Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for treatment of osteoarthritis and rheumatoid arthritis

  • Review
  • Intervention




The functional and clinical results to support the choice whether or not to retain the posterior cruciate ligament (PCL) during total knee arthroplasty have not been gathered and analysed so far. There are at least some trials showing no difference.


To identify the difference in functional, clinical, and radiological outcome between retention and sacrifice of the PCL in total knee arthroplasty in patients with osteoarthrosis and other non-traumatic diseases.

Search methods

A search was conducted in MEDLINE(Through PubMed; 1966 - March 2004), EMBASE (1980 - March 2004), Cochrane Central Register of Controlled Trials (CENTRAL Issue 2004 - 1), and Current Contents (1996 - March 2004). Also, references of selected articles were checked and citation tracking on the articles selected was performed.

Selection criteria

Randomised controlled trials comparing retention to sacrifice of the PCL during total knee arthroplasty with regard to functional, radiological and clinical outcome in patients with osteoarthritis and other non-traumatic diseases were selected by two independent reviewers.

Data collection and analysis

Methodological quality was assessed with the checklist by van Tulder and the Jadad list. Data was collected with a predeveloped form. Meta-analysis was performed with subgroup analyses on age, gender, disease severity, and follow-up time, if allowed by adequate power.

Main results

Eight randomised controlled trials were found. Two treatment options were compared against PCL retention: PCL sacrifice without additional stabilisation (post and cam mechanism) (2 studies), and PCL sacrifice with posterior stabilized design (5 studies). One study included all three options. Range of motion was found to be 8.1° higher in the posterior stabilized group compared to the PCL retention group (p=0.01, 95% confidence interval [1.7, 14.5]), although the heterogeneity was high (I2 = 66.3%). PCL resection without substituting the PCL with a posterior stabilised prosthesis showed no difference compared to PCL retention (p=0.31, I2 = 83.2%). On clinical scores, only Hospital for Special Surgery score revealed a significant difference of 1.6 points (p=0.03, 95% confidence interval [-3.1, -0.1]) between PCL retention versus PCL sacrifice and substitution combined favouring the latter group. The necessary subgroup analyses could not be performed for the clinical scores.

Authors' conclusions

These results should be interpreted with caution as the methodological quality of the studies was highly variable. We conclude that there is, so far, no solid base for the decision to either retain or sacrifice the PCL with or without use of a posterior stabilized design during total knee arthroplasty. The technique of PCL retention is difficult because the normal configuration and tension need to be reproduced with ligament tensioners. Knowledge of the technique needs to be improved before it can yield superior results compared to the more straightforward techniques of PCL sacrifice or use of a posterior stabilized design. Also, studies evaluating the effect of both techniques should address the right outcome parameters such as range of motion, contact position, and anterior-posterior stability. Suggestions are given to improve future research on this specific topic of knee arthroplasty.








搜尋包括MEDLINE (經PubMed; 1966  March 2004), EMBASE (1980  March 2004), Cochrane Central Register of Controlled Trials (CENTRAL Issue 2004 – 1), and Current Contents (1996  March 2004)。同時手動搜尋所選文章之參考文獻。




研究方法品質由van Tulder及Jadad以量表評估。資料收集於事先已發展好之表單。若統合分析有足夠之檢定力,則進行對年齡、性別、疾病嚴重度與追蹤時間之次群組綜合分析。


8個隨機對照試驗研究。2篇後十字韌帶犧牲未加穩定(post and cam mechanism)及5篇後十字韌帶犧牲加後方穩定設計與後十字韌帶保留之比較,另1篇包含所有三種方法。後十字韌帶犧牲加後方穩定之關節活動度比後十字韌帶保留組高8.1度(p = 0.01, 95% 信賴區間confidence interval [1.7, 14.5]),雖然異質性高(I 66.3%)。十字韌帶犧牲未加穩定與後十字韌帶保留組無顯著差異(p = 0.31, I2 = 83.2%)。後十字韌帶犧牲合併後方穩定與保留組,在臨床分數只有Hospital for Special Surgery score顯示有差異1.6點(p = 0.03, 95% 信賴區間confidence interval [−3.1, −0.1]),但無法做臨床分數次群組分析。





此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。


在膝退化性關節炎和類風濕性關節炎的全膝關節置換手術,保留後十字韌帶(PCL)或不保留哪個較好呢? 8個研究從低到高品質都被進行了回顧,並提供今日我們擁有最好的證據。該研究測試超過570位類風濕關節炎與退化性關節炎患者的膝蓋,手術後紀錄手術的好處與壞處長達 5年。 什麼是膝蓋退化性關節炎與類風濕性關節炎和 後十字韌帶保留與否可造成不同嘛? 退化性關節炎和類風濕性關節炎是關節炎的兩種形式,可以影響膝蓋。在一些人,因為關節炎造成的膝蓋破壞與疼痛可以嚴重到需要手術。在這些人,受損的膝蓋表面可以用人工膝關節植入物取代。後十字韌帶(PCL)是膝蓋其中一個主要的韌帶。它提供膝蓋的支持和穩定運動。在全膝關節置換術,後十字韌帶可以被保留或去除,選擇取決於PCL的條件,膝關節植入物的種類或外科醫生喜歡的手術類型。當去除後十字韌帶(PCL)時,有時需要一種特殊的膝蓋植入物來提供膝蓋穩定。這種特殊植入物有一個樁可以引導 /幫助促進向前和向後運動。保留後十字韌帶(PCL)是一種新的方法,手術時較困難,如果沒有做好,並可能導致關節疼痛或不穩定。目前尚不清楚哪種方法更好。 研究想表明什麼?疼痛和力量: 研究表明,與去除後十字韌帶(PCL)的患者相比,保留後十字韌帶(PCL)的患者術後有同樣疼痛和力量的改善。 運動範圍:研究表明,有沒有保留後十字韌帶(PCL)其改善是類似的。但是,在去除PCL後放入一個特殊的膝關節植入物,運動範圍會較好。比起保留後十字韌帶(PCL),去除後十字韌帶(PCL)後放入一個特殊的膝關節植入物,運動範圍會多8度。 疼痛,膝關節功能和力量:研究表明,比起保留後十字韌帶(PCL)的人,去除後十字韌帶(PCL)不論是否有沒有加特殊植入物)的患者其改善是更好的。 什麼是底線?證據品質是“銀”級。沒有足夠的證據來說明全膝關節置換手術保留或去除後十字韌帶(PCL)哪個是最好的。在被證實其優於去除後十字韌帶(PCL)的手術前,保留PCL後十字韌帶(PCL)的手術方法和知識需要加以改進。

Plain language summary

Total knee replacement for osteoarthritis and rheumatoid arthritis

In Total Knee Replacement surgery for osteoarthritis and rheumatoid arthritis of the knee, is it better to keep the Posterior Cruciate Ligament (PCL) or not?
Eight studies of low to high quality were reviewed and provide the best evidence we have today. The studies tested over 570 people with osteoarthritis or rheumatoid arthritis of the knee. The benefits and harms of the surgery were measured up to 5 years after surgery.

What is osteoarthritis and rheumatoid arthritis of the knee and how could the PCL make a difference?
Osteoarthritis and rheumatoid arthritis are two forms of arthritis that can affect the knees. In some people, damage and pain in the knee from arthritis may be severe enough for surgery. In these people, the damaged joint surfaces can be replaced by an artificial joint or knee implant.

The posterior cruciate ligament (PCL) is one of the major ligaments in the knee. It provides support and stable movement of the knee. In total knee replacement surgery, the PCL can be kept or removed and this choice depends on the condition of the PCL, the type of knee implant or the type of surgery the surgeon likes to do. When removing the PCL a special knee implant is sometimes used to provide some stability. The special implant has a peg which guides/facilitates forward and backward movement. Keeping the PCL is a new method, more difficult to do and may cause pain or an unstable joint if not done properly. It is not clear which method is better.

What did the studies show?
Pain and strength: Studies show that the people who kept their PCL had the same improvement in pain and strength after surgery than those who had the PCL removed.

Range of motion: Studies show that improvement was similar in people who did or did not keep their PCL. But when a special knee implant was inserted after the PCL was removed, range of motion was better.
Range of motion was 8 degrees better when the PCL was removed and a special implant inserted than when the PCL was kept

Overall pain, knee function and strength: Studies show that improvement was better in people who had the PCL removed (whether with a special implant or not) than people who kept their PCL.

What is the bottom line?
The level of quality of the evidence is "silver".

There is not enough evidence to say whether keeping the Posterior Cruciate Ligament (PCL) or removing the PCL is best in total knee replacement surgery.

It is likely that methods and knowledge about surgery for keeping the PCL will need to be improved before it is proven better than surgeries that remove the PCL.