Bicruciate-retaining Total Knee Replacement Provides Satisfactory Function and Implant Survivorship at 23 Years

Abstract

Background One of the goals of a TKA is to approximate the function of a normal knee. Preserving the natural ligaments might provide a method of restoring close to normal function. Sacrifice of the ACL is common and practical during a TKA. However, this ligament is functional in more than 60% of patients undergoing a TKA and kinematic studies support the concept of bicruciateretaining (that is, ACL-preserving) TKA; however, relatively few studies have evaluated patients treated with bicruciate-retaining TKA implants. Methods From January 1989 to September 1992, I performed 639 total knee replacements in 537 patients. Of these, 489 were performed in 390 patients using a bicruciate-retaining, minimally constrained device. During the period in question, this knee prosthesis was used for all patients observed intraoperatively to have an intact, functional ACL with between 15°varus and 15°valgus joint deformity. There were 234 women and 156 men with a mean age at surgery of 65 years (range, 42-84 years) and a primary diagnosis of osteoarthritis in 89%. The patella was resurfaced in all knees. The mean followup was 23 years (range, 20-24 years). At the time of this review, 199 (51%) patients had died and 31 (8%) patients were lost to followup, leaving 160 (41%) patients (214 knees) available for review. Component survivorship was determined by competing-risks analysis and Kaplan Meier survivorship analysis with revision for any reason as the primary endpoint. Patients were evaluated every 2 years to assess ROM, joint laxity, knee stability, and to determine American Knee Society scores. Results The Kaplan-Meier survivorship was 89% (95% CI, 82%-93%) at 23 years with revision for any reason as the endpoint. Competing-risks survivorship was 94% (95% CI, 91%%-96 %) at 23 years. At followup, the mean age of the patients was 84 years (range, 63-101 years), the mean flexion was 117°(range, 90°-130°), the mean American Knee Society score improved from a preoperative mean of 42 (range, 26-49) to 91 (range, 61-100; p \ .001). Twenty-two knees in 21 patients (5.6%) were revised, most commonly because of polyethylene wear.

The influence of polyethylene bearing thickness on the tibiofemoral kinematics of a bicruciate retaining total knee arthroplasty

“…In their study, no revisions were attributable to aseptic loosening of the tibial tray. Similar findings were noted by Pritchett, who reported a 23 year survivorship of 89% in 489 BCR TKAs, with only four revisions of the femoral and tibial components [6]. In contrast, Christensen et al reported higher frequency of revision and increased radiolucent lines under the tibial tray for BCR compared to a conventional cruciate-retaining TKA [41].…”

“…For example, Pritchett reported that patients preferred a BCR implant relative to a posteriorstabilized (PS) prosthesis two years post-implantation [3]. An additional study from Pritchett demonstrated a Kaplan-Meier survivorship of 89% at 23 years in a series of 489 BCR implants in 390 patients [6]. Baumann et al reported that proprioception following BCR is similar to unicompartmental knee arthroplasty and is significantly better than a PS TKA [7].…”

In‐vivo elongation of anterior and posterior cruciate ligament in bi‐cruciate retaining total knee arthroplasty

“…Anterior and posterior cruciate ligament (ACL and PCL) retaining TKA, or bi‐cruciate retaining (BCR) TKA has potential advantages over contemporary TKA. Functional outcomes and implant survivorship have been reported in 22‐year long‐term follow‐up studies, with a greater number of bilateral TKA patients preferring the BCR TKA over their contralateral PS or CR TKA . In‐vitro studies have reported reduced anteroposterior laxity in BCR TKA and closer replication of native knee kinematics when compared to contemporary TKA .…”

Approximately 30% of Functioning Anterior Cruciate Ligaments Are Sacrificed for Knee Arthroplasty

“…The cartilage status in other compartments can also influence the type of arthroplasty procedure selected. For patients with an intact, functional ACL, consideration may be given to bicondylar knee arthroplasty, 29 ACLretaining TKA, 30 or conventional TKA using a cruciate retaining, cruciate sacrificing, or medial pivot design.…”