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Bicruciate-Retaining
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Total Knee Arthroplasty
MichaelD.Ries
Contents
29.1 Introduction – 328
29.2 Illustrative Cases – 328
29.2.1 Case 1 – 328
29.2.2
Case 2 – 329
29.3 Results – 329
29.4 Discussion – 332
327
29
References – 333
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_29
328
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M. D. Ries
29
29.1 Introduction
Bicruciate-retaining total knee arthroplasty was performed regularly in the 1970s, but the procedure was
largely abandoned in the United States in the 1980s.
Early bicruciate-retaining knee replacements essentially
consisted of two unicondylar knee replacements in which
the tibial components were connected by an anterior bar
or bridge which allowed retention of the anterior cruciate ligament. However, unacceptable failure rates were
reported with these early designs, usually as a result
of tibial failure due to loosening, implant breakage,
wear, and baseplate–insert dissociation (. Fig. 29.1).
Other complications included stiffness and fracture
of the eminence or tibial bone island containing the
ACL insertion (Ries etal. 2018; Coventry etal. 1973;
Gunston and MacKenzie 1976). Results with ACLsacricing, posterior cruciate-retaining (CR), or posterior cruciate-substituting (PS) designs have consistently
provided reproducible pain relief and implant survivorship. However, approximately 20% of TKA patients are
unsatised with the functional results of the procedure
(Noble etal. 2006). This has been attributed to many
factors including altered kinematics and exion instability that likely results from loss of ACL function in CR
and PS designs (Pagnano etal. 1998; Dennis etal. 2003).
Newer bicruciate-retaining TKA designs have been
developed with the expectation that modern implant
materials, surgical techniques, and instrumentation
would allow retention of both cruciate ligaments in
TKA, but avoid the problems that occurred historically
with older bicruciate-retaining TKAs (Ries etal. 2018).
> Bicruciate-retaining TKA is generally considered
appropriate for younger more active patients with an
intact ACL, minimal knee deformity, and relatively
good bone stock.
29.2 Illustrative Cases
29.2.1 Case 1
An active 65-year-old female developed lateral and anterior knee pain, which impaired routine and recreational
activities. Treatment with NSAIDs did provide satisfactory relief and injections with cortisone were ineffective.
Her knee range of motion is 0–130°, and the knee is stable
to varus-valgus and anteroposterior stress. Radiographs
demonstrate osteoarthritis primarily involving the lateral tibiofemoral compartment (. Fig.29.2).
The patient is treated with bicruciate-retaining
TKA.Exposure is performed through a medial parapatellar approach and standard femoral bone cuts made
for a CR femoral component, which allows exposure of
the medial tibial plateau (. Fig.29.3a). Extramedullary
alignment is used to orient depth, coronal, and sagittal
alignment of the medial tibial plateau resection
Fig.29.3b). The medial tibial plateau is resected pre-
(.
serving the tibial eminence and cruciate ligaments
(. Fig. 29.3c). A trial reduction is performed for the
femoral component and medial tibial insert to ensure
adequate bone has been removed from the medial tibial
plateau. A lateral cutting guide is then attached to the
extramedullary alignment jig which allows making a lateral plateau resection parallel to the medial plateau
resection (. Fig.29.3d).
A trial reduction is performed with various medial
and lateral insert thicknesses and slopes to balance the
soft tissues (. Fig.29.3e).
> In order to optimize cement xation of the tibial
component, cancellous bone is curetted around the
tibial keel (.
tively liquid state to allow optimal penetration into
the bone (.
Fig.29.3f). Cement is applied in a rela-
Fig29.3g).
ab c
. Fig. 29.1 a Anteroposterior radiograph of a 68-year-old female
with rheumatoid arthritis 28years after bicruciate-retaining TKA
with a Geometric (Stryker, Mahwah, NJ) prosthesis including an allpoly tibial component and patellar non-resurfacing. b Lateral radio-
graph demonstrates screws that had been placed in the tibial
eminence during the original surgery. c Revision TKA was performed. The tibial component was found to be loose and fractured at
the anterior bridge between the two plateaus
ab
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. Fig. 29.2 a AP and b lateral radiographs demonstrate osteoarthritis
329
29
The anterior part of the tibial eminence is removed
and nal components are cemented in place
(. Fig29.3h).
29.2.2 Case 2
An active 38-year-old woman presented with complaints
of left knee pain limiting routine activities of daily living. She had sustained a knee injury as a result of a fall
which caused loss of cartilage on both the medial and
lateral femoral condyles. Her knee was subsequently
treated with three arthroscopic procedures in an effort
to restore the integrity of the articular cartilage.
However, she developed severe debilitating pain with all
weight-bearing activity. Her range of motion is 0–125°,
and the knee is well-aligned clinically. Radiographs
demonstrate mild medial joint space narrowing
(. Fig.29.4a) and relative preservation of the patellofemoral joint (. Fig. 29.4b). She is treated with
bicruciate- retaining TKA and patellar non-resurfacing
(. Fig.29.4c–e).
About 3years after surgery, she had no knee pain
and carries out all routine activities as well as hiking and
cycling long distances. Range of motion is 0–135°, and
strength and knee stability are normal.
29.3 Results
Steihl etal. assessed kinematics in bicruciate-retaining
TKA patients compared to CR TKA patients using
invivo uoroscopy (Stiehl etal. 2000) (. Table29.1).
Bicruciate TKA demonstrated gradual posterior femoral rollback during knee exion. CR TKA demonstrated
paradoxical motion and femorotibial contact began signicantly posterior in extension with progressive anterior translation during knee exion. Moro-oka et al.
similarly compared the kinematics of bicruciateretaining and CR TKAs using in vivo uoroscopy
(Moro-oka etal. 2007). Posterior translation of the lateral condyle was signicantly greater for the bicruciateretaining than CR TKAs during stair climbing and
maximum exion activities. Kono et al. studied 17
bicruciate- retaining TKA patients during squatting and
cross-legged sitting activity using in vivo uoroscopy
(Kono etal. 2019). During cross-legged sitting, a medial
pivot was observed beyond 60° of exion. From 80–110°
of exion, femoral external rotation during squatting
was signicantly larger than that during cross-legged sitting.
> These studies suggest that bicruciate-retaining TKAs
roll back and externally rotates in a pattern that is
similar to the normal knee.
ACL retention in TKA has been advocated to preserve
more normal proprioception, kinematics, and joint
function than conventional CR or PS TKA.Baumann
etal. assessed proprioception by balance testing during
single-leg stance with eyes closed compared to eyes open
in patients with bicruciate TKA, UKA, and PS TKA
(Baumann etal. 2017). The authors found a lower difference in the area of sway between eyes closed and eyes
open for the BCR and UKA patients compared to the
PS TKA group. Pritchett reported on functional out-
29
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330
M. D. Ries
abc
d e
fg h
. Fig. 29.3 a The femoral bone cuts are prepared for a CR femoral
component. After removal of resected femoral bone, the medial tibial plateau is exposed. A trial reduction is then performed for the
femoral component and medial tibial insert to ensure adequate bone
has been removed from the medial tibial plateau. b Extramedullary
tibial alignment is used to orient depth, coronal, and sagittal orientation of the medial tibial plateau resection. c The medial tibial plateau
is resected similar to that of medial unicompartmental knee arthroplasty. d A lateral tibial plateau bone cut is made parallel to the
medial plateau bone cut. The resected bone surfaces can be used to
assess tibial component size. e Trial reduction is performed with
various medial and lateral tibial insert thicknesses and posterior
slopes to determine the optimal soft tissue tension. f In order to optimize cement xation of the tibial component, cancellous bone is
curetted around the tibial keel. g Cement is applied in a low to
medium viscosity state to penetrate into the tibial bone. h The anterior part of the tibial eminence is removed and the nal components
are cemented in place
cd
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ab
331
29
e
. Fig. 29.4 a Preoperative AP radiograph demonstrates mild
medial compartment joint space narrowing and minimal bony deformity. b Axial patellar radiograph shows mild patellofemoral arthritic
changes. c 3years after surgery, AP radiograph demonstrates stable
position of the prosthetic components. d Lateral radiograph demonstrates cement penetration below the tibial keel and absence of any
radiolucencies. e Patellar radiograph demonstrates central tracking
of the unresurfaced patella
332
M. D. Ries
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. Table 29.1 Recent studies evaluating modern bicruciate- retaining TKA
Publication Methods Number of Patients Results
29
Steihl etal. (
Moro-
Kono etal. (
Baumann etal. (
Pritchett (
Pritchett (
Sabouret etal. (
Pelt etal. (
Boese etal. (
2000) Kinematic uoroscopic 16 BCR, 6 CR BCR had gradual posterior femoral
oka etal. (2007) Kinematic uoroscopic 9 BCR, 5 CR BCR showed greater posterior translation
2019) Kinematic uoroscopic 17 BCR Relatively normal kinematics after BCR
2017) Balance testing– single-leg
stance with eyes closed
compared to eyes open
2011) Comparative cohort study 440 bilateral TKA 89.1% preferred bicruciate TKA to PS TKA
2015) Retrospective review 489 BCR 89% survivorship at 23years
2013) Retrospective review 163 BCR 82% survivorship at 22.4years
2019) Retrospective review 141 BCR 88% survivorship at 3years
2019) Prospective multicenter study 149 BCR Clinically signicant improvements in both
20 BCR, 20 UKA, 20 PSSuperior balance ability after preservation
comes of 440 patients who underwent staged bilateral
TKA using a different type of prosthesis on each side
(Pritchett 2011). 89.1% preferred bicruciate TKA to PS
TKA and 76.2% preferred medial pivot TKA to PS
TKA.
A relatively high rate of complications was reported
with early bicruciate-retaining TKA designs (Ries etal.
2018). However, Pritchett reported favorable long-term
survivorship in 489 knees using a bicruciate-retaining,
minimally constrained device (Pritchett 2015). The
Kaplan–Meier survivorship was 89% at 23years with
revision for any reason as the endpoint. Sabouret etal.
reported on 163 bicruciate-retaining Hermes 2C total
knee replacements in 130 patients at a mean follow-up
of 22.4 years (Sabouret etal. 2013). The survival rate
using revision for any reason as the endpoint was 82%.
However, Pelt etal. reported on 141 bicruciate-retaining
TKAs with a more modern design (Pelt etal. 2019). At
3years, survivorship was 88% which is lower than that
expected for conventional CR and PS designs. Failures
occurred as a result of isolated tibial loosening, anterior
cruciate ligament (ACL) impingement, pain, unknown
reasons, femoral and tibial loosening, ACL deciency,
and arthrobrosis.
> More favorable early results have been reported in 156
patients (165 knees) with a newer implant design having a large keel and a more anatomically oriented
joint line (Boese etal. 2019).
rollback, CR most abnormal kinematics
than CR
of both cruciate ligaments
and 76.2% preferred medial pivot TKA to
PS TKA
functional and quality of life outcomes
29.4 Discussion
Conventional CR and PS TKAs that sacrice the ACL
provide predictable pain relief and favorable implant
survivorship. However, these implants have also been
associated with abnormal kinematics and exion instability (Pagnano etal. 1998; Dennis etal. 2003). Retention
of the ACL can provide more normal proprioception,
kinematics, and joint function. Partial knee replacements
(UKA, patellofemoral replacement, and bicompartmental knee arthroplasty) can provide more favorable functional results than TKA as a result of preservation of the
ACL.However, the durability and implant survivorship
of partial knee replacements has generally been less
favorable than TKA (Wilson etal. 2019).
Bicruciate-retaining TKAs have also demonstrated
kinematics and function closer to the normal knee than
after CR or PS TKA. Early patient satisfaction after
bicruciate-retaining TKA has been high. However, variable implant survivorship results have been reported
after bicruciate-retraining TKA.Early designs used in
the 1970s and 1980s were associated with a relatively
high rate of implant failure usually on the tibial side due
to wear, loosening, fracture, baseplate–insert dissociation, and implant breakage (Ries etal. 2018). However,
some of these designs demonstrated survivorship at
20years of over 80%, which is similar to conventional
CR and PS TKAs implanted during the same time
period (Pritchett 2015; Sabouret etal. 2013).
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333
29
Newer designs using modern implant materials and
surgical techniques could mitigate the problems associated with early bicruciate-retaining TKA. However,
results of one design with a cobalt-chrome tibial component and mechanically aligned joint line demonstrate
survivorship of only 88% at 3years, which is lower than
conventional CR and PS TKA (Pelt etal. 2019). Early
results with a newer design having a tibial keel and kinematically oriented joint line appear more favorable and
suggest that bicruciate-retaining TKA may be a feasible
option for relatively active patients with minimal deformity, an intact ACL, and good bone stock (Boese etal.
2019). However, the long-term durability and implant
survivorship in comparison to currently available CR
and PS TKA has not been established.
Take-Home Messages
5 Retention of both cruciate ligaments is pos-
sible in TKA.
5 BCR TKA can result in more normal kine-
matics and favorable joint function in comparison to conventional TKA.
5 Early BCR TKAs used in the 1970s and 1980s
were associated with a high failure rate in
comparison to conventional CR or PS TKA.
5 Early clinical results with a modern implant
design and surgical method which emphasizes cement technique have been favorable.
5 In order to optimize cement xation of the
tibial component, cancellous bone is curetted around the tibial keel. Cement is applied
in a relatively liquid state to allow optimal
penetration into the bone.
5
Long-term durability of currently available
new BCR designs has not been established.
References
Baumann F, Bahadin Ö, Krutsch W, Zellner J, Nerlich M, Angele P,
Tibesku CO (2017) Proprioception after bicruciate-retaining
total knee arthroplasty is comparable to unicompartmental knee
arthroplasty. Knee Surg Sports Traumatol Arthrosc 25:
1697–1704
Boese K, MacDonald J, Huang W, Schwarzkopf R, Gerlinger T,
Swank M, Huff T, Schinsky M, Amin N, Ast M, Ries M, Roche
M, Jones J, Cooper H. Early clinical and patient-reported results
of a bi-cruciate retaining total knee implant: six-month results
of a prospective multicenter study of 149 primary TKAs.
European Orthopaedic Research Society, October 2–5, 2019
Coventry MB, Upshaw JE, Riley LH, Finerman GA, Turner RH
(1973) Geometric total knee arthroplasty.II Patient data and
complications. Clin Orthop Relat Res 94:177–184
Dennis DA, Komistek RD, Mahfouz MR, Haas BD, Stiehl JB (2003)
Multicenter determination of invivo kinematics after total knee
arthroplasty. Clin Orthop Relat Res 416:37–57
Gunston FH, MacKenzie RI (1976) Complications of polycentric
knee arthroplasty. Clin Orthop Relat Res 120:11–17
Kono K, Inui H, Tomita T, Yamazaki T, Taketomi S, Tanaka S
(2019) In vivo kinematics of bicruciate-retaining total knee
arthroplasty with anatomical articular surface under high-exion conditions. J Knee Surg. https://doi.
org/10.1055/s-0039-1696959. [Epub ahead of print]
Moro-oka TA, Muenchinger M, Canciani JP, Banks SA (2007)
Comparing invivo kinematics of anterior cruciate-retaining and
posterior cruciate-retaining total knee arthroplasty. Knee Surg
Sports Traumatol Arthrosc 15:93–99
Noble PC, Conditt MA, Cook KF, Mathis KB (2006) Patients expec-
tations affect satisfaction with total knee arthroplasty. Clin
Orthop Relat Res 452:35–43
Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ (1998) Flexion
instability after primary posterior cruciate retaining total knee
arthroplasty. Clin Orthop Relat Res 356:39–46
Pelt CE, Sandifer PA, Gililland JM, Anderson MB, Peters CL (2019)
Mean three-year survivorship of a new bicruciate-retaining total
knee arthroplasty: are revisions still higher than expected? J
Arthroplasty 34:1957–1962
Pritchett JW (2011) Patients prefer a bicruciate-retaining or the
medial pivot total knee prosthesis. J Arthroplasty 26:
224–228
Pritchett JW (2015) Bicruciate-retaining total knee replacement pro-
vides satisfactory function and implant survivorship at 23 years.
Clin Orthop Relat Res 473:2327–2333
Ries MD, Lenz N, Jerry G, Salehi A, Haddock S (2018) Is modern
bicruciate retaining TKA feasible? Semin Arthroplasty 29:55–57
Sabouret P, Lavoie F, Cloutier JM (2013) Total knee replacement
with retention of both cruciate ligaments: a 22-year follow-up
study. Bone Joint J 95-B:917–922
Stiehl JB, Komistek RD, Cloutier JM, Dennis DA (2000) The cruci-
ate ligaments in total knee arthroplasty: a kinematic analysis of
2 total knee arthroplasties. J Arthroplasty 15:545–550
Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson
WF, Bottomley N, Hopewell S, Price AJ (2019) Patient relevant
outcomes of unicompartmental versus total knee replacement:
systematic review and meta-analysis. BMJ 364:l352
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Fixed- Versus Mobile-Bearing
Total Knee Arthroplasty
DanielN.Bracey andDouglasA.Dennis
Contents
30.1 Introduction – 336
30.2 Case Example – 337
30.3 Kinematics oftheNative Knee andTotal
Knee Arthroplasty – 343
30.4 Fears Associated withMobile-BearingTKA – 346
30.5 Benets ofaMobile-Bearing Design – 347
30
30.6 Clinical Outcomes After Mobile Versus
Fixed-Bearing TKA – 351
References – 353
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_30
336
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D. N. Bracey and D. A. Dennis
30
30.1 Introduction
The rst widely used mobile-bearing implant was the
Oxford knee, a unicompartmental knee arthroplasty
introduced in 1976 (Capella etal. 2016). Following FDA
approval in 1984, the Low Contact Stress TKA (LCS,
formerly the New Jersey Knee; Depuy, Warsaw, IN) was
released (Hamelynck 2006). It introduced a second
articulating surface under the polyethylene bearing, in
contrast to xed-bearing designs where the polyethylene
a
bearing is locked into a metal-backed tibial tray which
was designed to prevent inferior surface motion
Fig. 30.1) (Post etal. 2010). Utilization of mobile-
.
(
bearing TKA (MB TKA) has varied (Heckmann etal.
2019; Nguyen et al. 2015). Recent analysis from the
American Joint Replacement Registry showed that
mobile-bearing use was 9.4% in 2016 versus the New
Zealand Joint Registry in which mobile-bearing utilization approaches 30% in the 2018 report. Mobile-bearing
technology offers potential advantages over xed-
b
. Fig. 30.1 Conventional xed-bearing (right) and rotating plat-
form TKA design (left). a The xed-bearing tray has a locking mechanism no longer required with RP design. b The tray accepts the RP
bearing (left) which rotates around a central post while the xedbearing tray (right) engages the polyethylene with its locking mechanism (Post etal. (2010), with permission from Elsevier)
ab
Fixed- Versus Mobile-Bearing Total Knee Arthroplasty
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bearing designs with regard to knee kinematics, implant
xation, wear, and longevity which are discussed in this
chapter.
30.2 Case Example
A 62-year-old female with advanced right knee medial
and patellofemoral compartment osteoarthritis failed
extensive conservative treatment and is indicated for surgical intervention (. Fig. 30.2). We elect to proceed
with total knee arthroplasty (TKA) using a posterior
stabilized, mobile-bearing design.
337
Extension Gap Preparation
z
> A thigh tourniquet is no longer used at our institution
except for cementation based on our randomized trial
which demonstrated that tourniquet use is associated
with quadriceps strength decits up to 3months after
TKA (Dennis etal. 2016).
Following a standard midline incision, a medial parapatellar arthrotomy is performed (. Fig. 30.3a). A distal
femur osteotomy is made with an intramedullary guide
typically set at 4–6° valgus depending on the severity of
30
cd
. Fig. 30.2 Preoperative radiographs routinely obtained in our
clinic include standing AP a, tunnel b, lateral c, Merchant d, and
full- length standing e views. These images conrm the patient’s diag-
nosis of degenerative osteoarthritis with the collapse of the medial
and patellofemoral joint spaces, subchondral sclerosis, and medial
joint line osteophyte formation
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