Posterior cruciate ligament function following total knee arthroplasty: the effect of joint line elevation

One of the most commonly cited reasons for retaining the posterior cruciate ligament (PCL) during total knee arthroplasty is to preserve femoral rollback and theoretically improve extensor mechanism efficiency (lengthening the moment arm). This study was undertaken to assess PCL function in this regard and to delineate the effects of joint line elevation that can be manipulated intraoperatively by the surgeon. The anterior movement of tibiofemoral contact following PCL resection at flexion angles 60 degrees demonstrated the beneficial effect of the PCL on extensor function. This anterior translation and the concomitant increases in quadriceps tendon load and patellofemoral contact pressures were consistently observed. This study demonstrated that small changes of the joint line position significantly influenced PCL strain and knee kinematics. In order to preserve the desired functions that would be lost with an overly lax PCL and to avoid the potential adverse effects of an overly tight PCL (posterior edge loading and increased tibiofemoral contact), the surgeon should make every effort to restore the preoperative joint line. If this is not possible, consideration should be given to posterior cruciate recession or use of a posterior cruciate substituting design.