Bicruciate substituting total knee replacement: how effective are the added kinematic constraints in vivo?

The Journey bicruciate substituting (BCS) TKR was designed to restore normal knee kinematics. It has two cam-post mechanisms which substitute for the ACL and PCL. The aim of this study was to undertake a comprehensive study of the Journey BCS kinematics in vivo to assess the function of the cam-post mechanisms and their effect on functional kinematics and compared to the kinematics of a group of normal knees. The kinematics of 10 Journey BCS were assessed fluoroscopically during step-up and lunge exercises, and were compared to those of 20 normal knees. The fluoroscopic images were used to determine relative implant orientation using a 2D to 3D reconstruction method. The determined relative tibio-femoral orientations allowed for cam-post engagement and tibio-femoral contact points to be determined. Functional kinematics were assessed using the patella tendon angle (PTA) and the patella flexion angle (PFA) relationship with the knee flexion angle (KFA). The average maximum flexion achieved by the Journey was 124.7A degrees. Both cam mechanisms engaged: The anterior cam during extension at 12.6A degrees and the posterior cam in flexion at 45.4A degrees. During flexion, the contacts points on the tibia moved posteriorly with no paradoxical anterior translation. The PTA/KFA relationships of the Journey implant group for both the step-up and lunge exercises were broadly similar in terms of trend to those established for the normal knee but the PTA between 10A degrees KFA and 140A degrees KFA were significantly (P < 0.05) lower than that for the normal knees. The PFA/KFA trend for both the implant and normal groups showed a linear relationship; however, the values of PFA were higher for the Journey compared to the normal. The Journey BCS showed no paradoxical anterior movement and sufficient posterior femoral roll back which corresponded with the engagement of the anterior and posterior cam-post mechanisms. Trends shown by the PTA/KFA and PFA/KFA kinematic profiles observed for the Journey group were more normal than those seen with other designs of TKR. However, despite being more close to normal than other implants, the Journey group showed a different kinematic profile to that of the normal knees, which is most likely due to the femur being too far posterior relative to the tibia. Case-control study, retrospective, comparative study, Level III.