The role of the posterior cruciate ligament in total knee replacement. Proprioception, kinesthesia, and balance after total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. Posterior cruciate ligament at total knee replacement. Essential, beneficial or a hindrance? The stability of the cemented tibial component of total knee arthroplasty: posterior cruciate-retaining versus posterior-stabilized design. Functional comparison of posterior cruciate-retaining versus posterior stabilized total knee arthroplasty. Posterior-stabilized versus cruciate-retaining total knee arthroplasty: balancing the gap. Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. The influence of continuous passive motion on the results of total knee arthroplasty.
We randomised 129 knees which were to be replaced using a standard posterior-cruciate-ligament (PCL)-retaining cemented total knee replacement into two groups. In one the PCL was retained in the normal way and in the other it was resected. They were well matched, with a predominance of women, and a mean age of 67 years. There was no statistically significant difference in the Hospital for Special Surgery scores at a mean of 57 months (56 to 60) between the two groups although 21 patients (24 knees) were lost to follow-up. Relief from pain, correction of deformity, range of movement, stability and strength were comparable in both. Radiological assessment showed femoral rollback in approximately 20% of knees with a slightly higher incidence in the PCL-resected group. There was no significant loosening detected in either group at review at two years. At five years, one knee in the PCL-retained group had been revised because of infection and one patient in each group was awaiting revision for loosening. Our findings have shown no significant difference in the five-year results for a PCL-retaining total knee replacement if the PCL is excised or preserved. This suggests two important points. First, the PCL is not functional in most patients with a total knee replacement even when retained. Secondly, patients with an excised PCL show a good result with a PCL-retaining implant, thereby questioning the need for a posterior stabilised design in such a situation. The effect of total knee arthroplasty on proprioception, kinesthesia, and postural control remains controversial. It is argued that retaining the posterior cruciate ligament may help to preserve these sensorimotor functions and improve the longevity of the prosthesis and the functional outcome. We performed a prospective, randomized study to assess proprioception, kinesthesia, and balance following total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses.
                Twenty patients scheduled to undergo total knee arthroplasty were randomly assigned to receive either a cruciate-retaining or a posterior stabilized prosthesis. Joint-position sense, the threshold to detect joint motion, and the subject's ability to balance on an unstable platform were assessed prior to and at least six months after the operation. Paired two-tailed t tests (with a level of significance of p < 0.05) were used to assess the effect of the arthroplasty on the preoperative measures for all subjects. Analysis of covariance was performed to identify the effects of prosthetic design.
                Following total knee arthroplasty, patients detected motion significantly faster and reproduced joint position with less error. The balance index also improved significantly from the preoperative to the postoperative evaluation. The group treated with the posterior stabilized prosthesis more accurately reproduced joint position when the knee was extended from a flexed position.
                Total knee arthroplasty results in mild improvements in proprioception, kinesthesia, and balance. These changes may result from the retensioned capsuloligamentous structures and reduced pain and inflammation. Retention of the posterior cruciate ligament does not appear to significantly improve proprioception and balance compared with those functions in patients with a posterior stabilized total knee design. We report the results of a prospective randomised trial which assessed the role of the posterior cruciate ligament (PCL) following total knee replacement (Genesis I; Smith and Nephew, Memphis, Tennessee). Over a four-year period, 211 patients underwent total knee replacement by the senior author (TJW). They were randomised at surgery to have the PCL either retained, excised or substituted with a posterior stabilised insert. If it was not possible to retain the ligament due to soft-tissue imbalance, it was released from its tibial insertion until suitable tension was obtained. This created a fourth group, those who were intended preoperatively to have the ligament retained, but in whom it was partially released as a result of findings at the time of surgery. All patients were evaluated using the Knee Society rating system (adapted from Insall). A total of 188 patients (212 knees) was available for follow-up at a mean of 3.5 years after surgery. Preoperatively, there was a varus deformity in 191 knees (90%) and a valgus deformity in 21 (10%). There were no statistical differences in the knee or function scores or the range of movement between the excised, retained and substituted groups. There were, however, significantly worse knee and function scores in the group in whom the PCL was released (p = 0.002). Micromotion of the tibial component in 40 knee arthroplasties for gonarthrosis was studied using Roentgen stereophotogrammetric analysis. The stability of this component was assessed for 2 years' postoperatively. In all arthroplasties, an attempt was made to reconstruct the preoperative posterior slope. Posterior cruciate-retaining (CR) and posterior-stabilized (PS) components showed at 2 years a maximum total point motion of 0.6 +/- 0.4 mm and 0.7 +/- 0.5 mm, respectively. Whereas 92.5% of the implants were determined to be stable, 1 of the CR group and 2 of the PS group displayed migration between the first and the second year of at least 0.2 mm. A negative correlation between subsidence of the tibial component at 2 years of follow-up and the difference between preoperative and postoperative tibial slope was found. Consequently, we suggest that restoring the original posterior slope of the tibial plateau must be a goal of tibial component implantation. A prospective, randomized comparison of posterior cruciate-retaining (PCR) and posterior stabilized (PS) total knee arthroplasties (TKAs) was conducted in 20 patients who underwent bilateral TKAs for osteoarthritis. All procedures were performed by a single surgeon. One knee was implanted with a PCR TKA, and a contralateral knee with a PS TKA. Both prosthetic designs were of the same TKA series, with comparable surface geometries. Patients had a clinical and radiographic evaluation at a mean of 31.7 months for PCR TKAs and 30.6 months for PS TKAs postoperatively. There were no significant differences between the PCR and PS TKAs in postoperative knee scores. However, postoperative improvement in range of motion was significantly superior in the PS group. A prospective, randomized, double-blind trial was carried out to compare cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasties (TKAs). A total of 40 knees were randomized to receive either a NexGen CR (Zimmer, Warsaw, IN) or a Legacy PS (Zimmer, Warsaw, IN) TKA. All knees were implanted with identical surgical technique, making sure to balance precisely the flexion-extension gaps before implantation of the components. At 2-year follow-up, there was no difference between the CR and the PS TKAs with respect to their Knee Society clinical, functional, and radiographic scores. These findings suggest that with careful attention to surgical technique and balancing the knee, orthopaedic surgeons should expect similar results whether they use a CR or PS TKA.
                Copyright 2002, Elsevier Science (USA) Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published.
                The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction.
                Randomized controlled clinical trial; Level of evidence, 1.
                Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation.
                All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more "normal knees" in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08).
                In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed. The aim of this study was to evaluate whether anterior cruciate ligament (ACL) reconstruction using the double bundle technique (DB) improves stability in the knee compared with the single bundle technique (SB) with the femoral tunnel in a more horizontal position (2 or 10 o'clock). We conducted a randomized, prospective study. Forty patients were randomized to the DB group (20 patients) and the SB group (20 patients). Four-stranded semitendinosus and gracilis autologous grafts were used in the SB group and in the DB group the conventional four tunnel technique was carried out using the same tendons. The IKDC complete form was used for the preoperative evaluation, and in the follow-up the IKDC subjective knee evaluation form, IKDC current health assessment form and IKDC knee examination form were used. Anteroposterior (AP) laxity was evaluated by standardised and forced radiology in all patients. No significant preoperative between-group differences were found. During the follow-up, no differences were found between groups, except for significant between-group differences (P < 0.05) between the preoperative and postoperative evaluations. The IKDC index also showed significant differences in the 2-year follow-up. Median scores increased from 48 (range 41-54) to 81 (range 75-87) (P = 0.01) in the SB group and from 52 (range 46-58) to 80 (range 72-88) (P = 0.02) in the DB group. There were no significant differences between the groups in terms of functional scores. In conclusion, the 2 and 10 o'clock placements showed no significant differences between SB and DB techniques in the pivot-shift test, manual and radiological anterior posterior laxity and IKDC scores. However, significant between-group differences were found between the preoperative and postoperative evaluations. Twenty-two primary total knee arthroplasties were prospectively randomized into one of two treatment protocols. Ten of these patients were managed in the hospital after surgery by means of a postoperative splint. The remaining 12 patients were placed immediately postoperatively in the recovery room into the continuous passive motion (CPM) device. The study compares the range of motion, analgesic use, hospital stay, and the volume of hemovac output in the two groups. These cases demonstrated two statistically significant findings with the use of CPM: (1) decreased use of narcotic analgesics and (2) decreased length of hospital stay.
These results should be interpreted with caution as the methodological quality of the studies was highly variable. We conclude that there is, so far, no solid base for the decision to either retain or sacrifice the PCL with or without use of a posterior stabilized design during total knee arthroplasty. The technique of PCL retention is difficult because the normal configuration and tension need to be reproduced with ligament tensioners. Knowledge of the technique needs to be improved before it can yield superior results compared to the more straightforward techniques of PCL sacrifice or use of a posterior stabilized design. Also, studies evaluating the effect of both techniques should address the right outcome parameters such as range of motion, contact position, and anterior-posterior stability. Suggestions are given to improve future research on this specific topic of knee arthroplasty.