Total Knee Arthroplasty: Retention vs Sacrifice of the Posterior Cruciate Ligament


Osteoarthritis of the knee is a common degenerative condition causing joint pain, stiffness and disability. In end-stage knee osteoarthritis, total knee arthroplasty (TKA) can provide significant symptom relief and improve function. During the surgery, the posterior cruciate ligament (PCL) can either be retained or sacrificed. The optimal approach remains debated.

PCL Function and TKA Designs

The PCL provides anteroposterior and rotational knee stability. Retaining it aims to maintain natural kinematics. However, degeneration or improper balancing can disrupt its function after TKA.

PCL-retaining designs keep the native ligament. PCL-sacrificing designs use a cam-post mechanism to mimic its function. Hybrid designs have interchangeable components.

PCL Retention vs. Sacrifice: The Evidence

Numerous studies compare PCL retention versus sacrifice in TKA. A 2012 meta-analysis found no significant differences in knee pain, function, range of motion (ROM), or quality of life. PCL sacrifice had 2.4° greater ROM. A 2021 randomized trial found no difference in 2-year outcomes.

Notably, a 2003 observational study suggested PCL retention has better 10-year implant survival. However, confounding factors likely influenced this result. Overall, current evidence does not support a significant clinical advantage for either approach.

Surgical Considerations

Surgeon experience and ligament quality help guide PCL management. Retention is more technically demanding to balance properly. Osteoarthritic knees often have attenuation, making sacrifice preferable. Knee deformity or contracture can also necessitate sacrifice.

Patient factors like demographics, activity level, and culture should be considered when choosing TKA implant designs. Younger, active patients may benefit from newer high-flexion implants


Research does not clearly favor PCL retention or sacrifice in TKA for osteoarthritis. While small differences in outcomes exist, they are of unclear clinical significance. Proper surgical technique tailored to the patient and their knee anatomy remains most important for optimizing results. Further study on newer implant designs is warranted.

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© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow