Posterior-stabilized Arthroplasty Versus Cruciate-retaining Arthroplasty in Treatment of Osteoarthritis: a 5-year Follow-up Study

Posterior-stabilized Arthroplasty Versus Cruciate-retaining Arthroplasty in Treatment of Osteoarthritis: a 5-year Follow-up Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Posterior-stabilized Arthroplasty Versus Cruciate-retaining Arthroplasty in Treatment of Osteoarthritis: a 5-year Follow-up Study Yingzhen Niu, Weixia Bai, Gang Ji, Huijun Kang, Kang Piao, Zhenyue Dong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-467722/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Backgroud: A prospective cohort study was performed to compare clinical outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) arthroplasty. Methods: In total, 210 patients (210 knees) underwent CR arthroplasty (n=102) and PS arthroplasty (n=108) from January 2014 to January 2015. The Knee Society Score (KSS), range of motion, patellar stability, and complications were compared between the CR and PS groups 5 years postoperatively. Results: The CR group comprised 99 knees and the PS group comprised 105 knees at the 5-year follow-up. In the CR and PS groups, the mean postoperative KSS improved to 90±5 and 91±4, and the function score improved to 87±4 and 84±6, respectively (p>0.05). The mean postoperative range of motion was −2°±3° extension to 114°±8° flexion in the CR group and −2°±4° extension to 126°±7° flexion in the PS group, with no significant difference (p>0.05). In terms of patellofemoral complications, eight patients had patellar clunk syndrome, one had patellar subluxation, and one had patellar lateral facet fracture in the PS group. Three patients had patellar clunk syndrome, and one had symptomatic subluxation in the CR group. These patellofemoral complications were significantly different between the groups (p<0.05). Conclusions: CR and PS TKA can achieve good clinical outcomes with respect to the KSS. Better knee flexion but more patella complications in the PS arthroplasty than CR group 5 years postoperatively. Trail registration: This study was approved by our hospital institutional ethics committee. Orthopedic Surgery posterior-stabilized arthroplasty cruciate-retaining arthroplasty patellofemoral joint total knee arthroplasty patellar dislocation Backgroud Total knee arthroplasty (TKA) is effective for advanced osteoarthritis, rheumatoid arthritis, and other knee disorders 1 . Increasingly more patients are obtaining good knee function and improvements in daily life, and some research has demonstrated 87% Kaplan–Meier survivorship after primary TKA 2 . The demand for primary total knee replacement, especially among patients of advanced age, is expected to increase in future. Both posterior cruciate-retaining (CR) and posterior-stabilized (PS) TKA are widely used for primary TKA. Many researchers have shown that both CR and PS have good clinical outcomes 3 , 4 . However, the optimal procedure for primary TKA remains controversial 5 . The posterior cruciate ligament (PCL) has different kinematic functions, and CR TKA provides inherent stability, increased rollback, improved proprioception, improved knee kinematics 3 , 6 . PS TKA with a post-cam design and PCL removal provides a conforming articulation, better knee flexion and stair-climbing ability, more predictable kinematics, reduced peak and mean patellofemoral pressure, and lower ranges of axial rotation and condylar translation 3 . The main procedural difference between CR and PS TKA is that PS TKA involves removal of the PCL and osteotomy of the femoral intercondylar fossa 3 . The choice of CR or PS TKA depends on the degenerative status of the PCL and the surgeon’s experience. Because of these inconsistencies, a clear standard with which to select the CR or PS technique for primary TKA has not been established 7 . Many studies have shown no difference in clinical outcomes between CR and PS TKA, and many researchers have focused on tibiofemoral functions 5 , 8 – 11 . Patellofemoral function is very important after TKA, but patellar instability occurs in some patients 12 . Patellar instability after TKA is a severe complication that impairs the functions of the knee and may lead to the need for revision 13 . Patella clunk syndrome is another potential complication with complex causes. To explore the differences in patellofemoral complications between CR and PS TKA, we performed a prospective cohort study to compare the clinical outcomes between CR and PS TKA, and we assessed patellofemoral function and patellar stability 5 years after surgery. The hypothesis was that PS TKA is associated with more complications involving the patellofemoral joint than is CR TK 5 years postoperatively. Methods From January 2014 to January 2015, a total of 241 patients (252 knees) with advanced osteoarthritis were treated with CR and PS TKA in our hospital. All patients provided informed consent to participate. This study was approved by our hospital institutional ethics committee. (Study No. 2014-K-076). The inclusion criteria were as follows: (1) Severe osteoarthritis (Kellgren–Lawrence grade > III) (2) Substantial pain and loss of function in the knee (3) Primary total knee replacement The exclusion criteria were as follows: (1) History of high tibial osteotomy in the knee or contralateral total knee replacement (2) Hemophilia or juvenile rheumatoid arthritis (3) Severe bony defect, valgus deformity, revision TKA, or active knee joint infection (4) Concomitant performance of another surgery with the TKA, such as ligament repair Based on these criteria, 210 patients were included in this study; among them, 102 patients underwent CR TKA and 108 underwent PS TKA. The demographic data were compared between the two groups (Table 1 ). All patients underwent clinical follow-up for at least 5 years after surgery. The follow-up parameters were the Knee Society Score (KSS), range of motion (ROM), patient satisfaction, patellar stability, and complications. Table 1 Demographics of the patients CR PS P value No. of patients 102 108 n.s. Sex (male/female) 42/60 43/65 n.s. Side involved (right/left) 54/48 53/55 n.s. Age (years) 67 ± 5 65 ± 4 n.s. BMI (kg/m 2 ) 31 ± 4 32 ± 5 n.s. Kellgren & Lawerence III 20 31 Kellgren & Lawerence IV 82 77 n.s. Passive flexion 87 ± 7 90 ± 5 Passive extension 14 ± 5 15 ± 7 n.s. Follow-up time (months) 60 ± 4 60 ± 3 n.s. Surgical technique All surgical procedures were performed by a senior surgeon. A pneumatic tourniquet was used for all cases. A standard medial parapatellar approach was performed in all surgeries. All tibial and femoral components were cemented, incorporating a posterior referencing guide for sizing the femoral component. Sequential soft tissue release was performed if the flexion and extension gaps were not balanced. All patients underwent patelloplasty in which an oscillating saw was used to trim the patella. No patients underwent patellar replacement. No drainage tube was used in any cases. The Gemini MK II CR TKA prosthesis (Link, Hamburg, Germany) and Gemini Legacy PS TKA prosthesis (Zimmer Biomet, Warsaw, IN, USA) were used in our experiment. Postoperative rehabilitation training All patients were given rehabilitation instructions and training by a rehabilitation team. After the operation, walking was encouraged on the day of surgery under the supervision of a physiotherapist. Walking and active ROM exercises were conducted by the rehabilitations every day after the operative procedure. A follow-up evaluation was scheduled 5 years postoperatively. This postoperative follow-up was completed by the same follow-up team and involved assessment of the KSS, ROM, patellar stability, and complications. Passive postoperative flexion and extension were measured using a standard goniometer with the patient in the supine position. Patellar grinding, catching, and clunking were tested and recorded. Postoperative radiographs were reviewed, and the position of the implant, Insall-Salvati ratio, and joint line position were evaluated. Patellar stability was evaluated with the apprehension test, and the patients were divided into three groups according to the test result: those with patellar stability, subluxation, and dislocation. According to the lateral translation grade, grades I and II with a hard end point were consistent with patellar stability, grade III with a hard end point was consistent with patellar subluxation, and a soft end point was consistent with patellar dislocation. Grade > III was also consistent with patellar dislocation. Radiographic evaluation included the patellar tilt and the patellar lateral shift. Statistical analysis SPSS statistical software, version 20.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. A t-test or nonparametric test was used to compare the measurement data among the groups, and the chi-square test or a nonparametric test was used to compare the count data. A p value of < 0.05 indicated a statistically significant difference. Results In total, 99 knees in the CR group and 104 knees in the PS group were available for the 5-year follow-up examination. Three patients in the CR group and four patients in the PS group were lost to follow-up because their addresses had changed. No prosthesis infections, deep vein thrombosis of the lower extremities, or blood vessel or nerve injury were observed, and no obvious immune rejection, hepatitis B, or acquired immunodeficiency syndrome were reported during the follow-up period. In the CR group, the mean postoperative KSS improved to 90 ± 5 and the function score improved to 87 ± 4. In the PS group, the mean postoperative KSS improved to 91 ± 4 and the function score improved to 84 ± 6. There was no significant difference between the two groups. The mean postoperative ROM was − 2°±3° extension to 114°±8° flexion in the CR group and − 2°±4° extension to 126°±7° flexion in the PS group, with no significant difference (p > 0.05). With respect to patellofemoral complications (Table 2 ), eight developed patellar clunk syndrome, one developed patellar subluxation, and one developed patellar lateral facet fracture in the PS group. Three patients developed patellar clunk syndrome, and one developed symptomatic subluxation in the CR group. There were significant differences in patellofemoral complications between the CR and PS groups (p < 0.05). No patients underwent revision. Table 2 Patellofemoral Complication CR PS P value Patella clunk 3 8 Patellar subluxations 1 1 Patellar fracture 0 1 Totals 4 10 n < 0.05 Discussion The most important finding in this study was the lack of a difference in the KSS 5 years after surgery between CR and PS TKA. There is a better flexion of knee in PS group but more patellofemoral complications (i.e., more patellar clunk, subluxations). In terms of clinical scores, both CR and PS TKA can achieve a high KSS. In the CR group, the mean postoperative KSS improved to 90 ± 5 and the function score improved to 87 ± 4. In the PS group, the mean postoperative KSS improved to 91 ± 4 and the function score improved to 84 ± 6. Other studies have also shown that patients recover very well after CR and PS TKA and achieve a good KSS and Hospital for Special Surgery knee score 5 , 7 , 11 . Our study also showed that CR and PS TKA allowed patients to return to their normal life. Both CR and PS TKA are effective for treatment of advanced osteoarthritis 10 , 14 , 15 . Our study showed that the mean postoperative ROM was − 2°±3° extension to 114°±8°° flexion in the CR group and − 2°±4° extension to 126°±7° flexion in the PS group 5 years after surgery, there was a difference between the two groups (P < 0.05). As other researchers have reported that ROM was better after PS TKA, and they considered that the PS design results in better ROM and a better reproduction angle and that PS TKA with a post-cam design and PCL removal provides a conforming articulation, better knee flexion and stair-climbing ability, and more predictable kinematics 12 . However other researchers have shown that the ROM was not significantly different after PS and CR TKA 9 , 11 , 16 , 17 . Although most of studies have shown that patients can perform knee flexion and straightening well enough after surgery to return to live. The PS prothesis is still a good choice for patients who needed a good ROM in their activities of daily living. These patellofemoral complications were more in PS than CR groups. In the PS group of the present study, eight developed patellar clunk syndrome, one developed patellar subluxation, and one developed patellar lateral facet fracture. In the CR group, three patients developed patellar clunk syndrome, and one developed symptomatic subluxation. All procedures were performed by one senior surgeon, and no other complications were reported. The main difference between the CR and PS groups was the femoral component. So PS femoral component may lead patellofemoral complications. For PS TKA, more bony cuts and shorter trochlear were accepted in the femoral component, and the changed track of the femoral trochlea may lead to patella impact and anterior knee pain, patellar clunk syndrome, patellar subluxation, and patellar fracture. In the CR group, the Lachman test was performed for the four patients with complications, and the Lachman test was positive in three of the patients. Loss of the PCL may be the main cause of patellofemoral complications with changes in pressure on the patella. A recent study showed that PCL rupture results in higher pressure on the medial patella. Some researchers have found that more complications occur after PS than CR TKA. A study involving 108 PS TKAs and 136 improved PS TKAs showed that femoral components with a deep trochlear groove and smooth transition of the intercondylar box were associated with fewer cases of crepitance and patellar clunk syndrome 18 . The patellofemoral complications in this study included patellar grinding, catching or clunking, patellar instability, and patellar fracture. Alleviation of anterior knee pain is integral to the overall success of TKA 19 , 20 . Such pain continues to be associated with problematic complications that often lead to revision surgery 12 . Anterior knee pain is a common patellofemoral complication, and patellofemoral complications are associated with anterior knee pain 13 , 20 . Causes of anterior knee pain include the patellofemoral implant design, surgical technique, patient characteristics, and degree of chondromalacia. Patellofemoral crepitance and patellar clunk syndrome develop in the early postoperative period. Patellar clunk is mainly associated with the surgical technique and component positioning. Hamlin reported that more cases of patellar clunk occurred after PS TKA 19 . Instability after TKA is a severe complication, but few studies have compared patellofemoral complications between CR and PS TKA. Few patellar dislocations occurred in both groups of the present study. Patellar instability after TKA has many causes, including the surgical technique, component position, and extensor mechanism imbalance 13 , 21 . This study had several limitations. First, this was not a randomized controlled study. A good control group will lead to improved studies in the future. Second, an inadequate number of samples was obtained, and the 5-year follow-up was short. More samples and a longer follow-up study are needed in the future. Finally, a mechanics study is needed to further confirm our hypothesis. Conclusions In conclusion, we found that CR and PS TKA can attain good clinical outcomes in terms of the KSS. However, PS TKA is associated with more complications involving the patellofemoral joint than is CR TKA after 5 years of follow-up. List Of Abbreviations Cruciate-retaining (CR) Posterior-stabilized (PS) The Knee Society Score (KSS) Total knee arthroplasty (TKA) Range of motion (ROM) Declarations Ethics approval and consent to participate This study was approved by our hospital institutional ethics committee. Consent for publication Written informed consent for publication was obtained from all participants. Availability of data and materials The datasets used or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing financial interests. Funding None Authors' contributions Fei Wang and Yingzhen Niu conceived and designed the study. Fei Wang performed the procedures. Weixia Bai, Gang Ji and Kang Piao gather data. Zhenyue Dong and Conglei Dong wrote the paper. Acknowledgements We thank Angela Morben, DVM, ELS, from Liwen Bianji, Edanz Editing China (www.liwenbianji.cn/ac) References Catani F, Leardini A, Ensini A, Cucca G, Bragonzoni L, ToksvigLarsen S, et al. The stability of the cemented tibial component of total knee arthroplasty. Journal of Arthroplasty. 2004;19: 775-82. Yang CP, Hsu KY, Chang YH, Chan YS, Shih HN, Chen CY. Mid-term survivorship of cruciate-retaining versus posterior-stabilized total knee arthroplasty using modular mini-keel tibial implants. Journal of Orthopaedic Surgery and Research. 2018;13: 35. Wook HC, Hwan YI, Suk LW, Kyu PK, Dong HC. Evaluation of Postoperative Range of Motion and Functional Outcomes after Cruciate-Retaining and Posterior-Stabilized High-Flexion Total Knee Arthroplasty. Yonsei Medical Journal. 2012;53: 794-00. Cankaya D, Ozkurt B, Aydin C, Tabak A. No difference in blood loss between posterior-cruciate-ligament-retaining and posterior-cruciate-ligament-stabilized total knee arthroplasties. Knee Surgery Sports Traumatology Arthroscopy. 2014;22: 1865-69. Cho KY, Kim KI, Song SJ, Bae DK. Does Cruciate-Retaining Total Knee Arthroplasty Show Better Quadriceps Recovery than Posterior-Stabilized Total Knee Arthroplasty? - Objective Measurement with a Dynamometer in 102 Knees. Clinics in Orthopedic Surgery. 2016;8. Wünschel M, Leasure JM, Dalheimer P, Kraft N, Wülker N, Müller O. Differences in knee joint kinematics and forces after posterior cruciate retaining and stabilized total knee arthroplasty. The Knee. 2013;20: 416-21. Bercik MJ, Joshi A, Parvizi J. Posterior Cruciate-Retaining Versus Posterior-Stabilized Total Knee Arthroplasty: A Meta-Analysis. The Journal of arthroplasty. 2013;28: 439-44. Tanzer M, Smith K, Burnett S. Posterior-stabilized versus cruciate-retaining total knee arthroplasty - Balancing the gap. The Journal of Arthroplasty. 2002;17: 813-19. Nowak AC. Outcomes of Posterior-Stabilized Compared with Cruciate-Retaining Total Knee Arthroplasty. The Journal of Knee Surgery. 2018;31: 321-40. Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. Soft Tissue Tension in Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty. Journal of Arthroplasty. 2011;26: 788-95. Götz J, Beckmann J, Sperrer I, Baier C, Koeck F. Retrospective comparative study shows no significant difference in postural stability between cruciate-retaining (CR) and cruciate-substituting (PS) total knee implant systems. International Orthopaedics. 2015;40: 1441-46. Van dGS, Van dVP, Kremers-Van dHK, S K, Verdonschot N. Flexion and anterior knee pain after high flexion posterior stabilized or cruciate retaining knee replacement. Acta Orthopaedica Belgica. 2015;81: 730. Motsis EK, Paschos N, Pakos EE, Georgoulis AD. Review Article: Patellar Instability after Total Knee Arthroplasty. Journal of Orthopaedic Surgery. 2009;17: 351-57. Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. Intraoperative Soft Tissue Balance Reflects Minimum 5-Year Midterm Outcomes in Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty. The Journal of Arthroplasty. 2012;27: 1723-30. Matsumoto T, Kubo… S. Different pattern in gap balancing between the cruciate-retaining and posterior-stabilized total knee arthroplasty. Knee Surgery Sports Traumatology Arthroscopy. 2013;21: 2338-45. Matsumoto T, Muratsu H, Kawakami Y, Takayama K, Ishida K, Matsushita T, et al. Soft-tissue balancing in total knee arthroplasty: cruciate-retaining versus posterior-stabilised, and measured-resection versus gap technique. International Orthopaedics. 2014;38: 531-37. Hino K, Oonishi Y, Kutsuna T, Watamori K, Iseki Y, Kiyomatsu H, et al. Preoperative varus–valgus kinematic pattern throughout flexion persists more strongly after cruciate-retaining than after posterior-stabilized total knee arthroplasty. The Knee. 2016;23: 637-41. Frye BM, Floyd MW, Pham DC, Feldman JJ, Hamlin BR. Effect of Femoral Component Design on Patellofemoral Crepitance and Patella Clunk Syndrome After Posterior-Stabilized Total Knee Arthroplasty. Journal of Arthroplasty. 2012;27: 0-0. Zou YG, Chen ZW, Feng ZQ, Xing JS. [Factors related to anterior knee pain after total knee arthroplasty]. Nan fang yi ke da xue xue bao = Journal of Southern Medical University. 2011;31: 1428-30. Duan G, Liu C, Lin W, Shao J, Fu K, Niu Y, et al. Different Factors Conduct Anterior Knee Pain Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty. 2018;33(6). Doi: 10.1016/j.arth.2017.12.024 Rothman RH, Parvizi J, Mortazavi SMJ, Devulapalli C, Sharkey PF, Hozack WJ. Secondary Resurfacing of the Patella after Primary TKA: Does the Anterior Knee Pain Resolve? Journal of Arthroplasty. 2011;27:21-6 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-467722","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":25187684,"identity":"30acfe84-2ba0-4a47-b29c-d332c10f6a66","order_by":0,"name":"Yingzhen Niu","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yingzhen","middleName":"","lastName":"Niu","suffix":""},{"id":25187685,"identity":"9d6e90fe-423e-41d6-a6dd-590638fdec5e","order_by":1,"name":"Weixia Bai","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weixia","middleName":"","lastName":"Bai","suffix":""},{"id":25187686,"identity":"8bf1e2e9-7625-4622-bc05-5e40d661f882","order_by":2,"name":"Gang Ji","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Ji","suffix":""},{"id":25187687,"identity":"b03601cc-c45e-43d8-b667-899bf91684c2","order_by":3,"name":"Huijun Kang","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huijun","middleName":"","lastName":"Kang","suffix":""},{"id":25187688,"identity":"4b7254b4-0d26-49a0-844a-281d0965fce2","order_by":4,"name":"Kang Piao","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kang","middleName":"","lastName":"Piao","suffix":""},{"id":25187689,"identity":"e58d3f12-0879-4f55-9dad-a7d0216b132d","order_by":5,"name":"Zhenyue Dong","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhenyue","middleName":"","lastName":"Dong","suffix":""},{"id":25187690,"identity":"b682c621-f29c-425c-b746-4446814bc74f","order_by":6,"name":"Conglei Dong","email":"","orcid":"","institution":"Hebei Medical University Third Affiliated Hospital","correspondingAuthor":false,"prefix":"","firstName":"Conglei","middleName":"","lastName":"Dong","suffix":""},{"id":25187691,"identity":"030a7834-c7e7-4bba-bff8-1ea34b5ec3ac","order_by":7,"name":"Fei Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDCCAxCKnx9IMBOrhbEBSEnObIBq4SFay4YDxGrhO978/MHHPYcljG8kH/xcwHBHzp6QFskzxwwbZzw7LGF2Iy1ZegbDM2OCthjcyGFs5jlwu87sRo6BNA/D4cQeYrVIGM/I//wbqKWeeC0GEjlsIFsSCDoM5JeZMw78l5A488zMmsfgsGHPAQJagCH24MOHA2kS/O3Jj2/zVByWZ28gZA0cCCSA3Em0chDgJ+SgUTAKRsEoGLEAAEnWRDa08oMrAAAAAElFTkSuQmCC","orcid":"","institution":"Third Hospital of Hebei Medical University","correspondingAuthor":true,"prefix":"","firstName":"Fei","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2021-04-27 08:25:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-467722/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-467722/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13691845,"identity":"d717be12-e63b-47d9-b181-bd92bf141ce0","added_by":"auto","created_at":"2021-09-17 12:40:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":242389,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-467722/v1/1021891f-0076-4bbe-beb5-115e073bb547.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003ePosterior-stabilized Arthroplasty Versus Cruciate-retaining Arthroplasty in Treatment of Osteoarthritis: a 5-year Follow-up Study\u003c/p\u003e","fulltext":[{"header":"Backgroud","content":" \u003cp\u003eTotal knee arthroplasty (TKA) is effective for advanced osteoarthritis, rheumatoid arthritis, and other knee disorders\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Increasingly more patients are obtaining good knee function and improvements in daily life, and some research has demonstrated 87% Kaplan\u0026ndash;Meier survivorship after primary TKA\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The demand for primary total knee replacement, especially among patients of advanced age, is expected to increase in future.\u003c/p\u003e \u003cp\u003eBoth posterior cruciate-retaining (CR) and posterior-stabilized (PS) TKA are widely used for primary TKA. Many researchers have shown that both CR and PS have good clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, the optimal procedure for primary TKA remains controversial\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The posterior cruciate ligament (PCL) has different kinematic functions, and CR TKA provides inherent stability, increased rollback, improved proprioception, improved knee kinematics\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. PS TKA with a post-cam design and PCL removal provides a conforming articulation, better knee flexion and stair-climbing ability, more predictable kinematics, reduced peak and mean patellofemoral pressure, and lower ranges of axial rotation and condylar translation\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The main procedural difference between CR and PS TKA is that PS TKA involves removal of the PCL and osteotomy of the femoral intercondylar fossa\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The choice of CR or PS TKA depends on the degenerative status of the PCL and the surgeon\u0026rsquo;s experience. Because of these inconsistencies, a clear standard with which to select the CR or PS technique for primary TKA has not been established\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMany studies have shown no difference in clinical outcomes between CR and PS TKA, and many researchers have focused on tibiofemoral functions\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Patellofemoral function is very important after TKA, but patellar instability occurs in some patients\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Patellar instability after TKA is a severe complication that impairs the functions of the knee and may lead to the need for revision\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Patella clunk syndrome is another potential complication with complex causes. To explore the differences in patellofemoral complications between CR and PS TKA, we performed a prospective cohort study to compare the clinical outcomes between CR and PS TKA, and we assessed patellofemoral function and patellar stability 5 years after surgery. The hypothesis was that PS TKA is associated with more complications involving the patellofemoral joint than is CR TK 5 years postoperatively.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eFrom January 2014 to January 2015, a total of 241 patients (252 knees) with advanced osteoarthritis were treated with CR and PS TKA in our hospital. All patients provided informed consent to participate. This study was approved by our hospital institutional ethics committee. (Study No. 2014-K-076).\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) Severe osteoarthritis (Kellgren\u0026ndash;Lawrence grade\u0026thinsp;\u0026gt;\u0026thinsp;III)\u003c/p\u003e\n\u003cp\u003e(2) Substantial pain and loss of function in the knee\u003c/p\u003e\n\u003cp\u003e(3) Primary total knee replacement\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows:\u003c/p\u003e\n\u003cp\u003e(1) History of high tibial osteotomy in the knee or contralateral total knee replacement\u003c/p\u003e\n\u003cp\u003e(2) Hemophilia or juvenile rheumatoid arthritis\u003c/p\u003e\n\u003cp\u003e(3) Severe bony defect, valgus deformity, revision TKA, or active knee joint infection\u003c/p\u003e\n\u003cp\u003e(4) Concomitant performance of another surgery with the TKA, such as ligament repair\u003c/p\u003e\n\u003cp\u003eBased on these criteria, 210 patients were included in this study; among them, 102 patients underwent CR TKA and 108 underwent PS TKA. The demographic data were compared between the two groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All patients underwent clinical follow-up for at least 5 years after surgery.\u003c/p\u003e\n\u003cp\u003eThe follow-up parameters were the Knee Society Score (KSS), range of motion (ROM), patient satisfaction, patellar stability, and complications.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e\u0026emsp;Demographics of the patients\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePS\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo. of patients\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e108\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSex (male/female)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42/60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43/65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSide involved (right/left)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54/48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53/55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKellgren \u0026amp; Lawerence III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKellgren \u0026amp; Lawerence IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePassive flexion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePassive extension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFollow-up time (months)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed by a senior surgeon. A pneumatic tourniquet was used for all cases. A standard medial parapatellar approach was performed in all surgeries. All tibial and femoral components were cemented, incorporating a posterior referencing guide for sizing the femoral component. Sequential soft tissue release was performed if the flexion and extension gaps were not balanced.\u003c/p\u003e\n\u003cp\u003eAll patients underwent patelloplasty in which an oscillating saw was used to trim the patella. No patients underwent patellar replacement. No drainage tube was used in any cases. The Gemini MK II CR TKA prosthesis (Link, Hamburg, Germany) and Gemini Legacy PS TKA prosthesis (Zimmer Biomet, Warsaw, IN, USA) were used in our experiment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative rehabilitation training \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were given rehabilitation instructions and training by a rehabilitation team. After the operation, walking was encouraged on the day of surgery under the supervision of a physiotherapist. Walking and active ROM exercises were conducted by the rehabilitations every day after the operative procedure.\u003c/p\u003e\n\u003cp\u003eA follow-up evaluation was scheduled 5 years postoperatively. This postoperative follow-up was completed by the same follow-up team and involved assessment of the KSS, ROM, patellar stability, and complications.\u003c/p\u003e\n\u003cp\u003ePassive postoperative flexion and extension were measured using a standard goniometer with the patient in the supine position. Patellar grinding, catching, and clunking were tested and recorded. Postoperative radiographs were reviewed, and the position of the implant, Insall-Salvati ratio, and joint line position were evaluated.\u003c/p\u003e\n\u003cp\u003ePatellar stability was evaluated with the apprehension test, and the patients were divided into three groups according to the test result: those with patellar stability, subluxation, and dislocation. According to the lateral translation grade, grades I and II with a hard end point were consistent with patellar stability, grade III with a hard end point was consistent with patellar subluxation, and a soft end point was consistent with patellar dislocation. Grade\u0026thinsp;\u0026gt;\u0026thinsp;III was also consistent with patellar dislocation. Radiographic evaluation included the patellar tilt and the patellar lateral shift.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003cp\u003eSPSS statistical software, version 20.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. A t-test or nonparametric test was used to compare the measurement data among the groups, and the chi-square test or a nonparametric test was used to compare the count data. A p value of \u0026lt;\u0026thinsp;0.05 indicated a statistically significant difference.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 99 knees in the CR group and 104 knees in the PS group were available for the 5-year follow-up examination. Three patients in the CR group and four patients in the PS group were lost to follow-up because their addresses had changed. No prosthesis infections, deep vein thrombosis of the lower extremities, or blood vessel or nerve injury were observed, and no obvious immune rejection, hepatitis B, or acquired immunodeficiency syndrome were reported during the follow-up period.\u003c/p\u003e\n\u003cp\u003eIn the CR group, the mean postoperative KSS improved to 90\u0026thinsp;\u0026plusmn;\u0026thinsp;5 and the function score improved to 87\u0026thinsp;\u0026plusmn;\u0026thinsp;4. In the PS group, the mean postoperative KSS improved to 91\u0026thinsp;\u0026plusmn;\u0026thinsp;4 and the function score improved to 84\u0026thinsp;\u0026plusmn;\u0026thinsp;6. There was no significant difference between the two groups.\u003c/p\u003e\n\u003cp\u003eThe mean postoperative ROM was \u0026minus;\u0026thinsp;2\u0026deg;\u0026plusmn;3\u0026deg; extension to 114\u0026deg;\u0026plusmn;8\u0026deg; flexion in the CR group and \u0026minus;\u0026thinsp;2\u0026deg;\u0026plusmn;4\u0026deg; extension to 126\u0026deg;\u0026plusmn;7\u0026deg; flexion in the PS group, with no significant difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eWith respect to patellofemoral complications (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), eight developed patellar clunk syndrome, one developed patellar subluxation, and one developed patellar lateral facet fracture in the PS group. Three patients developed patellar clunk syndrome, and one developed symptomatic subluxation in the CR group. There were significant differences in patellofemoral complications between the CR and PS groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No patients underwent revision.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatellofemoral Complication\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePS\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatella clunk\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatellar subluxations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatellar fracture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe most important finding in this study was the lack of a difference in the KSS 5 years after surgery between CR and PS TKA. There is a better flexion of knee in PS group but more patellofemoral complications (i.e., more patellar clunk, subluxations).\u003c/p\u003e \u003cp\u003eIn terms of clinical scores, both CR and PS TKA can achieve a high KSS. In the CR group, the mean postoperative KSS improved to 90\u0026thinsp;\u0026plusmn;\u0026thinsp;5 and the function score improved to 87\u0026thinsp;\u0026plusmn;\u0026thinsp;4. In the PS group, the mean postoperative KSS improved to 91\u0026thinsp;\u0026plusmn;\u0026thinsp;4 and the function score improved to 84\u0026thinsp;\u0026plusmn;\u0026thinsp;6. Other studies have also shown that patients recover very well after CR and PS TKA and achieve a good KSS and Hospital for Special Surgery knee score \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Our study also showed that CR and PS TKA allowed patients to return to their normal life. Both CR and PS TKA are effective for treatment of advanced osteoarthritis \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study showed that the mean postoperative ROM was \u0026minus;\u0026thinsp;2\u0026deg;\u0026plusmn;3\u0026deg; extension to 114\u0026deg;\u0026plusmn;8\u0026deg;\u0026deg; flexion in the CR group and \u0026minus;\u0026thinsp;2\u0026deg;\u0026plusmn;4\u0026deg; extension to 126\u0026deg;\u0026plusmn;7\u0026deg; flexion in the PS group 5 years after surgery, there was a difference between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). As other researchers have reported that ROM was better after PS TKA, and they considered that the PS design results in better ROM and a better reproduction angle and that PS TKA with a post-cam design and PCL removal provides a conforming articulation, better knee flexion and stair-climbing ability, and more predictable kinematics\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However other researchers have shown that the ROM was not significantly different after PS and CR TKA\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Although most of studies have shown that patients can perform knee flexion and straightening well enough after surgery to return to live. The PS prothesis is still a good choice for patients who needed a good ROM in their activities of daily living.\u003c/p\u003e \u003cp\u003eThese patellofemoral complications were more in PS than CR groups. In the PS group of the present study, eight developed patellar clunk syndrome, one developed patellar subluxation, and one developed patellar lateral facet fracture. In the CR group, three patients developed patellar clunk syndrome, and one developed symptomatic subluxation. All procedures were performed by one senior surgeon, and no other complications were reported. The main difference between the CR and PS groups was the femoral component. So PS femoral component may lead patellofemoral complications. For PS TKA, more bony cuts and shorter trochlear were accepted in the femoral component, and the changed track of the femoral trochlea may lead to patella impact and anterior knee pain, patellar clunk syndrome, patellar subluxation, and patellar fracture. In the CR group, the Lachman test was performed for the four patients with complications, and the Lachman test was positive in three of the patients. Loss of the PCL may be the main cause of patellofemoral complications with changes in pressure on the patella. A recent study showed that PCL rupture results in higher pressure on the medial patella. Some researchers have found that more complications occur after PS than CR TKA. A study involving 108 PS TKAs and 136 improved PS TKAs showed that femoral components with a deep trochlear groove and smooth transition of the intercondylar box were associated with fewer cases of crepitance and patellar clunk syndrome\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe patellofemoral complications in this study included patellar grinding, catching or clunking, patellar instability, and patellar fracture. Alleviation of anterior knee pain is integral to the overall success of TKA\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Such pain continues to be associated with problematic complications that often lead to revision surgery\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Anterior knee pain is a common patellofemoral complication, and patellofemoral complications are associated with anterior knee pain\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Causes of anterior knee pain include the patellofemoral implant design, surgical technique, patient characteristics, and degree of chondromalacia. Patellofemoral crepitance and patellar clunk syndrome develop in the early postoperative period. Patellar clunk is mainly associated with the surgical technique and component positioning. Hamlin reported that more cases of patellar clunk occurred after PS TKA\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Instability after TKA is a severe complication, but few studies have compared patellofemoral complications between CR and PS TKA. Few patellar dislocations occurred in both groups of the present study. Patellar instability after TKA has many causes, including the surgical technique, component position, and extensor mechanism imbalance\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, this was not a randomized controlled study. A good control group will lead to improved studies in the future. Second, an inadequate number of samples was obtained, and the 5-year follow-up was short. More samples and a longer follow-up study are needed in the future. Finally, a mechanics study is needed to further confirm our hypothesis.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eIn conclusion, we found that CR and PS TKA can attain good clinical outcomes in terms of the KSS. However, PS TKA is associated with more complications involving the patellofemoral joint than is CR TKA after 5 years of follow-up.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eCruciate-retaining (CR)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePosterior-stabilized (PS)\u003c/p\u003e\n\u003cp\u003eThe Knee Society Score (KSS)\u003c/p\u003e\n\u003cp\u003eTotal knee arthroplasty (TKA)\u003c/p\u003e\n\u003cp\u003eRange of motion (ROM)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by our hospital institutional ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFei Wang and Yingzhen Niu conceived and designed the study. Fei Wang performed the procedures. Weixia Bai, Gang Ji and Kang Piao gather data. Zhenyue Dong and Conglei Dong wrote the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Angela Morben, DVM, ELS, from Liwen Bianji, Edanz Editing China (www.liwenbianji.cn/ac)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCatani F, Leardini A, Ensini A, Cucca G, Bragonzoni L, ToksvigLarsen S, et al. The stability of the cemented tibial component of total knee arthroplasty. Journal of Arthroplasty. 2004;19: 775-82.\u003c/li\u003e\n\u003cli\u003eYang CP, Hsu KY, Chang YH, Chan YS, Shih HN, Chen CY. Mid-term survivorship of cruciate-retaining versus posterior-stabilized total knee arthroplasty using modular mini-keel tibial implants. Journal of Orthopaedic Surgery and Research. 2018;13: 35.\u003c/li\u003e\n\u003cli\u003eWook HC, Hwan YI, Suk LW, Kyu PK, Dong HC. Evaluation of Postoperative Range of Motion and Functional Outcomes after Cruciate-Retaining and Posterior-Stabilized High-Flexion Total Knee Arthroplasty. Yonsei Medical Journal. 2012;53: 794-00.\u003c/li\u003e\n\u003cli\u003eCankaya D, Ozkurt B, Aydin C, Tabak A. No difference in blood loss between posterior-cruciate-ligament-retaining and posterior-cruciate-ligament-stabilized total knee arthroplasties. Knee Surgery Sports Traumatology Arthroscopy. 2014;22: 1865-69.\u003c/li\u003e\n\u003cli\u003eCho KY, Kim KI, Song SJ, Bae DK. Does Cruciate-Retaining Total Knee Arthroplasty Show Better Quadriceps Recovery than Posterior-Stabilized Total Knee Arthroplasty? - Objective Measurement with a Dynamometer in 102 Knees. Clinics in Orthopedic Surgery. 2016;8.\u003c/li\u003e\n\u003cli\u003eW\u0026uuml;nschel M, Leasure JM, Dalheimer P, Kraft N, W\u0026uuml;lker N, M\u0026uuml;ller O. Differences in knee joint kinematics and forces after posterior cruciate retaining and stabilized total knee arthroplasty. The Knee. 2013;20: 416-21.\u003c/li\u003e\n\u003cli\u003eBercik MJ, Joshi A, Parvizi J. Posterior Cruciate-Retaining Versus Posterior-Stabilized Total Knee Arthroplasty: A Meta-Analysis. The Journal of arthroplasty. 2013;28: 439-44.\u003c/li\u003e\n\u003cli\u003eTanzer M, Smith K, Burnett S. Posterior-stabilized versus cruciate-retaining total knee arthroplasty - Balancing the gap. The Journal of Arthroplasty. 2002;17: 813-19.\u003c/li\u003e\n\u003cli\u003eNowak AC. Outcomes of Posterior-Stabilized Compared with Cruciate-Retaining Total Knee Arthroplasty. The Journal of Knee Surgery. 2018;31: 321-40.\u003c/li\u003e\n\u003cli\u003eMatsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. Soft Tissue Tension in Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty. Journal of Arthroplasty. 2011;26: 788-95.\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;tz J, Beckmann J, Sperrer I, Baier C, Koeck F. Retrospective comparative study shows no significant difference in postural stability between cruciate-retaining (CR) and cruciate-substituting (PS) total knee implant systems. International Orthopaedics. 2015;40: 1441-46.\u003c/li\u003e\n\u003cli\u003eVan dGS, Van dVP, Kremers-Van dHK, S K, Verdonschot N. Flexion and anterior knee pain after high flexion posterior stabilized or cruciate retaining knee replacement. Acta Orthopaedica Belgica. 2015;81: 730.\u003c/li\u003e\n\u003cli\u003eMotsis EK, Paschos N, Pakos EE, Georgoulis AD. Review Article: Patellar Instability after Total Knee Arthroplasty. Journal of Orthopaedic Surgery. 2009;17: 351-57.\u003c/li\u003e\n\u003cli\u003eMatsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R. Intraoperative Soft Tissue Balance Reflects Minimum 5-Year Midterm Outcomes in Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty. The Journal of Arthroplasty. 2012;27: 1723-30.\u003c/li\u003e\n\u003cli\u003eMatsumoto T, Kubo\u0026hellip; S. Different pattern in gap balancing between the cruciate-retaining and posterior-stabilized total knee arthroplasty. Knee Surgery Sports Traumatology Arthroscopy. 2013;21: 2338-45.\u003c/li\u003e\n\u003cli\u003eMatsumoto T, Muratsu H, Kawakami Y, Takayama K, Ishida K, Matsushita T, et al. Soft-tissue balancing in total knee arthroplasty: cruciate-retaining versus posterior-stabilised, and measured-resection versus gap technique. International Orthopaedics. 2014;38: 531-37.\u003c/li\u003e\n\u003cli\u003eHino K, Oonishi Y, Kutsuna T, Watamori K, Iseki Y, Kiyomatsu H, et al. Preoperative varus\u0026ndash;valgus kinematic pattern throughout flexion persists more strongly after cruciate-retaining than after posterior-stabilized total knee arthroplasty. The Knee. 2016;23: 637-41.\u003c/li\u003e\n\u003cli\u003eFrye BM, Floyd MW, Pham DC, Feldman JJ, Hamlin BR. Effect of Femoral Component Design on Patellofemoral Crepitance and Patella Clunk Syndrome After Posterior-Stabilized Total Knee Arthroplasty. Journal of Arthroplasty. 2012;27: 0-0.\u003c/li\u003e\n\u003cli\u003eZou YG, Chen ZW, Feng ZQ, Xing JS. [Factors related to anterior knee pain after total knee arthroplasty]. Nan fang yi ke da xue xue bao = Journal of Southern Medical University. 2011;31: 1428-30.\u003c/li\u003e\n\u003cli\u003eDuan G, Liu C, Lin W, Shao J, Fu K, Niu Y, et al. Different Factors Conduct Anterior Knee Pain Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty. 2018;33(6). Doi:\u003ca href=\"https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.1016%2Fj.arth.2017.12.024?_sg%5B0%5D=u4aZHP2YVTxGL-jqXCZkg6f88wOJLRKGJe-FGooZRpGYnr4uHSiSzTfVbAXaXLrA7BnBZRUy05Zz1cvnxtqkpQZXlA.jzZ7--D7FbjCFZBomtAcdpYFlb3rldDgm9N3aowrBniBuIQSzT6fsasueU4L6ZSHViy6gSxHNWeC099HBD0U4g\"\u003e10.1016/j.arth.2017.12.024\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eRothman RH, Parvizi J, Mortazavi SMJ, Devulapalli C, Sharkey PF, Hozack WJ. Secondary Resurfacing of the Patella after Primary TKA: Does the Anterior Knee Pain Resolve? Journal of Arthroplasty. 2011;27:21-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"posterior-stabilized arthroplasty, cruciate-retaining arthroplasty, patellofemoral joint, total knee arthroplasty, patellar dislocation","lastPublishedDoi":"10.21203/rs.3.rs-467722/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-467722/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackgroud: A prospective cohort study was performed to compare clinical outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) arthroplasty.\u003c/p\u003e\u003cp\u003eMethods: In total, 210 patients (210 knees) underwent CR arthroplasty (n=102) and PS arthroplasty (n=108) from January 2014 to January 2015. The Knee Society Score (KSS), range of motion, patellar stability, and complications were compared between the CR and PS groups 5 years postoperatively. \u003c/p\u003e\u003cp\u003eResults: The CR group comprised 99 knees and the PS group comprised 105 knees at the 5-year follow-up. In the CR and PS groups, the mean postoperative KSS improved to 90±5 and 91±4, and the function score improved to 87±4 and 84±6, respectively (p\u0026gt;0.05). The mean postoperative range of motion was −2°±3° extension to 114°±8° flexion in the CR group and −2°±4° extension to 126°±7° flexion in the PS group, with no significant difference (p\u0026gt;0.05). In terms of patellofemoral complications, eight patients had patellar clunk syndrome, one had patellar subluxation, and one had patellar lateral facet fracture in the PS group. Three patients had patellar clunk syndrome, and one had symptomatic subluxation in the CR group. These patellofemoral complications were significantly different between the groups (p\u0026lt;0.05).\u003c/p\u003e\u003cp\u003eConclusions: CR and PS TKA can achieve good clinical outcomes with respect to the KSS. Better knee flexion but more patella complications in the PS arthroplasty than CR group 5 years postoperatively.\u003c/p\u003e\u003cp\u003eTrail registration: This study was approved by our hospital institutional ethics committee.\u003c/p\u003e","manuscriptTitle":"Posterior-stabilized Arthroplasty Versus Cruciate-retaining Arthroplasty in Treatment of Osteoarthritis: a 5-year Follow-up Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-05-07 13:25:17","doi":"10.21203/rs.3.rs-467722/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b07e61ec-7a05-4078-bc7a-356de50c3342","owner":[],"postedDate":"May 7th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":4151322,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2021-08-31T15:42:18+00:00","versionOfRecord":[],"versionCreatedAt":"2021-05-07 13:25:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-467722","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-467722","identity":"rs-467722","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}