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

Wilco Jacobs; Darren J Clement; Ate AB Wymenga

doi:10.1002/14651858.CD004803.pub2

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

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Referencias

References to studies included in this review

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estudios excluidos
estudios a la espera de valoración
otras referencias

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References to studies excluded from this review

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estudios a la espera de valoración
otras referencias

Cash RM, Gonzalez MH, Garst J, Barmada R, Stern SH. Proprioception after arthroplasty: role of the posterior cruciate ligament. Clinical Orthopedics and related Research 1996, (331):172‐178. [MEDLINE: 911]

Cope MR, O'Brien BS, Nanu AM. The influence of the posterior cruciate ligament in the maintenance of joint line in primary total knee arthroplasty: a radiologic study. Journal of Arthroplasty 2002;17(2):206‐208. [MEDLINE: 92]

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Laskin RS. The Insall Award. Total knee replacement with posterior cruciate ligament retention in patients with a fixed varus deformity. Clinical Orthopedics and related Research 1996, (331):29‐34. [MEDLINE: 247]

Laskin RS. Cemented total knee replacement in patients with osteoarthritis: A five‐year follow‐up study using a prosthesis allowing both retention and resection of the posterior cruciate ligament. Knee 1997;. 4(1):1‐6. [MEDLINE: 773]

Simmons S, Lephart S, Rubash H, Borsa P, Barrack RL. Proprioception following total knee arthroplasty with and without the posterior cruciate ligament. Journal of Arthroplasty 1996;11(7):763‐768. [MEDLINE: 909]

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References to studies awaiting assessment

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Aigner C, Windhager R, Pechmann M, Rehak P, Engeleke K. The influence of an anterior‐posterior gliding mobile bearing on range of motion after total knee arthroplasty. A prospective, randomized, double‐blinded study. Journal of Bone and Joint Surgery (American) 2004;86‐A(10):2257‐2262.

Additional references

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Catani 2004

Methods	RCT, method of randomisation, allocation concealment or blinding not described
Participants	Group A: 20 Group B: 20 Inclusion: Not described (OA selected) Exclusion: Not described
Interventions	PCL: Group A: Retention Group B: PS Brand: Optetrak, Exactech, Gainesville, FL, US Patella: Not described Bearing: Not described Cement: Yes Flexion space: AP/ML: Not described
Outcomes	RSA Knee Society Score Hospital Special Surgery Score Range of motion
Notes	Duration of follow‐up: 48 Months Follow‐up rate: 100%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Clark 2001

Methods	RCT, Multicentre, stratified by surgeon, method of randomisation, allocation concealment or blinding not described
Participants	Group A: 59 Group B: 69 Inclusion: Speaking English 57‐89 years of age OA, OA plus psoriasis, or fracture OA Intact PCL Exclusion: Previous TKA Patellectomy High Tibial Osteotomy Cruciate ligament reconstruction Knee sepsis Flexion <90 degrees flexion contracture > 15 degrees Willing to comply with the assessments Varus > 20 and Valgus > 15 degrees
Interventions	PCL: Group A: Retention Group B: Resection + posterior stabilized Brand: AMK, DePuy / Johnson & Johnson, Warsaw Indiana, US Patella: Yes Bearing: Not described Cement: Yes Flexion space: AP: Spacer blocks ML: Not described
Outcomes	Knee Society Score Range of motion SF‐12 WOMAC
Notes	Duration of follow‐up: 6 Weeks, 3 and 6 Months and Yearly thereafter. Follow‐up rate: 90% 1 Year, 76% 2 Years, 51% 3 years
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Maruyama 2004

Methods	RCT, Bilateral procedures, method of randomisation, allocation concealment or blinding not described
Participants	Group A: 10 Group B: 10 Inclusion: Bilateral procedure within 2 years OA Correction of alignment can be achieved with retention of the PCL Exclusion: Significant fixed deformity
Interventions	PCL: Group A: Retention Group B: Excision + posterior stabilized Brand: PFC from DePuy / Johnson & Johnson, Warsaw, Indiana, US Patella: Not described Bearing: Not described Cement: Flexion space: AP: Not described ML: Posterior condylar axis
Outcomes	Knee Society score Extension angle Flexion angle Range of motion Joint line
Notes	Duration of follow‐up: 30 Months Follow‐up rate: 100%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Misra 2003

Methods	RCT, Table generated, observer blinded. Method of allocation concealment not described.
Participants	Group A: 51 Group B: 54 Inclusion: Not described (OA/RA selected) Exclusion: Not described
Interventions	PCL: Group A: Retention Group B: Resection Brand: Press Fit Condylar (PFC), DePuy, Warsaw Indina, US Patella: Criteria for resurfacing Bearing: Not described Cement: Yes Flexion space: AP: Not described ML: Not described
Outcomes	Hospital Special Surgery Score Range of Motion Satisfaction Rollback Loosening
Notes	Duration of follow‐up: 57 Months Follow‐up rate: 81%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Shoji 1994

Methods	RCT, Bilateral procedures, method of randomisation, allocation concealment or blinding not described
Participants	Group A: 28 Group B: 28 Inclusion: Not described (OA/RA selected) Exclusion: Not described
Interventions	PCL: Group A: Retention Group B: Resection Brand: Total Condylar Modifier, Biomed, Warsaw Indiana, US Patella: Not described Bearing: Not described Cement: Not described Flexion space: AP: Not described ML: Not described
Outcomes	Hospital Special Surgery Score HSS Pain subscore HSS Muscle power subscore Range of motion
Notes	Duration of follow‐up: 2.5‐4.5 Years (3.2 Years average) Follow‐up rate: 100%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Straw 2003

Methods	RCT, observer blinded, method of randomisation or allocation concealment not described
Participants	Group A: 66 Group B: 101 Inclusion: Not described (OA/RA selected) Exclusion: Not described
Interventions	PCL: Group A: Retention Group B: Resection Brand: Genesis I, Smith & Nephew Patella: Yes Bearing: Not described Cement: Not described Flexion space: AP: Monogram balancer ML: Monogram balancer
Outcomes	Knee Society Score Knee Society Score Function Range of motion KSS Knee pain AP stability ML stability
Notes	Duration of follow‐up: 1‐ 6.5 Years (3.5 Years average) Follow‐up rate: 89%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

swanik 2004

Methods	RCT, Table generated, Patient blinded. Method of allocation concealment not described.
Participants	Group A: 10 Group B: 10 Inclusion: Unilateral grade 2‐3 OA Exclusion: VV > 10 degrees flexion contracture > 10 degrees Peripheral neuropathy History of cerebro vascular incidents Diabetes Mellites RA History of Total knee arthroplasty
Interventions	PCL: Group A: Retention Group B: Resection + posterior stabilized Brand: Nexgen, Zimmer, Warsaw Indiana, US Patella: Not described Bearing: Not described Cement: Not described Flexion space: AP: Not described ML: Not described
Outcomes	Roproduction of passive positioning Threshold to detection of passive motion Balance index
Notes	Duration of follow‐up: 7.6 Months Follow‐up rate: 100%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Tanzer 2002

Methods	RCT, patient and observer blinded, method of randomisation or allocation concealment not described
Participants	Group A: 20 Group B: 20 Inclusion: Not described (OA, RA, Avascular necrosis selected) Exclusion: Not described
Interventions	PCL: Group A: Retention Group B: Resection + posterior stabilized Brand: Retention: Nexgen; Posterior stabilized: Legacy Zimmer, Warsaw Indiana, US Patella: Partly Bearing: Not described Cement: Yes Flexion space: AP: Spacer blocks ML: Epicondylar axis
Outcomes	Knee Society Score Clinical Knee Society Score Functional Flexion
Notes	Duration of follow‐up: 6 Weeks, 3 and 6 Months, and 1 and 2 Years Follow‐up rate: 100%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

PCL = Posterior Cruciate Ligament
PCL = Posterior Cruciate Ligament; OA = Osteoarthritis; RA = Rheumatoid arthritis; TKA = Total knee arthroplasty; AP = antero‐posterior; ML = medial‐lateral

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Cash 1996	Not randomised
Cope 2002	outcome parameter or timing
Dorr 1988	Not randomised
Ishii 1998	Not randomised
Laskin 1996	Not randomised
Laskin 1997	Not randomised
Simmons 1996	Not randomised
Stiehl 1997	Not randomised
Vinciguerra 1994	Not randomised

Data and analyses

Open in table viewer

Comparison 1. Posterior cruciate retention vs Sacrifice (all types)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	6	540	Mean Difference (IV, Random, 95% CI)	‐4.38 [‐8.60, ‐0.16]
Open in figure viewer Analysis 1.1 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 1 Range of motion.
2 Flexion angle Show forest plot	2	60	Mean Difference (IV, Fixed, 95% CI)	‐2.53 [‐9.15, 4.08]
Open in figure viewer Analysis 1.2 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 2 Flexion angle.
3 Extension angle Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐2.08, 0.88]
Open in figure viewer Analysis 1.3 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 3 Extension angle.
4 Roll‐Back Show forest plot	1	105	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.44, 1.81]
Open in figure viewer Analysis 1.4 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 4 Roll‐Back.
5 Improvement of ROM Show forest plot	4	309	Mean Difference (IV, Fixed, 95% CI)	0.93 [‐4.75, 6.60]
Open in figure viewer Analysis 1.5 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 5 Improvement of ROM.
6 Knee Society Clinical score Show forest plot	4	291	Mean Difference (IV, Fixed, 95% CI)	0.52 [‐1.71, 2.75]
Open in figure viewer Analysis 1.6 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 6 Knee Society Clinical score.
7 Knee Society Function Score Show forest plot	3	271	Mean Difference (IV, Fixed, 95% CI)	‐3.55 [‐8.71, 1.61]
Open in figure viewer Analysis 1.7 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 7 Knee Society Function Score.
8 Hospital Special Surgery Score Show forest plot	3	201	Mean Difference (IV, Fixed, 95% CI)	‐1.64 [‐3.13, ‐0.14]
Open in figure viewer Analysis 1.8 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 8 Hospital Special Surgery Score.
9 HSS Pain Show forest plot	1	56	Mean Difference (IV, Random, 95% CI)	‐0.20 [‐1.54, 1.14]
Open in figure viewer Analysis 1.9 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 9 HSS Pain.
10 HSS Muscle power Show forest plot	1	56	Mean Difference (IV, Random, 95% CI)	0.30 [‐0.36, 0.96]
Open in figure viewer Analysis 1.10 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 10 HSS Muscle power.
11 Loosening Show forest plot	1	105	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.22, 5.01]
Open in figure viewer Analysis 1.11 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 11 Loosening.
12 Joint line Show forest plot	1	34	Mean Difference (IV, Random, 95% CI)	20.6 [18.49, 22.71]
Open in figure viewer Analysis 1.12 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 12 Joint line.
13 Clinical score Show forest plot	5	412	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.23, 0.16]
Open in figure viewer Analysis 1.13 Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 13 Clinical score.

Open in table viewer

Comparison 2. Posterior cruciate retention vs Sacrifice (same prosthesis)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	3	286	Mean Difference (IV, Random, 95% CI)	‐3.69 [‐10.78, 3.41]
Open in figure viewer Analysis 2.1 Comparison 2 Posterior cruciate retention vs Sacrifice (same prosthesis), Outcome 1 Range of motion.
2 Improvement of ROM Show forest plot	2	161	Mean Difference (IV, Fixed, 95% CI)	2.02 [‐5.82, 9.86]
Open in figure viewer Analysis 2.2 Comparison 2 Posterior cruciate retention vs Sacrifice (same prosthesis), Outcome 2 Improvement of ROM.

Open in table viewer

Comparison 3. Posterior cruciate retention vs sacrifice (PS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	4	296	Mean Difference (IV, Random, 95% CI)	‐8.07 [‐14.49, ‐1.66]
Open in figure viewer Analysis 3.1 Comparison 3 Posterior cruciate retention vs sacrifice (PS), Outcome 1 Range of motion.
2 Improvement of ROM Show forest plot	2	148	Mean Difference (IV, Fixed, 95% CI)	‐0.27 [‐8.50, 7.96]
Open in figure viewer Analysis 3.2 Comparison 3 Posterior cruciate retention vs sacrifice (PS), Outcome 2 Improvement of ROM.

Analysis 1.1

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 1 Range of motion.

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Analysis 1.2

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 2 Flexion angle.

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Analysis 1.3

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 3 Extension angle.

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Analysis 1.4

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 4 Roll‐Back.

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Analysis 1.5

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 5 Improvement of ROM.

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Analysis 1.6

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 6 Knee Society Clinical score.

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Analysis 1.7

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 7 Knee Society Function Score.

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Analysis 1.8

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 8 Hospital Special Surgery Score.

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Analysis 1.9

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 9 HSS Pain.

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Analysis 1.10

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 10 HSS Muscle power.

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Analysis 1.11

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 11 Loosening.

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Analysis 1.12

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 12 Joint line.

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Analysis 1.13

Comparison 1 Posterior cruciate retention vs Sacrifice (all types), Outcome 13 Clinical score.

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Analysis 2.1

Comparison 2 Posterior cruciate retention vs Sacrifice (same prosthesis), Outcome 1 Range of motion.

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Analysis 2.2

Comparison 2 Posterior cruciate retention vs Sacrifice (same prosthesis), Outcome 2 Improvement of ROM.

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Analysis 3.1

Comparison 3 Posterior cruciate retention vs sacrifice (PS), Outcome 1 Range of motion.

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Analysis 3.2

Comparison 3 Posterior cruciate retention vs sacrifice (PS), Outcome 2 Improvement of ROM.

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Table 1. Search strategy

Dimension	Search strings
Diagnosis	Posterior cruciate ligament[MH] Cruciate[TW] PCL[TW] Gonarthrosis[TW] Osteoarthritis[TW] Rheuma[TW] "Arthritis, Rheumatoid"[MH] Arthrosis[TW] arthrit[TW] Arthritis[MH]
Treatment	"Knee replacement"[TW] Arthroplasty[TW] Prosthesis[TW] Prostheses[TW] Endoprosthesis[TW] Endoprostheses[TW] Implant[TW] Prostheses and implants[MH] Prosthesis implantation[MH]
Study design	RANDOMIZED‐CONTROLLED TRIAL[PT] RANDOMIZED‐CONTROLLED‐TRIALS[TW] "Controlled Clinical Trial"[PT] RANDOM‐ALLOCATION[TW] DOUBLE‐BLIND‐METHOD[TW] SINGLE‐BLIND‐METHOD[TW] CLINICAL‐TRIAL[PT] random[TW] RESEARCH DESIGN[MH] "Multicentre study"[TW] "Multicenter study"[PT] "Review, Multicase"[PT] trial(TW) "Random allocation"[MH] Controlled[TW] Prospective[TW] "Prospective studies"[MH]

Table 1. Search strategy

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Table 2. Methodological criteria

	Aspect	Description	van tulder Item
Van Tulder	Randomisation	Is a valid randomisation technique applied?	A
	Allocation concealment	Was the treatment allocation concealed?	B
	prognostic factors	Are the patient groups comparable on prognostic factors?	C
	Patient blinding	Is the patient blinded for the treatment allocation?	D
	Surgeon blinding	Is the surgeon blinded for the treatment allocation?	E
	Outcome assessor blinding	Is the outcome assessor blinded for the treatment allocation?	F
	Co‐interventions	Are the co‐interventions described in sufficient detail?	G
	Compliance	Is the compliance acceptable?	H
	Drop‐out	Is the drop‐out rate given and acceptable?	I
	Timing	Is the timing of the outcome assesments comparable between groups and consistent within groups?	J
	Intention to treat	Is an intention to treat analysis given?	K
Homogeneity	Homogeneity	Is the patient group homogeneous on prognostic factors	‐
	Homogeneous subgroups	If the total group is not homogeneous, are there subgroups given which are homogeneous?‐	‐
Jadad Checklist	Randomisation	Was the study described as randomised?	‐
		Was the method of randomisation described and appropriate?	‐
	Blinding	Was the study described as double blind?	‐
		Was the method of blinding described and appropriate?	‐
	Lost patients	Was there a description of withdrawals and dropouts?	‐
Clinical relevance		Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice?	‐
		Are the interventions and treatment settings described well enough so that you can provide the same for your patients?	‐
		Were all clinically relevant outcomes measured and reported?	‐
		Is the size of the effect clinically important?	‐
		Are the likely treatment benefits worth the potential harms?	‐

Table 2. Methodological criteria

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Table 3. Methodological Quality (van Tulder)

Study	A, B	C	D, E, F	G	H	I	J	K
Catani 2004	?, ?	Yes	?, ?, ?	No	Yes	Yes	Yes	Yes
Clark 2001	?, ?	Yes	?, No, ?	Yes	Yes	No	Yes	?
Maruyama 2004	?, ?	?	No, No, No	No	Yes	Yes	Yes	Yes
Misra 2003	Yes, No	Yes	?, No, Yes	No	Yes	No	Yes	?
Shoji 1994	?, ?	?	?, No, ?	No	?	Yes	No	Yes
Straw 2003	?, ?	Yes	No, No, Yes	Yes	No	No	?	?
Swanik 2004	Yes, ?	?	Yes, No, Yes	No	Yes	Yes	?	Yes
Tanzer 2002	?, ?	Yes	Yes, No, Yes	Yes	Yes	Yes	Yes	Yes
Legend ‐ see Additional Table 02

Table 3. Methodological Quality (van Tulder)

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Table 4. Methodological Quality (Jadad)

Study	Descr as Randomised?	Valid Randomisation?	Described as Blinded	Valid blinding?	Withdr And dropouts?
Catani 2004	Yes	No	No	NA	Yes
Clark 2001	Yes	No	No	NA	No
Maruyama 2004	Yes	No	No	NA	No
Misra 2003	Yes	Yes	No	NA	Yes
Shoji 1994	Yes	No	No	NA	No
Straw 2003	Yes	No	No	NA	Yes
Swanik 2004	Yes	Yes	No	NA	No
Tanzer 2002	Yes	No	Yes	Unsure	Yes

Table 4. Methodological Quality (Jadad)

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Table 5. Complications

Study	Complications PCR	Complications PCS/PS
Catani 2004	1 lateral release and patella resurfacing for anterior knee pain, 1 manipulation for limited ROM	2 lateral release and patella resurfacing for anterior knee pain
Clark 2001	Not reported	Not reported
Maruyama 2004	None	1 Superficial wound infection
Misra 2003	3 instability, 1 infection, 2 aseptic loosening, 2 stiffness	3 instability, 3 aseptic loosening, 2 stiffness, 1 reflex sympathetic dystrophy
Shoji 1994	Not reported	Not reported
Straw 2003	Not reported	Not reported
Swanik 2004	Not reported	Not reported
Tanzer 2002	No revisions or migration, non‐progressive radiolucencies in 3 patella, 1 tibial and 1 femoral component	No revisions or migration, non‐progressive radiolucencies in 2 patella, 2 tibial and 4 femoral component

Table 5. Complications

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Table 6. Assessment of clincial relevance

Study	Description patients	Intervention described	Outcome measures	Effect size	Benefits / harms
	Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice?	Are the interventions and treatment settings described well enough so that you can provide the same for your patients?	Were all clinically relevant outcomes measured and reported?	Is the size of the effect clinically important?	Are the likely treatment benefits worth the potential harms?
Catani 2004	No	No	No	Unsure	Unsure
Clark 2001	No	Yes	No	No	Unsure
Maruyama 2004	Yes	no	no	Yes	Yes
Misra 2003	No	No	No	No	Unsure
Shoji 1994	No	No	No	No	Unsure
Straw 2003	No	No	No	No	Unsure
Swanik 2004	Yes	No	No	No	Unsure
Tanzer 2002	Yes	Yes	No	No	Unsure

Table 6. Assessment of clincial relevance

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Comparison 1. Posterior cruciate retention vs Sacrifice (all types)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	6	540	Mean Difference (IV, Random, 95% CI)	‐4.38 [‐8.60, ‐0.16]

2 Flexion angle Show forest plot	2	60	Mean Difference (IV, Fixed, 95% CI)	‐2.53 [‐9.15, 4.08]

3 Extension angle Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐2.08, 0.88]

4 Roll‐Back Show forest plot	1	105	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.44, 1.81]

5 Improvement of ROM Show forest plot	4	309	Mean Difference (IV, Fixed, 95% CI)	0.93 [‐4.75, 6.60]

6 Knee Society Clinical score Show forest plot	4	291	Mean Difference (IV, Fixed, 95% CI)	0.52 [‐1.71, 2.75]

7 Knee Society Function Score Show forest plot	3	271	Mean Difference (IV, Fixed, 95% CI)	‐3.55 [‐8.71, 1.61]

8 Hospital Special Surgery Score Show forest plot	3	201	Mean Difference (IV, Fixed, 95% CI)	‐1.64 [‐3.13, ‐0.14]

9 HSS Pain Show forest plot	1	56	Mean Difference (IV, Random, 95% CI)	‐0.20 [‐1.54, 1.14]

10 HSS Muscle power Show forest plot	1	56	Mean Difference (IV, Random, 95% CI)	0.30 [‐0.36, 0.96]

11 Loosening Show forest plot	1	105	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.22, 5.01]

12 Joint line Show forest plot	1	34	Mean Difference (IV, Random, 95% CI)	20.6 [18.49, 22.71]

13 Clinical score Show forest plot	5	412	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.23, 0.16]

Comparison 1. Posterior cruciate retention vs Sacrifice (all types)

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Comparison 2. Posterior cruciate retention vs Sacrifice (same prosthesis)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	3	286	Mean Difference (IV, Random, 95% CI)	‐3.69 [‐10.78, 3.41]

2 Improvement of ROM Show forest plot	2	161	Mean Difference (IV, Fixed, 95% CI)	2.02 [‐5.82, 9.86]

Comparison 2. Posterior cruciate retention vs Sacrifice (same prosthesis)

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Comparison 3. Posterior cruciate retention vs sacrifice (PS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of motion Show forest plot	4	296	Mean Difference (IV, Random, 95% CI)	‐8.07 [‐14.49, ‐1.66]

2 Improvement of ROM Show forest plot	2	148	Mean Difference (IV, Fixed, 95% CI)	‐0.27 [‐8.50, 7.96]

Comparison 3. Posterior cruciate retention vs sacrifice (PS)

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Referencias

References to studies included in this review

Catani 2004 {published data only}

Clark 2001 {published data only}

Maruyama 2004 {published data only}

Misra 2003 {published data only}

Shoji 1994 {published data only}

Straw 2003 {published data only}

swanik 2004 {published data only}

Tanzer 2002 {published data only}

References to studies excluded from this review

Cash 1996 {published data only}

Cope 2002 {published data only}

Dorr 1988 {published data only}

Ishii 1998 {published data only}

Laskin 1996 {published data only}

Laskin 1997 {published data only}

Simmons 1996 {published data only}

Stiehl 1997 {published data only}

Vinciguerra 1994 {published data only}

References to studies awaiting assessment

Aigner 2004 {published data only}

Additional references

Becker 1991

Dennis 1998

emodi 1999

Fleiss 1993

Freeman 2003

Higgins 2005

Hill 2000

Hirsch 1994

Hogervorst 1998

Iwaki 2000

Jacobs 2004

Jadad 1996

Kafer 2005

Komistek 2003

Lombardi 2001

Mahoney 1994

Maloney 1992

Migaud 2002

Mihalko 1999

Morberg 2002

Most 2003

Nozaki 2002

Pagnano 1998

Pellengahr 1999

Pereira 1998

Poss 2002

Tugwell 2004

Udomkiat 2000

van Tulder 1997

van Tulder 2003

Waslewski 1998

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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