciate-retaining prosthesis. In addition, Migaud et al evaluated the influence of posterior tibial slope and ACL sparing on anterior tibial translation in 68 Cloutier total knee prostheses (38 ACL sparing; 30 ACL sacrificing) after a mean follow-up period of 5.5 years (range, 2–15 years).37 The authors were unable to demonstrate statistical differences in range of motion, HSS knee scores, and function between the two prostheses cohorts. However, they demonstrated that the posterior tibial slope (mean, 6.2 degrees) was the only significant factor influencing the anterior tibial translation (mean, 3.9 mm) (p ¼ 0.0007). They reported that a 10 degree increase in the posterior tibial slope would result in a rise of anterior tibial translation by 5.6 mm during weight bearing. When the ACL was preserved, the anterior tibial translation was lower, but not significant. The authors concluded the posterior tibial slope had a higher impact than ACL-sparing on anterior tibial translation. Controversy surround ACL preservation in TKA is still a topic of discussion, with some studies demonstrating superiority with ACL-retaining prostheses, while others showing no difference with cruciate-sacrificing designs. However, given the positive results seen in some of these studies, we believe that with improved designs and techniques, ACL-sparing prostheses may make a reemergence in the future. Refer to ►Table 1 for a brief summary of outcomes of bicruciateretaining TKA.
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Table 2 Concerns surrounding bicruciate-retaining prostheses Design • • • •
Tibial component fixation with limited contact surface available after retention of cruciate ligaments Thicker components can endanger valuable bone-stock or even cause disruption of the ACL Variation in differences between tibial plateau’s slope Implant designed to replicate the natural 3 degrees varus slope of the joint line
Technique • • • • •
Difficult exposure to the joint when the ACL remains intact Careful three-dimensional positioning of the tibial component to avoid component overhang Appropriate ligamentous balancing to avoid abnormal tensioning of cruciate ligaments Joint line restoration to ensure optimal ACL and PCL functionality and knee kinematics Potential for femoral component impingement on remaining central bone block
ACL viability • Numerous studies have demonstrated that there is degeneration of the ACL in a majority of patients who are undergoing TKA • If functionally present with anterior drawer testing, studies have demonstrated good long-term outcomes
Abbreviations: ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; TKA, total knee arthroplasty.
current posterior cruciate-retaining or posterior-stabilizing arthroplasties may potentially lose popularity.
Conclusion
5 Clement ND, Macdonald D, Patton JT, Burnett R. Post-operative
6
As the population in which TKA is being performed changes, questions have arisen about the use of posterior-stabilizing and posterior cruciate-retaining arthroplasty and their functionality in highly active, young patients. The recent development of bicruciate-retaining prostheses is aimed at addressing the need for an implant that can mimic a natural knee during high activity levels. Currently, the use of bicruciate-retaining knee arthroplasty has fallen out of favor due to concerns with prosthesis design and fixation, as well as the potentially difficult surgical technique. However, the results from some prior studies have demonstrated similar results to that of ACL-sacrificing TKA in terms of function and survivorship outcomes. Furthermore, developments of these designs and techniques may lead to an increase in usage in the future.
7
8
9 10 11 12
13
References 1 Skinner HB. Pathokinesiology and total joint arthroplasty. Clin
Orthop Relat Res 1993;(288):78–86 2 Mont MA, John M, Johnson A. Bicruciate retaining arthroplasty. Surg Technol Int 2012;22:236–242 3 Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand 2000;71(3):262–267 4 Dunbar MJ, Richardson G, Robertsson O. I can’t get no satisfaction after my total knee replacement: rhymes and reasons. Bone Joint J 2013;95-B(11, Suppl A):148–152
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