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Doctor Jean-Marie Cloutier is a pioneer of knee
arthroplasty. In the late seventies, the inventive
surgeon imagined a way to replace worn
articular surfaces of the knee while preserving
its native ligaments [1]. The concept he proposed
was to minimize prosthetic constraints and let
knee motion and stability be dictated by the soft
tissues. Through commercial partnerships, he
developed an implant that turned out to be one
of the very few to remain in use for decades
without significant design modifications.
Currently it is implanted by only a handful of
surgeons worldwide: why is that so?
Better knee
kinematics…
The most logical way to restore or preserve
normal function is to replicate or preserve
normal anatomy. The field of orthopedic
surgery is filled with demonstrations of this
principle for every part of the human body.
Cloutier understood that: in addition to
preserving all the knee ligaments, he designed
the prosthetic femoral component to replicate
the shape of the human femur, including an
asymmetrical trochlear groove, a first at the
time. Therefore, it is perhaps not surprising that
his bicruciate-retaining knee prosthesis
outperformed various posterior-stabilized (PS)
and posterior-cruciate-retaining (CR) designs
in their ability to restore normal knee kinematics
[2-3]. Other studies also showed that patients
implanted with different arthroplasty designs
in their left and right knees preferred the
bicruciate-retaining design over PS and CR
implants [4-5]. Knowing that, shouldn’t this
technique be widespread?
…But stiffer knees?
Obviously, better knee kinematics in a gait lab
and patient preference don’t tell the whole
story. Many surgeons stopped performing
bicruciate-retaining arthroplasty as they felt it
resulted in stiff knees more often than with CR
or PS arthroplasty. This perception was
reinforced in the orthopedic community by
Goutallier
et al.
who reported that knees with a
bicruciate-retaining implant were in average
stiffer and more painful than with a PS implant
[6]. These conclusions should however be
regarded with caution as they were drawn from
a non-randomized retrospective study with
significant differences between the groups for
pre-operative weight, height, frontal alignment,
and AP laxity; pre-operative flexion also
differed between groups but did not reach
clinical significance; most importantly, the
surgical technique was not the same for the two
groups. Indeed, the extra-articular tensioning
device developed by Cloutier was only used for
Bicruciate-retaining TKA:
A Concept Worth Exploring
F. Lavoie, K. Iguer, F. Al-Shakfa