The Surgeon’s Role in Relative Success of PCL-Retaining and PCL-Substituting Total Knee Arthroplasty

BACKGROUND: The orthopedic literature has not shown a universal and replicated difference, outside of flexion, in clinical results between posterior cruciate ligament retention and posterior cruciate ligament substitution in total knee arthroplasty. QUESTIONS/PURPOSES: This study was performed to compare the restoration of flexion and knee function in a large series of cruciate-retaining and cruciate-substituting total knee arthroplasties (TKRs). In addition, we aimed to study how other variables, such as those unique to each surgeon, may have affected the results. PATIENTS AND METHODS: The current study evaluated 8,607 total knee arthroplasties in 5,594 patients performed by six surgeons, each using one of four prosthesis designs (two posterior cruciate ligament retaining, two posterior cruciate ligament substituting). Knees were compared at the level of cruciate-retaining and cruciate-substituting knees, at the level of the four prostheses, and at the level of surgeon-implant combinations. Least squared means scores were obtained through multiple linear regression, analysis of variance, and the maximum likelihood method. RESULTS: At the level of posterior cruciate ligament treatment, posterior cruciate ligament substitution as a whole showed 3.2° greater flexion than posterior cruciate ligament retention. At the prosthesis level, cruciate-substituting models provided greater flexion and cruciate-retaining models provided higher function scores. In the surgeon-implant combinations, surgeons provided mixed results that often did not reflect findings from other levels; one surgeon's use of a posterior cruciate ligament retaining prosthesis achieved 14.7° greater flexion than the surgeon's use of a corresponding posterior cruciate ligament substituting design. CONCLUSIONS: Posterior cruciate ligament treatment is confounded by other variables, including the operating surgeon. The arthroplasty surgeon should choose a prosthesis based, not only on outside results, but also on personal experience and comfort. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11420-014-9389-5) contains supplementary material, which is available to authorized users.