Bicruciate-retaining versus cruciate-retaining total knee arthroplasty in implant fixation: a 10-year follow-up of a randomized RSA trial
DOI:
https://doi.org/10.2340/17453674.2026.46805Keywords:
Arthroplasty, ImplantsAbstract
Background and purpose: Bicruciate-retaining (BCR) total knee arthroplasty (TKA) aims to restore physiological knee kinematics and joint stability by preserving both cruciate ligaments, potentially improving patient satisfaction. However, long-term clinical outcomes and tibial component migration remain insufficiently understood. We therefore aimed to evaluate long-term implant fixation and clinical outcome after BCR-TKA compared with cruciate-retaining (CR) TKA.
Methods: We performed a long-term follow-up of a randomized controlled trial using radiostereometric analysis (RSA) to compare tibial implant migration between BCR-TKA and CR-TKA. The primary outcome was maximum total point motion (MTPM) of the tibial component, measured with model-based RSA at 3 months, 1, 2, 5, and 10 years. Secondary outcomes included the Oxford Knee Score (OKS) and Forgotten Joint Score (FJS) at identical time points. Mortality, reoperations, and revisions were recorded.
Results: 25 patients were included in each group. At 10 years, the estimated mean MTPM was 0.88 mm (95% confidence interval [CI] 0.64–1.12) in the BCR group and 0.64 mm (CI 0.40–0.88) in the CR group (between-group difference −0.23 mm, CI −0.57 to 0.10). Estimated changes in OKS and FJS showed no evidence of differing longitudinal trajectories between groups. 2 revisions occurred in the BCR group, whereas none occurred in the CR group.
Conclusion: No significant differences were detected between BCR-TKA and CR-TKA in tibial implant migration or patient-reported outcomes over the 10-year follow-up. In contrast, the incidence of complications was higher in the BCR group, indicating that careful patient selection and optimization of surgical strategies remain important for BCR-TKA.
Downloads
References
Zhou C, Peng Y, An S, Bedair H, Li G. Does contemporary bicruciate retaining total knee arthroplasty restore the native knee kinematics? A descriptive literature review. Arch Orthop Trauma Surg 2022; 142(9): 2313-22. doi: 10.1007/s00402-021-04116-3. DOI: https://doi.org/10.1007/s00402-021-04116-3
Nishio Y, Onodera T, Kasahara Y, Takahashi D, Iwasaki N, Majima T. Intraoperative medial pivot affects deep knee flexion angle and patient-reported outcomes after total knee arthroplasty. J Arthroplasty 2014; 29(4): 702-6. doi: 10.1016/j.arth.2013.06.035. DOI: https://doi.org/10.1016/j.arth.2013.06.035
Dennis D A, Komistek R D, Mahfouz M R, Haas B D, Stiehl J B. Multicenter determination of in vivo kinematics after total knee arthroplasty. Clin Orthop Relat Res 2003; (416): 37-57. doi: 10.1097/01.blo.0000092986.12414.b5. DOI: https://doi.org/10.1097/01.blo.0000092986.12414.b5
Lavoie F, Al-Shakfa F, Moore J R, Mychaltchouk L, Iguer K. Postoperative stiffening after bicruciate-retaining total knee arthroplasty. J Knee Surg 2018; 31(5): 453-8. doi: 10.1055/s-0037-1604145. DOI: https://doi.org/10.1055/s-0037-1604145
Pelt C E, Sandifer P A, Gililland J M, Anderson M B, Peters C L. Mean three-year survivorship of a new bicruciate-retaining total knee arthroplasty: are revisions still higher than expected? J Arthroplasty 2019; 34(9): 1957-62. doi: 10.1016/j.arth.2019.04.030. DOI: https://doi.org/10.1016/j.arth.2019.04.030
Puijk R, Singh J, Puijk R H, Laende E K, Plevier J W M, Nolte P A, et al. Evaluation and refinement of thresholds for early migration of total knee replacements as an estimator of late aseptic loosening: an updated systematic review of RSA and survival studies. Acta Orthop 2025; 96: 1-10. doi: 10.2340/17453674.2024.42574. DOI: https://doi.org/10.2340/17453674.2024.42574
Pijls B G, Valstar E R, Nouta K A, Plevier J W, Fiocco M, Middeldorp S, et al. Early migration of tibial components is associated with late revision: a systematic review and meta-analysis of 21,000 knee arthroplasties. Acta Orthop 2012; 83(6): 614-24. doi: 10.3109/17453674.2012.747052. DOI: https://doi.org/10.3109/17453674.2012.747052
Troelsen A, Ingelsrud L H, Thomsen M G, Muharemovic O, Otte K S, Husted H. Are there differences in micromotion on radiostereometric analysis between bicruciate and cruciate-retaining designs in TKA? A randomized controlled trial. Clin Orthop Relat Res 2020; 478(9): 2045-53. doi: 10.1097/CORR.0000000000001077. DOI: https://doi.org/10.1097/CORR.0000000000001077
Hopewell S, Chan A W, Collins G S, Hróbjartsson A, Moher D, Schulz K F, et al. CONSORT 2025 statement: updated guideline for reporting randomised trials. BMJ 2025; 389: e081123. doi: 10.1136/bmj-2024-081123. DOI: https://doi.org/10.1136/bmj-2024-081123
Kaptein B L, Pijls B, Koster L, Kärrholm J, Hull M, Niesen A, et al. Guideline for RSA and CT-RSA implant migration measurements: an update of standardizations and recommendations. Acta Orthop 2024; 95: 256-67. doi: 10.2340/17453674.2024.40709. DOI: https://doi.org/10.2340/17453674.2024.40709
Ryd L, Albrektsson B E, Carlsson L, Dansgård F, Herberts P, Lindstrand A, et al. Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Joint Surg Br 1995; 77(3): 377-83. PMID: 7744919 DOI: https://doi.org/10.1302/0301-620X.77B3.7744919
Beard D J, Harris K, Dawson J, Doll H, Murray D W, Carr A J, et al. Meaningful changes for the Oxford hip and knee scores after joint replacement surgery. J Clin Epidemiol 2015; 68: 73-9. doi:10.1016/j.jclinepi.2014.08.009. DOI: https://doi.org/10.1016/j.jclinepi.2014.08.009
Longo U G, De Salvatore S, Candela V, Berton A, Casciaro C, Sciotti G, et al. Unicompartmental knee arthroplasty: minimal important difference and patient acceptable symptom state for the Forgotten Joint Score. Medicina (Kaunas) 2021; 57(4): 324. doi: 10.3390/medicina57040324. DOI: https://doi.org/10.3390/medicina57040324
Arnout N, Victor J, Vermue H, Pringels L, Bellemans J, Verstraete M A. Knee joint laxity is restored in a bi-cruciate retaining TKA-design. Knee Surg Sports Traumatol Arthrosc 2020; 28(9): 2863-71. doi: 10.1007/s00167-019-05639-4. DOI: https://doi.org/10.1007/s00167-019-05639-4
Pritchett J W. Patients prefer a bicruciate-retaining or the medial pivot total knee prosthesis. J Arthroplasty 2011; 26(2): 224-8. doi: 10.1016/j.arth.2010.02.012. DOI: https://doi.org/10.1016/j.arth.2010.02.012
Mills K, Defoort K, van Hellemondt G, Heesterbeek P. Implant stability and clinical performance of a bicruciate-retaining total knee arthroplasty: a radiostereometric analysis up to 7.5 years follow-up. Clin Biomech (Bristol) 2025; 124: 106473. doi: 10.1016/j.clinbiomech.2025.106473. DOI: https://doi.org/10.1016/j.clinbiomech.2025.106473
Lavoie F, Denis A, Chergui S, Al-Shakfa F, Sabouret P. Bicruciate-retaining total knee arthroplasty non-inferior to posterior-stabilized prostheses after 5 years: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2023; 31(3): 1034-42. doi: 10.1007/s00167-022-07210-0. DOI: https://doi.org/10.1007/s00167-022-07210-0
Kyriakidis T, Hernigou J, Pitsilos C, Verdonk R, Koulalis D. No clinical superiority of bi-cruciate retaining versus posterior stabilized total knee arthroplasty at two years follow-up. Acta Orthop Belg 2024; 90(3): 409-14. doi: 10.52628/90.3.11905. DOI: https://doi.org/10.52628/90.3.11905
Biazzo A, D’Ambrosi R, Staals E, Masia F, Izzo V, Verde F. Early results with a bicruciate-retaining total knee arthroplasty: a match-paired study. Eur J Orthop Surg Traumatol 2021; 31(4): 785-90. doi: 10.1007/s00590-020-02834-9. DOI: https://doi.org/10.1007/s00590-020-02834-9
Eggenberger E E, Hurst J M, Morris M J, Berend K R, Lombardi A V Jr, Crawford D A. Midterm outcomes of a bicruciate-retaining compared with the bicruciate-sacrificing knee system. J Arthroplasty 2022; 37(6S): S245-S249. doi: 10.1016/j.arth.2021.12.010. DOI: https://doi.org/10.1016/j.arth.2021.12.010
Additional Files
Published
How to Cite
License
Copyright (c) 2026 Tomofumi Kinoshita, Kristian R L Mortensen, Lina H Ingelsrud, Omar Muharemovic, Kirill Gromov, Anders Troelsen
This work is licensed under a Creative Commons Attribution 4.0 International License.
PlumX (by Elsevier) is an altmetrics platform that tracks and visualizes the online attention, usage, captures, citations, and social media engagement.
