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Bi-cruciate retaining total knee arthroplasty: a systematic literature review of clinical outcomes

  • Knee Arthroplasty
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Abstract

Total knee arthroplasty (TKA) has been shown to have good long-term outcomes and survivorship. Nonetheless, dissatisfied patients are frequently reported in the literature. Bi-cruciate retaining total knee prostheses (BCR TKA) were designed to address the demand for more kinematically functional implants that better reconstruct natural knee kinematics. In BCR TKA, the anterior cruciate ligament (ACL) is preserved. Improved patient-reported outcomes and satisfaction levels are expected. This review aimed to summarize indications for and clinical outcomes of BCR TKA. A systematic literature review on BCR TKA was performed. 24 articles were included for data analysis. Indications covered osteoarthritis, inflammatory arthritis and others. The degree of deformity was often but not always limited to minor axial deformity and contractures: maximum acceptable varus/valgus deformity reached 10°–30° and flexion contractures of 15°–65°. ACL intactness was macroscopically examined intraoperatively in nine studies and clinically tested in ten studies (e.g., Lachmann Test, drawer-test). Objective and patient-reported outcome scores were reported for follow-up periods of up to 22 years. Survival rates varied significantly. For first generation implants, 22-year survival reached 82% while a second generation design was associated with 13.5% revision rate at 18 months. Reasons for varying outcomes were not clear and may be attributed to the implant itself, surgical techniques and patient specific variables including changed expectations and functional demand. The literature has not shown clear indications and guidelines for the use of BCR implants. The promising results of first generation BCR TKA designs may be optimized through improved implant designs in the future. Further studies are advocated to provide the necessary evidence of second generation BCR TKA designs.

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Abbreviations

ACL:

Anterior cruciate ligament

BCR:

Bi-cruciate retaining total knee arthroplasty

BMI:

Body mass index

CR:

Cruciate retaining

FU:

Follow-up

KSS:

Knee Society Score

OA:

Osteoarthritis

PE:

Polyethylene

PCL:

Posterior cruciate ligament

PS:

Posterior stabilized

ROM:

Range of motion

TKA:

Total knee arthroplasty

UKA:

Unicondylar knee arthroplasty

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Author information

Authors and Affiliations

  1. Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne, Germany

    Christoph Kolja Boese

  2. Smith + Nephew GmbH, Hamburg, Germany

    Christoph Kolja Boese

  3. Smith + Nephew, Hull, UK

    Stephen Ebohon

  4. Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Christian Ries

  5. Smith + Nephew, Baar, Switzerland

    Diarmuid De Faoite

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Contributions

SE carried out the pilot search strategy and screened the titles and abstracts. Full text retrieval and analysis were carried out by CKB. CKB and DDF conceived and drafted the manuscript. CR advised on the review design and helped to draft the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Christoph Kolja Boese.

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Conflict of interest

CKB and SE are employees of Smith and Nephew. DDF was employee of Smith and Nephew during creation of the work. Employees of Smith and Nephew may own or be eligible to stock and stock options of Smith and Nephew. CR did not report any conflicts of interest.

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Appendix

Appendix

Arthroplasty systems and manufacturers based on the identified literature:

First generation:

Genesis™ II (Smith + Nephew, Memphis, TN, USA).

Hermes™ 2C ACR (Ceraver-Osteal, Roissy, France).

LCS™ BCR, CR, PS & Rotating (DePuy, Warsaw, IN, USA).

MLP (Wright Medical Technology, Memphis, TN, USA).

N2C™ & Natural-Knee™ (Zimmer GmbH, Winterthur, Switzerland)

Oxford™ UKA (Biomet, Warsaw, IN, USA).

Search™ BCR TKA (Aesculap, Tuttlingen, Germany).

Townley Anatomic™ & Biopro™ (Biopro, Port Huron, MI, USA).

Second Generation:

Journey™ II XR (Smith + Nephew, Memphis, TN, USA).

Vanguard™ XP & CR (Biomet, Warsaw, IN, USA).

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Boese, C.K., Ebohon, S., Ries, C. et al. Bi-cruciate retaining total knee arthroplasty: a systematic literature review of clinical outcomes. Arch Orthop Trauma Surg 141, 293–304 (2021). https://doi.org/10.1007/s00402-020-03622-0

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