The Journal of Arthroplasty xxx (2018) 1e7

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Stair Climbing and High Knee Flexion Activities in Bi-Cruciate

Retaining Total Knee Arthroplasty: In Vivo Kinematics and
Articular Contact Analysis
Paul Arauz, PhD, Christian Klemt, PhD, Sakkadech Limmahakhun, MD, PhD,
Shuai An, MD, Young-Min Kwon, MD, PhD *
Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

a r t i c l e i n f o a b s t r a c t

Article history: Background: Bi-cruciate retaining (BCR) total knee arthroplasty (TKA) preserves both anterior and pos-
Received 28 September 2018 terior cruciate ligaments with the potential to restore normal posterior femoral rollback and joint ki-
Received in revised form nematics. However, there is limited information regarding articular contact behavior in the
26 October 2018
contemporary BCR TKA design during high knee flexion activities. This study aimed to investigate the
Accepted 12 November 2018
Available online xxx
articular knee contact performance in unilateral BCR TKA patients during strenuous flexion activities.
Methods: Twenty-nine unilateral BCR TKA patients were evaluated for both knees during single deep lunges,
step-ups, and sit-to-stand (STS) using a validated combined computer tomography and dual fluoroscopic
Keywords:
bi-cruciate retaining total knee arthroplasty
imaging system. Medial and lateral condylar contact positions were quantified during weight-bearing flexion.
high flexion Results: Contact excursions of the lateral condyle in BCR TKAs were significantly more anteriorly located
in vivo articular contact kinematics than the contralateral non-operated knees during STS (
4.9 ± 3.1 vs
9.7 ± 4.6 mm, P < .05), single deep
sit-to-stand lunge (
5.7 ± 3.2 vs
10.0 ± 4.5 mm, P < .05), and step-ups (
4.8 ± 3.6 vs
9.1 ± 3.9 mm, P < .05).
lunging Contact points of BCR TKAs indicated reduced femoral external rotation during STS (2.1 ± 4.8 vs 7.7 ±
5.4 , P < .05), single deep lunges (1.8 ± 4.8 vs 7.0 ± 7.1, P < .05), and step-ups (0.1 ± 4.1 vs 6.2 ± 4.9 ,
P < .05). Medial pivoting patterns were observed in only 59%, 56%, and 48% of the BCR TKA knees for
step-ups, STS, and single deep lunge, respectively.
Conclusion: The contemporary BCR TKA design demonstrated asymmetric femoral rollback, medial
translation, as well as lateral pivoting in about half of the patient cohort, suggesting that in vivo tibio-
femoral kinematic parameters were not fully restored in BCR patients during strenuous flexion activities.
© 2018 Elsevier Inc. All rights reserved.

Total knee arthroplasty (TKA) is a common surgical procedure
for end-stage osteoarthritis, and by 2030, the annual incidence of
primary TKA is expected to be 3.5 million in the Unites States [1]. As
an increasing number of young patients require joint replacements,
the expected life time of the prostheses is increasing. At the same
time, the prostheses undergo increased loading due to more
demanding functional activities that are being performed by the
younger patient group, necessitating new materials and designs to
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2018.11.013.
* Reprint requests: Young-Min Kwon, MD, PhD, Department of Orthopaedic
Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street,
Boston, MA 02114.
be introduced in order to ensure that the joint replacements can
restore joint functionality [2,3]. Inability to reproduce 6-degrees of
freedom kinematics, abnormal “paradoxical” anterior femoral
translation, and loss of normal medial pivot rotation are challenges
associated with contemporary posterior cruciate retaining (CR) and
posterior stabilized TKA [4e6]. The removal of the anterior and/or
both cruciate ligaments in CR/posterior stabilized TKA, leading to
significant kinematic alteration of the knee joint, has been
suggested as one of the potential contributory factors resulting in
8%-25% of patients remaining dissatisfied after TKA [7e10]. The
interplay of intact cruciate ligaments with the bony articulating
structures plays an imperative role in maintaining knee joint
function and stability in normal deconditioned subjects [11].
Therefore, the preservation of both cruciate ligaments in TKA is
important when aiming to restore normal posterior femoral roll-
back [12], replicate near-normal knee joint kinematics [13], and
reproduce medial pivot rotation [14].

https://doi.org/10.1016/j.arth.2018.11.013
0883-5403/© 2018 Elsevier Inc. All rights reserved.
2 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7

Bi-cruciate retaining (BCR) TKA was designed to allow preser-

vation of both anterior and posterior cruciate ligaments (ACL and
PCL), and have shown several potential advantages over contem-
porary TKA [15]. Several in vitro studies have shown reduced
anteroposterior (AP) laxity in BCR TKA and closer replication of
native knee kinematics when compared to contemporary TKA,
other studies have demonstrated that the rotational kinematics of
the native knee are not always preserved after BCR TKA [16].
Similarly, an in vivo study has demonstrated that kinematic gait
symmetry was not fully restored in unilateral BCR TKA patients
[17]. In addition, although previous in vivo studies have reported on
BCR TKAs [18], there is a paucity of information regarding the
currently available BCR TKA systems in terms of articular contact
kinematics during high flexion activities. Physically demanding
tasks such as sit-to-stand (STS), step-ups, and lunging may be more
sensitive tools for investigating preserved ACL function and kine-
matic abnormalities following BCR TKA [19]. Therefore, the aim of
this study is to compare in vivo articular contact kinematics be-
tween the operated and the contralateral non-operated knees in
patients unilaterally implanted with a contemporary BCR TKA
design during functionally strenuous high knee flexion activities.
Fig. 1. Dual fluoroscopic imaging system approach used for registration of 3D models
on fluoroscopic silhouettes.
Methods
system surveillance (BV Pulsera; Philips Medical, USA) at 30 frames
Patients per second with an 8 ms pulse width, 60-80 kV, and 0.042-0.066
mAs [20]. Four patients were unable to complete the single leg deep
Twenty-nine well-functioning unilateral BCR TKA patients (14 lunge due to discomfort, leaving 25 of /29 who completed the test.
males and 15 females) with no history of any surgical complication All 29 patients completed the step-up and STS test. The
were included in this study with the institution’s Internal Review two-dimensional dynamic fluoroscopic images and the three-
Board approval. Patients underwent unilateral (16 left, 13 right) BCR dimensional (3D) TKA computer-aided design models were im-
TKA (Vanguard XP Total Knee System; Biomet, Warsaw, IN). All BCR ported into a customized program in MATLAB (MathWorks, Natick,
TKAs in this study had pre-operative varus deformity and were MA). A virtual dual fluoroscopic imaging system environment was
implanted by a single surgeon using a standard medial parapatellar constructed in the customized program for determination of the
approach. The BCR TKA features bearing modularity, thus the TKA component positions. Furthermore, the position of each TKA
thickness of the lateral and medial polyethylene insert was selected component in 3D space was determined with a previously pub-
to balance BCR TKA tibiofemoral tightness of the joint gap in both, lished protocol [21] by performing optimal matching of TKA
flexion and extension (Table 1). The average age was 65.7 years (±7.7, computer-aided design model projections with the dynamic fluo-
range 47-76; Table 1). The average body weight and height were 89.2 roscopic TKA images (Fig. 1). In addition, all 29 patients received
kg (±15.9, range 57.7-120.3) and 172.7 cm (±9.2, range 154.9-185.4), computer tomography scan (Sensation 64; Siemens, Germany; 140
with average body mass index of 29.8 kg/m2 (±4, range 21.8-38.1). kVp, image resolution 512  512 pixels, voxel size 0.97  0.97 
The femoral and tibial component sizes were 66.8 mm (±5, range 60- 0.60 mm3) from the pelvis to the ankles for the creation of 3D
42.5) and 75.3 mm (±4.5, range 67-83), respectively. The average surface models of both knees (BCR TKA and non-operated). Since
follow-up time was 12.7 months (±5.1, range 10.9-21.3) from surgical the polyethylene inserts were invisible to the fluoroscopic images,
data. All patients included in the study were evaluated pre- they were assumed to be rigidly fixed to the tibial baseplate.
operatively and post-operatively at 1-year follow-up, with the The medial and lateral anterior-posterior positions of the femoral
Knee Society Score questionnaire completed. condyles were measured by tracking the lowest point on the medial
and lateral femoral condyles with respect to the tibia [22]. A coordi-
Three-Dimensional In Vivo Knee Kinematic Analysis nate system on the tibial plateau was created to allow quantitative
description of BCR TKA articular contact kinematics. The mediolateral
All patients performed sequential step-ups, single leg deep axis was defined as a line connecting the centers of 2 circles fitted to
lunges, and STS under synchronized dual fluoroscopic imaging the medial and lateral tibial condyles or tibial trays (Fig. 2). The long

Table 1
Demographic Data of Bi-Cruciate Retaining Total Knee Arthroplasty Patients.

N ¼ 29 Average ± Standard Deviation (Range)

Age (y) 65.7 ± 7.7 (47.0-76.0)

Gender 14 male, 15 female
Operated side 16 left, 13 right
Mass (kg) 89.2 ± 15.9 (57.7-120.3)
Height (cm) 172.7 ± 9.2 (154.9-185.4)
Body mass index (kg/m2) 29.8 ± 4.0 (21.8-38.1)
Follow-up (mo) 12.7 ± 5.1 (3.9-21.3)
Femoral component size (mm) 66.9 ± 5.0 (60.0-72.5)
Poly-thickness medial 9.7 ± 0.9 (9.0-12.0)
Fig. 2. Contralateral non-operated knee (left) and BCR TKA (right) medial-lateral
Poly-thickness lateral 9.7 ± 0.9 (9.0-12.0)
midlines defined by connecting the 2 circles fitted to the corresponding medial and
Tibial component size (mm) 75.3 ± 4.5 (67.0-83.0)
lateral tibial condyles or tibial plateaus and trays, respectively.
 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7
Fig. 3. Lateral and medial condyle anterior-posterior (AP) excursion, lateral-medial (LM) excursion, and femoral axial rotation exhibited in BCR TKAs and the contralateral non-
operated knees during sit-to-stand. Black bars on the horizontal axis (knee flexion) indicate statistical significant differences between limbs. P/A, anterior-posterior excursion;
IR/ER, internal-external femoral rotation.
axis was parallel to the posterior cortex of the tibial shaft. The AP axis
was set at a perpendicular distance with respect to the other 2 axes.
The mean contact position of the BCR TKA and contralateral non-
operated knees during step-ups, lunge, and STS was projected on
the tibial plateau surfaces and measured using the above-mentioned
mediolateral and AP axes [22,23]. Articular contact kinematics was
analyzed from full extension to 50 , 90 , and 100 of knee flexion
during step-ups, STS, and single deep lunges, respectively.
Statistical Analysis
For statistical analysis, the paired-sample Wilcoxon signed-rank
test was performed to compare differences in mid-points of artic-
ular contact point excursions between the BCR TKA designs and the
contralateral non-operated knee during (1) single leg deep lunge
and (2) STS. A level of significance was set at 0.05.
Results
In Vivo Articular Contact Kinematics During Sit-to-Stand
At 1-year follow-up, significant improvement in KSS was noted in
BCR TKA patients (pre-operative 58.1 ± 11.8 vs post-operative 87.9 ±
16.7, P < .001). Contact excursions of the lateral condyle in BCR TKAs
were significantly less posteriorly located than the contralateral
non-operated knee (5 ± 3.2 vs 9.9 ± 4.6 mm, P < .05) from 6 to 90 of
knee flexion during STS (Figs. 3 and 4). Articular contact excursions
of the medial condyle in BCR TKAs were less posteriorly located than
the non-operated knee (2 ± 3.2 vs 3.8 ± 3.9 mm, P < .05) from 79 to
90 of knee flexion during STS (Figs. 3 and 4). Although no significant
difference was detected in the lateral excursions of the lateral
condyle between BCR TKAs and the non-operated knees (23.8 ± 1 vs
23.5 ± 4.2 mm, P > .05) from 0 to 90 of knee flexion during STS,
3
medial excursions of the medial condyle were significantly lower in
BCR TKAs than the contralateral non-operated knees (23.7 ± 1 vs 31
± 5 mm, P < .05) from 0 to 90 of flexion (Figs. 3 and 4). In addition,
BCR TKAs experienced less femoral external rotation than the
contralateral non-operated knees (2.2 ± 5 vs 7.4 ± 5.5 , P < .05) from
22 to 90 of knee flexion during STS (Figs. 3 and 4). Medial pivoting
patterns were observed in only 56% of the BCR TKA knees for STS
(medial contact point excursion: 8.2 ± 6.1 mm; lateral contact point
excursion: 9.4 ± 7.5 mm; Fig. 4).
In Vivo Articular Contact Kinematics During Single Leg Deep Lunge
Similar to the articular contact excursions observed during STS,
contact excursions of the lateral condyle in BCR TKAs were signifi-
cantly less posteriorly located than the contralateral non-operated
knee (5 ± 6 vs 10.4 ± 4.6 mm, P < .05) from 25 to 100 of knee
flexion during single deep lunge (Figs. 5 and 6). However, posterior
articular contact excursions of the medial condyle in BCR TKAs were
similar to the non-operated knee (3.7 ± 2.6 vs 3.9 ± 4.9 mm, P > .05)
from 0 to 100 of knee flexion during single deep lunge (Figs. 5 and 6).
Although no significant difference was detected in the lateral excur-
sions of the lateral condyle between BCR TKAs and the non-operated
knees (23.9 ± 1 vs 23.4 ± 3.9 mm, P > .05) from 0 to 100 of knee
flexion during single deep lunge, medial excursions of the medial
condyle were significantly lower in BCR TKAs than the contralateral
non-operated knees (23.5 ± 0.7 vs 31 ± 4 mm, P < .05) from 0 to 100
of flexion (Figs. 5 and 6). Furthermore, BCR TKAs experienced less
femoral external rotation than the contralateral non-operated knees
(1.8 ± 4.9 vs 6.9 ± 7.7, P < .05) from 30 to 100 of knee flexion during
single deep lunge (Figs. 5 and 6). Medial pivoting patterns were
observed in only (14/25) 56% of the BCR TKA knees for single deep
lunge (medial contact point excursion: 7.2 ± 5.4 mm; lateral contact
point excursion: 7.4 ± 6.2 mm; Fig. 6).
4 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7

Fig. 4. Average excursion of condylar contact points shown on the medial and lateral polyethylene inserts of BCR TKA patients at selected knee flexion angles during sit-to-stand.

In Vivo Articular Contact Kinematics During Step-Ups
Contact excursions of the lateral condyle in BCR TKAs were
significantly less posteriorly located than the contralateral non-
operated knee (
4.8 ± 3.6 vs
9.1 ± 3.9 mm, P < .05) from 21 to
50 of knee flexion during step-up (Figs. 7 and 8). Articular contact
excursions of the medial condyle in BCR TKAs were more posteri-
orly located than the non-operated knee (
5.4 ± 1.8 vs
3.2 ± 4.5
mm, P < .05) from 35 to 50 of knee flexion during step-up (Figs. 7
and 8). Significant differences were detected in lateral excursions of
the lateral condyle between BCR TKAs and the non-operated knees
(24 ± 1.4 vs 21.8 ± 3.9 mm, P < .05) from 0 to 7 of knee flexion
during step-up. Similarly, medial excursions of the medial condyle
were significantly lower in BCR TKAs than the contralateral non-
operated knees (23.1 ± 1.7 vs 31.6 ± 5.1 mm, P < .05) from 0 to
50 of flexion during step-ups (Figs. 7 and 8). In addition, BCR TKAs
experienced less femoral external rotation than the contralateral
non-operated knees (
0.1 ± 4.1 vs 6.2 ± 4.9 , P < .05) from 22 to
50 of knee flexion during step-up (Figs. 7 and 8). Medial pivoting
patterns were observed in only 59% of the BCR TKA knees for step-

Fig. 5. Lateral and medial condyle anterior-posterior (AP) excursion, lateral-medial (LM) excursion, and femoral axial rotation exhibited in BCR TKAs and the contralateral non-
operated knees during single deep lunge. Black bars on the horizontal axis (knee flexion) indicate statistical significant differences between limbs. P/A, anterior-posterior excur-
sion; IR/ER, internal-external femoral rotation.
 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7 5

Fig. 6. Average excursion of condylar contact points shown on the medial and lateral polyethylene inserts of BCR TKA patients at selected knee flexion angles during single deep
lunge.

ups (medial contact point excursion: 8.7 ± 6.5 mm; lateral contact
point excursion: 7.6 ± 6.6 mm; Fig. 8).
Discussion
This study investigated patients with a contemporary BCR TKA
to determine if preservation of both cruciate ligaments is reflected
in tibiofemoral articular contact kinematic similarities when
compared to the contralateral non-operated knee. The contempo-
rary BCR TKA design demonstrated significantly reduced posterior
contact excursions of the lateral condyle, as well as similar poste-
rior contact excursion of the medial condyle suggesting incomplete
replication of the “screw home” mechanism as quantified through a
smaller magnitude of external tibial rotation during early knee
flexion, when compared to the contralateral non-operated knees
during strenuous flexion activities. Although pronounced pivot

Fig. 7. Lateral and medial condyle anterior-posterior (AP) excursion, lateral-medial (LM) excursion, and femoral axial rotation exhibited in BCR TKAs and the contralateral non-
operated knees during step-ups. Black bars on the horizontal axis (knee flexion) indicate statistical significant differences between limbs. P/A, anterior-posterior excursion; IR/
ER, internal-external femoral rotation.
6 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7
Fig. 8. Average excursion of condylar contact points shown on the medial and lateral polyethylene inserts of BCR TKA patients at selected knee flexion angles during step-ups.
position variability was observed with only 59% of patients
demonstrating medial pivoting patterns, our findings indicate that
the contemporary BCR TKAs do not fully replicate the in vivo
articular contact kinematics of the contralateral non-operated knee
during most of the knee flexion ranges for STS, single deep lunge,
and step-up activities.
The patterns of femoral condyle anterior-posterior and axial
rotation of BCR TKAs were mostly similar to those of the contra-
lateral non-operated knee at the initial position and during early
flexion. However, lateral-medial discrepancies at the medial
condyle between BCR TKAs and the contralateral non-operated
knees were found during the entire range of knee flexion. Agree-
ment in tibiofemoral articular kinematic patterns of femoral con-
dyles regarding anterior-posterior translation and axial rotation
between BCR TKAs and the contralateral non-operated knees in
early flexion suggest the ACL and PCL preservation in BCR TKAs may
have the potential to effectively reproduce the normal knee func-
tion. However, others factors, such as implant positioning or
articular surface design of the tibial liner, such as the absence of a
convex lateral tibial plateau [24], may also attribute to articular
contact asymmetries between BCR TKAs and the contralateral non-
operated knees. Retention of the cruciate ligaments in BCR TKA may
have potential disadvantages as well. In a recent study comparing
the identical BCR TKA design evaluated in our study, Christensen
et al [25] reported longer mean surgical durations for BCR TKA and
a higher frequency of all-cause revision, re-operation, and radio-
lucent lines at a mean of 18 months in comparison with CR TKA. In
addition, there were no differences in patient-reported clinical
outcomes between the BCR and CR TKA groups. It has been sug-
gested that these findings may be related to the initial learning
curve and challenging surgical technique [26].
Significantly less lateral femoral rollback was observed during
STS, single deep lunge, and step-ups in BCR TKA knees when
compared to the contralateral non-operated knees. These findings
are in contrast with the results presented by Grieco et al [22], in
which the anterior-posterior motion of the medial condyle in bi-
cruciate stabilized TKA was different from the healthy knee at 60
of knee flexion, but it was similar for the lateral condyle beyond
early knee flexion. It has been suggested that the anterior cam-post
design and asymmetric articular contact geometry may effectively
substitute for the ACL motion with regard to AP motion, but not for
axial rotation [22]. However, consistent with our results, Moro-oka
et al [18] demonstrated that BCR TKAs presented greater posterior
femoral translation when compared to CR implants, but failed to
restore native femoral rollback. Stiehl et al [27] studied 16 BCR TKA
implants which also demonstrated the absence of paradoxical
anterior sliding with improved femoral rollback when compared to
CR TKA. The lack of femoral rollback has also been described in CR
TKA studies and has been attributed to the possible overstretching
of the PCL [28]. Yue et al reported reduced femoral rollback in CR
TKA and attributed it to overstretching of the PCL in CR TKA during
deep flexion and the phenomenon of kinematic conflict. Kinematic
conflict occurs in CR TKA when the posterior lip of the dished tibial
insert prevents femoral rollback, resulting in progressive tightening
of the PCL [29].
Stiehl et al [27] reported that the absolute femoral rollback
between the medial and lateral condyles was very similar (3 and 4
mm, respectively), therefore resulting in the inability to reproduce
a normal medial pivoting pattern despite achieving improved
femoral rollback. Despite using a different, contemporary BCR TKA
prosthesis, our patients demonstrated pronounced pivoting vari-
ability with 17 of 29 (58.6%) in step-up patients, 14 of 25 (56.0%) in
lunge patients, and 13 of 29 (44.8%) of STS patients displaying
medial pivoting while the remaining patients showed the lateral
pivoting. This finding concurs with a previous study reporting on
pre-TKA and post-TKA changes in kinematics, indicating consid-
erable pivoting variability pre-operatively and post-operatively
[30]. Our results suggest that ACL preservation alone may not be
sufficient to restore native knee motion and medial pivot rotation.
This may, in part, be related to the implant orientation and
alignment as well as the implant design such as non-anatomical
articular surface design of the BCR TKA evaluated in our study
[31e34]. Zumbrunn et al performed dynamic computer simula-
tions with biomimetic BCR TKA with anatomical articular surfaces
of convex lateral plateau and concave medial plateau. The authors
reported activity-dependent restoration of normal knee kine-
matics and medial pivot rotation similar to the healthy knee
in vivo and concluded that ACL preservation together with
anatomic articular surface is essential to restore native knee mo-
tion [14].
 P. Arauz et al. / The Journal of Arthroplasty xxx (2018) 1e7
The results of this study need to be interpreted in light of
several limitations. First, we analyzed the articular contact kine-
matics between BCR TKA and the contralateral non-operated, as
there was no pre-operative data available for comparisons. How-
ever, all participants in this study presented with no radiographic
signs of osteoarthritis in the contralateral non-operated knee.
Second, all patients in this study had a single BCR TKA design.
Thus, the findings of this study may not be generalized to different
types of BCR TKA system. Third, all patients in this study had a
short follow-up time. Although functional improvements have
been demonstrated up to 12 months post-surgery, the mean
follow-up time of 12.7 months (range 10.9-21.3) ensures that the
key findings of this study would not significantly change if pa-
tients with less than 12-month follow-up time were excluded
from the analysis. Fourth, proprioception data were not collected
in this study which may be an important parameter in BCR THA
patients. Finally, although all patients had morphologically intact
cruciate ligaments, there may be degenerative histological changes
which may affect in vivo cruciate ligament function. However,
cruciate ligament elongation patterns in normal healthy knees
have been reported to be similar even when compared to knees
with osteoarthritis [23].
In conclusion, the BCR TKA design demonstrated asymmetric
femoral rollback as well as lateral pivoting, when compared to the
non-operated knee, suggesting that BCR TKA does not fully repli-
cate the kinematics of the contralateral non-operated knee during
most of the knee flexion ranges for STS, single deep lunge, and
step-up activities. Further studies are required to elucidate the
importance of surgical component positioning and implant artic-
ular geometry in optimizing in vivo kinematics of the BCR TKA
during strenuous flexion activities.
Acknowledgments
This study received partial financial support from Biomet
(Warsaw, IN) and the Department of Orthopaedic Surgery, Massa-
chusetts General Hospital.
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