A contemporary bicruciate total knee arthroplasty

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Abstract

Bicruciate retaining total knee arthroplasty dates back to the 1970s. The polycentric knee and the duocondylar spared the cruciate ligaments but led to early failures and loss of fixation. Designing surgeons excised the cruciates in order to facilitate the surgical procedure and improve the clinical results. Ultimately, the posterior cruciate sparing and substituting designs dominated the market. Most total knees are now anterior cruciate ligament deficient and 15–20% of patients are not satisfied with their surgical result. Bicruciate sparing total knee arthroplasties are now returning to the market and may afford improved results and satisfaction.

Introduction

Bicruciate ligament retaining (BCR) total knee arthroplasty (TKA) dates to the early 1970s and in the 1980s both Townley [1] and Cloutier [2] developed designs that reported results that were similar to those of the standard posterior stabilized (PS) [3], [4] and posterior cruciate retaining (CR) [5], [6] total knees. Both authors published their results but the other designs remained more popular and surgeons were concerned about the failures of the geometric total knee [7], [8], [9]. In all, 15–20% of patients with TKAs are not satisfied with their results [10], [11]. This may be a product of inappropriate expectations and compromised preoperative counseling or the present prostheses may still require improved kinematics and design [12], [13], [14], [15]. Preservation of both of the cruciate ligaments certainly improves the kinematics of the knee and may lead to better proprioception and patient satisfaction [16], [17], [18]. The surgical procedure is slightly more demanding than the cruciate sparing and cruciate substituting procedures [19], [20]. Long-term follow up of Townley’s knee design was encouraging [21]. However, the early results of one new design are presently questionable and there is certainly need for improvement [22], [23].

Section snippets

Materials and methods

This article will review the surgical technique for a new BCR knee design that has been 8 years in development and has just come to the market with a limited release dating back to March, 2016. The indications for the procedure are presently very limited in order to preserve precise surgical technique and to maximize the benefit to the patient. Both cruciate ligaments must be intact; the deformity should not exceed 10° in any given plane; the range of motion must be at least 120° before

The operation

The arthrotomy is performed in the standard manner without any attempt to limit the exposure. The author uses a midline skin incision with a median parapatellar arthrotomy that is extended 2 cm into the quadriceps tendon. The patella is not everted for the procedure.

The femoral preparation is a standard measured resection that references the axes of the knee and uses a cruciate retaining type implant. The anteroposterior axis is drawn and an intramedullary instrument is used to complete the

Postoperative management

The knee is covered with a light dressing. Ambulation and range of motion exercises are instituted a few hours after surgery.

Results

This knee design was released in March of 2016 and at the present time 150 procedures have been completed in the United States. The author has performed 13 cases without complications either in the operating room or in the months to follow. The early range of motion and pain relief both appear to be good. Thus far, the x-rays have shown stable components without evidence of loosening, radiolucencies, or bone resorption. No patients have anteriorly base knee pain as of yet.

Discussion

BCR TKA has a mixed history with early failures and some good results among a few selected surgeons [1], [2], [23]. The design is now being revisited as it becomes evident that TKA results are not as good as those of total hip arthroplasty in the eyes of the patients [10], [11]. Designing the BCR knee is difficult because it must combine ligament preservation with prosthetic surface stability. The ligaments should drive the knee through a kinematically correct range of motion. However, if the

Disclosures

The author receives royalties from Smith and Nephew Orthopedics and from Springer Publishing.

The author is a consultant for Smith and Nephew Orthopedics and Pacira.

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