Abstract
Introduction:
Patient expectations have escalated over the past several decades with respect to demand for success with total knee arthroplasty (TKA). It is reported that 15% to 20% of TKA recipients are unsatisfied with their result. Dynamic fluoroscopic studies and gait analyses have demonstrated that patients with TKA do not exhibit normal kinematics. On the other hand, patients with partial knee arthroplasty demonstrate more normal kinematics, thought to be secondary to retention of the anterior cruciate ligament (ACL) along with the posterior cruciate ligament (PCL). While not a new concept, bicruciate-retaining designs in TKA that preserve the natural ligament structure of the knee are drawing renewed interest as an option for patients with higher and more complex activity demand. These designs may result in a more natural kinematic feel as perceived by the patient. In a study of 2313 knees in patients undergoing primary knee arthroplasty at our center, the ACL was observed to be intact in 80% and normal in 53%. Bi-cruciate retaining TKA has recently been re-introduced for use in patients with an intact ACL and PCL. As with the introduction of any new technology into orthopaedic surgery, there is a concern regarding learning curve and adverse outcomes. Therefore we review and describe our initial experience with bi-cruciate retaining TKA.
Methods:
To assess the utility of bi-cruciate retaining TKA, six developer surgeons (Adolph V. Lombardi, Jr. MD, Keith R. Berend MD, Craig J. Della Valle MD, Thomas P. Andriacchi MD, PhD, Jeffrey H. DeClaire MD, Christopher L. Peters MD) treated 383 patients (67% female, mean age 65 years) with primary, cemented bi-cruciate retaining TKA with patella resurfacing between May 2013 and April 2014, and followed them for a minimum of 90 days. After the first 119 cases, the surgeons discussed the adverse outcomes and surgical technique was re-assessed. The frequency of complications prior to and following the change in technique were compared.
Results:
The most common complication was intraoperative fracture of the bone island. There were 11 island fractures among the first 119 cases compared to 5 in the subsequent 258 cases (9.2% vs. 1.9%; p = 0.001). There were 4 manipulations performed for range of motion <90 degrees in the first group compared to none in the second group (3.4% vs. 0%; p = 0.003). There were two reoperations overall (0.5%; one for instability and one for tibial loosening), both in the first group. Mean operative time decreased from 82.7 minutes in the first group to 77.5 minutes in the second (p = 0.031).
Discussion:
Bi-cruciate retaining TKA may provide a better solution for patients with competent ACLs who are not candidates for partial knee arthroplasty.
