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63 (); 196-200
doi:
10.1016/j.jor.2025.04.001

Comparative outcomes of kinematically aligned TKA with medial stabilized design vs. mechanically aligned TKA with bi-cruciate stabilized design: A propensity score-matched analysis

, , , ,
a Department of Orthopedic Surgery, Kobari General Hospital, Noda, Japan
b Department of Orthopaedics, School of Medicine, Jichi Medical University, Shimotsuke, Japan
c Department of Orthopedic Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
d Department of Orthopedic Surgery, Nihon University Itabashi Hospital, Tokyo, Japan

⁎Corresponding author: Tsuneari Takahashi. tsuneari9@jichi.ac.jp

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Patient dissatisfaction after total knee arthroplasty (TKA) is often linked to altered knee kinematics and stability. This study compared the short-term clinical outcomes of kinematically aligned TKA (KA-TKA) and mechanically aligned TKA (MA-TKA) using bi-cruciate stabilized (BCS) implants.

In this propensity score-matched study, 60 patients who underwent either KA-TKA or MA-TKA (30 per group) with BCS implants were analyzed. Baseline characteristics, including age, sex, preoperative range of motion (ROM), and hip-knee-ankle alignment, were matched. ROM and clinical outcomes were evaluated preoperatively and at 1 year postoperatively using the 2011 Knee Society Score (KSS) subscales and Forgotten Joint Score-12 (FJS).

At 1 year, the KA group achieved higher scores in KSS subscales for symptoms (23.2 vs. 20.0, p < 0.001), satisfaction (28.1 vs. 22.5, p < 0.001), functional activities (82.1 vs. 74.2, p = 0.011), and FJS (83.8 vs. 62.5, p < 0.001). No significant differences were observed in maximum extension, flexion, or KSS expectations.

KA-TKA demonstrated superior satisfaction and functional recovery than MA-TKA with BCS implants in the short term. These results suggested that KA-TKA, which reconstructs patient-specific alignment, may provide a more natural knee feel, leading to higher patient satisfaction compared to implant-driven BCS-TKA.

Keywords

Bi-cruciate stabilized total knee arthroplasty
Kinematically-aligned total knee arthroplasty
Medial stabilized implant
2011 knee society score
Forgotten joint Score-12
Level of evidence: III
ACL
BCS
FJS
HKA
KA
KOOS
KSS
MA
MS
MCID
PCL
PF
PROs
PS
QOL
ROM
SR
TKA
PubMed
1

1 Introduction

Total knee arthroplasty (TKA) is extensively recognized as a safe and effective surgical procedure for treating advanced knee arthritis, generally ensuring long-lasting implant survival.1,2 However, approximately 20 % of patients report dissatisfaction with TKA results,3,4 often attributed to altered knee kinematics and instability compared with a natural knee.5,6 Recently, two approaches have been introduced to address these challenges: kinematically-aligned TKA (KA-TKA) and mechanically-aligned TKA (MA-TKA) with a bi-cruciate stabilized (BCS) implant.

KA-TKA aims to restore the patient's pre-arthritic joint line and kinematics with minimal soft tissue disruption, theoretically enhancing functional recovery and patient satisfaction.7 Evidence suggests that KA-TKA may provide superior kinematics and clinical outcomes than traditional MA-TKA.8–10

Conversely, BCS-TKA achieves kinematics closer to natural knee motion through implant design rather than alignment. BCS implants use guided motion to enhance anterior-posterior stability and replicate normal knee movement. The BCS design features a concave medial and convex lateral shape, providing medial stability and increased relative posterior translation of the lateral condyle with flexion. BCS implants substitute both cruciate ligaments using a dual post-cam design. Clinical evidence indicates that BCS implants improve stability, ROM, and patient-reported outcomes (PROs) compared with conventional implants.11–14

While both KA-TKA and MA-TKA with BCS aim to replicate natural knee mechanics, their strategies diverge: KA-TKA emphasizes patient-specific alignment, whereas BCS prioritizes implant-driven motion. Existing literature provides limited direct comparisons between these strategies. Therefore, this study aimed to evaluate the differences in short-term clinical results, including PROs, between KA-TKA and BCS-TKA at 1 year postoperatively.

2

2 Materials and methods

2.1

2.1 Study design

Patients with valgus deformities, post-traumatic or post-surgical knees, prior osteotomies, or rheumatoid arthritis were excluded. Between April 2021 and November 2023, 73 consecutive patients (61 women and 12 men) who underwent TKA were preliminarily included in the study. These patients were divided into two groups:•KA Group: 37 patients (31 women and 6 men) who underwent KA-TKA with the GMK SPHERE CS (Medacta International, Castel San Pietro, Switzerland).•BCS Group: 36 patients (31 women and 6 men) who underwent BCS-TKA with the JOURNEY II system (Smith & Nephew Inc., Memphis, TN, USA).

All surgeries were performed by a single senior surgeon. To adjust for baseline differences between the groups, a propensity score algorithm was used to match the KA group and the BCS groups in a 1:1 ratio. The patients were matched based on age, sex, uni/bilateral surgery, preoperative hip-knee-ankle angle (HKA), maximum extension, and maximum flexion. Propensity score matching was performed between 30 patients each in the KA and BCS groups, who were ultimately included in the analysis.

2.2

2.2 Surgical procedures

Both KA-TKA and BCS-TKA surgeries began with tourniquet inflation and a medial parapatellar approach. In both procedures, the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were resected. In the BCS-TKA, patellar resurfacing was performed.

In the BCS-TKA procedure, guided-motion technology was used to replicate natural knee kinematics through the anatomically designed femoral component and insert configuration. The osteotomies were performed according to traditional MA-TKA techniques. The distal femur was cut perpendicular to its mechanical axis using an intramedullary alignment system. A proximal tibial osteotomy involved removing 10 mm of bone from the lateral tibial plateau and creating a 3° posterior slope in the sagittal plane. This cut was perpendicular to the mechanical axis in the coronal plane, using an extramedullary alignment system. Posterior femoral resection was performed with 3° external rotation relative to the posterior condylar axis, using a conventional guide. Alignment of the distal femur and proximal tibia cuts was checked to ensure neutrality. Tibial rotational alignment was determined by referencing Akagi's line.

In the KA-TKA procedure, the goal is to replace the bone and cartilage removed with an implant of the same thickness; by positioning the femoral and tibial components to match the original joint lines, KA aims to restore natural (pre-arthritic) knee alignment without limiting the extent of correction achievable during surgery. Any damaged cartilage was completely removed from both the distal femur and the posterior condyle, and a referencing guide was set against the distal femur to compensate for a 2-mm cartilage defect. An osteotomy of the same thickness as the distal and posterior parts of the component was performed. The caliper verification method, developed by Howell, uses manual tools to measure and guide bone cuts. This technique involves verifying bone resections with calipers to confirm whether the correct amount of bone has been removed. Any osteophytes (particularly on the posterior condyle) were carefully removed to minimize their impact on soft tissue balance. The osteotomy line of the proximal tibia was made parallel to the distal femur by grasping the ankle with one hand and manually drawing the leg in the distal direction. The osteotomy line of the proximal tibia was determined using a 19 mm spacer to allow for a 10 mm polyethylene insert. The posterior slope was made somewhat smaller (around 3–5°) than the native slope. A proximal tibial osteotomy was performed using an unrestricted (soft-tissue respecting) technique with an extramedullary alignment system.15 Tibial rotational alignment was determined by referencing Akagi's line. KA-TKA has been reported to demonstrate better patellofemoral (PF) kinematics and lower PF contact pressure compared with MA-TKA.16 Additionally, the MP implant is a patella-friendly design, with reportedly good long-term outcomes, even without patellar resurfacing.17 Based on these factors, patellar resurfacing was not performed because of concerns about complications such as fractures.

2.3

2.3 Clinical evaluation 1 year after surgery

ROM, 2011 Knee Society Score (KSS) (patient symptoms, satisfaction, expectations, and functional activities) and Forgotten Joint Score-12 (FJS) were assessed preoperatively and 1 year postoperatively.

2.4

2.4 Statistical analysis

The groups were propensity score matched to minimize bias. Specifically, single nearest‐neighbor matching (also known as one‐to‐one matching) was employed. In this study, each KA-MS case was matched with a BCS case that closely mirrored the observed patient's characteristics.

To control for selection bias and ensure balanced covariates between the two groups, we matched cases to controls based on confounding variables such as age, sex, unilateral-bilateral, preoperative ROM, and preoperative HKA using a propensity score calculated by logistic regression. A prior sample size calculation was performed using the unpaired t-test, with the significance level set at p < 0.05. The minimum sample size required for an α error of 0.05, β error of 0.20, and effect size of 0.8 was 52 patients (calculated using G Power 3.1, Franz Paul).18

Based on the sample size determined through propensity matching, 30 patients were assigned to each group. A post hoc power analysis indicated that the study had at least 84.1 % power. Data are presented as means and standard deviations. All statistical analyses were performed using EZR software.19 The sample size was calculated in advance based on the results of an unpaired t‐test for the primary outcome, with the significance level set at p < 0.05.

3

3 Results

This study enrolled 60 patients (30 in the KA group and 30 in the BCS group). Preoperatively, the BCS group showed significantly better outcomes in the KSS symptoms subscales (4.3 ± 2.8 in the KA group vs. 6.8 ± 4.5 in the BCS group, p = 0.014), while other demographic characteristics were similar (Table 1).

Table 1 Preoperative demographic data.
KA group BCS group p-value
Number of patients 30 30
Sex (male/female) 9/21 9/21 1.000
Side (uni/bi) 22/8 22/8 1.000
Age (years) 72.6 ± 10.4 73.2 ± 7.8 0.790
Body mass index (kg/m2) 28.5 ± 4.3 27.5 ± 4.0 0.356
Femoro-tibial angle (°) 184.6 ± 5.3 183.5 ± 4.0 0.353
Hip-knee-ankle angle (°) −9.8 ± 5.5 −10.2 ± 4.6 0.761
Maximum extension (°) 11.7 ± 8.7 10.3 ± 9.0 0.563
Maximum flexion (°) 121.7 ± 11.8 121.0 ± 9.8 0.822
2011 KSS
Symptoms 4.3 ± 2.8 6.8 ± 4.5 <0.05a
Satisfaction 12.7 ± 6.7 13.5 ± 6.1 0.631
Expectations 12.8 ± 1.8 12.5 ± 2.1 0.510
Functional activities 36.4 ± 17.6 36.4 ± 17.6 0.767
FJS 14.3 ± 12.3 19.8 ± 14.4 0.117
a p < 0.05.

Postoperatively, no significant differences were found between the groups in maximum extension (1.5 ± 3.3° vs. 2.5 ± 3.7°) or maximum flexion (128.8 ± 9.5° vs. 128.2 ± 7.2°). Additionally, there were no differences in the KSS expectations subscale (13.1 ± 1.6 vs. 12.4 ± 2.3). However, the KA group showed significantly better outcomes in the KSS subscales for symptoms (23.2 ± 1.8 vs. 20.0 ± 2.7, p < 0.001), satisfaction (28.1 ± 4.8 vs. 22.5 ± 3.6, p < 0.001), functional activities (82.1 ± 12.5 vs. 74.2 ± 10.8, p = 0.011), and FJS scores (83.8 ± 10.6 vs. 62.5 ± 15.3, p < 0.001) (Table 2).

Table 2 One-year postoperative clinical results.
KA group BCS group p-value
Maximum extension (°) 1.5 ± 3.3 2.5 ± 3.7 0.268
Maximum flexion (°) 128.8 ± 9.5 128.2 ± 7.2 0.762
2011 KSS
Symptoms 23.2 ± 1.8 20.0 ± 2.7 <0.001b
Satisfaction 33.9 ± 4.8 28.1 ± 4.8 <0.001b
Expectations 13.1 ± 1.6 12.4 ± 2.3 0.179
Functional activities 82.1 ± 12.5 74.2 ± 10.8 <0.05a
FJS 83.8 ± 10.6 62.5 ± 15.3 <0.001b
a p < 0.05.
b p < 0.001.
4

4 Discussion

This study evaluated the short-term clinical outcomes between KA-TKA and MA-TKA with BCS implants. This study is the first to report on FJS comparisons between KA-TKA and BCS-TKA. In this study, true KA-TKA was performed using Howell's calipered kinematic alignment technique, ensuring a more precise restoration of native alignment compared with previous studies. This methodological accuracy is crucial for evaluating the clinical benefits of KA-TKA. The most important finding of this study was that the short-term clinical results of the KA-TKA were superior to those of BCS-TKA, as evidenced by the KSS subscales for symptoms, satisfaction, functional activities, and the FJS. However, no significant differences were found in the KSS subscale for expectations or ROM between the two groups. The limited follow-up duration of this study warrants a cautious interpretation of the findings.

Previous studies have reported that KA-TKA demonstrated superior KSS and FJS compared with MA-TKA,10 and that MS implants in KA-TKA achieve better functional recovery and clinical outcomes compared with other implants.20–24 MS implants enhance mid-flexion stability and replicate natural knee motion.25,26 It has been reported that the MS implant improves kinematics more than the MA-TAK in KA-TKA,24 and this may contribute to the better improvement in PROs compared with other implants. Tran et al. reported that both the Knee injury and Osteoarthritis Score (KOOS) symptom scale and the FJS showed continuous improvement at 1 and 5 years postoperatively, with no evidence of implant loosening, supporting the sustained benefits of KA-TKA.27 However, recent reviews have raised concerns about methodological flaws in studies comparing KA and MA in TKA. Issues such as inconsistent definitions of KA, mixing of time points, and inappropriate inclusion of restricted KA studies may compromise the validity of conclusions. These findings highlight the need for a cautious interpretation of claims regarding the superiority of KA over MA.28 To enhance the quality of evidence, more standardized randomized controlled trials and large-scale studies are required.

Conversely, BCS implants are designed to restore normal knee biomechanics by utilizing guided motion technology. Some studies have reported the clinical advantages of BCS implants, particularly in achieving natural knee kinematics and improving anterior-posterior stability.29–32 BCS-TKA have demonstrated better patient-reported outcomes compared with conventional implants.13,31,33 However, some reports have indicated that the short-to mid-term clinical outcomes of BCS-TKA are comparable to those of MA-TKA.34 Anjiki et al. reported that KA-TKA with tibial-restricted modification demonstrated better KSS scores at 1 year postoperatively compared with BCS-TKA. They suggested that this improvement might be attributed to the greater tolerance of KA-TKA for rotational alignment mismatches.35

In the present study, although the follow-up period was short, the KA-TKA group showed better KSS subscale scores and FJS at 1 year postoperatively than the BCS-TKA group. Given previous reports indicating that KA-TKA with PS implants achieved better KSS scores at 1 year postoperatively compared with BCS-TKA,35 and that KA-TKA with MS implants resulted in superior KSS scores compared with PS implants,22,23 the KSS findings in our study were expected. Unlike traditional knee-specific PROs, which may exhibit ceiling effects in well-performing patients, the FJS evaluates the extent to which patients "forget" about their joint in daily life, reflecting a more natural joint perception. The FJS has been shown to be more responsive and to have a lower ceiling effect than most other knee-specific PROs. This suggests that it may be a more sensitive tool for assessing high-level function in ever-improving TKA.36,37 The minimal clinically important difference (MCID) for the FJS has been reported as 14 points.38 In this study, the KA group (83.8 ± 10.6) demonstrated significantly better FJS than the BCS group (62.5 ± 15.3) at 1 year postoperatively, exceeding the MCID (Fig. 1). This suggests that, in the short term, KA-TKA may provide a more natural knee feel, leading to higher patient satisfaction. These findings indicate that patient-specific alignment strategies have a greater influence on postoperative outcomes than implant-driven motion alone.

Forgotten joint scores The FJS of the KA group was significantly better than that of the BCS group 1 year postoperatively (83.8 ± 10.6 vs. 62.5 ± 15.3, p < 0.001). The minimal clinically important difference (MCID) has been reported to be 14 points. The difference between the groups exceeded 14 points at 1 year postoperatively. In the graph, the MCID is represented by the horizontal reference line.
Fig. 1 Forgotten joint scores The FJS of the KA group was significantly better than that of the BCS group 1 year postoperatively (83.8 ± 10.6 vs. 62.5 ± 15.3, p < 0.001). The minimal clinically important difference (MCID) has been reported to be 14 points. The difference between the groups exceeded 14 points at 1 year postoperatively. In the graph, the MCID is represented by the horizontal reference line.

Several limitations of this study should be acknowledged. First, although propensity score matching was performed to minimize baseline differences, a significant difference remained in preoperative KSS symptom scores, introducing a potential bias. The BCS group had better preoperative symptom scores, whereas the KA group showed superior postoperative outcomes. Ideally, matching should have included preoperative FJS and KSS. Second, patellar resurfacing was performed only in the BCS group, which may have influenced the clinical outcomes. Third, the short follow-up period limits the ability to evaluate long-term implant performance and survival. In a 16-year follow-up study by Howell et al., the revision rate for KA-TKA was only 7 % in 222 knees, suggesting that the long-term durability of KA-TKA is comparable to that of MA-TKA.39,40 However, further mid-to long-term studies are necessary to clarify the sustained clinical impact of these alignment and implant strategies.

5

5 Conclusion

The KA-TKA group exhibited superior 2011 KSS subscales (symptoms, satisfaction, and functional activities) and FJS at 1 year postoperatively compared with those of the MA-TKA with BCS group. A significant improvement exceeding the MCID of the FJS was observed, suggesting that KA-TKA—which reconstructs patient-specific alignment—may provide a more natural knee feel, leading to higher patient satisfaction than that achievable with implant-driven BCS-TKA. However, further mid-to long-term studies are necessary to clarify the sustained clinical impact of these alignment and implant strategies.

Statements and declarations

Ryota Fujii: Study conception and design; data acquisition; data analysis and interpretation; article drafting; critical revision of the article for important intellectual content. Tsuneari Takahashi: Study conception and design; data analysis and interpretation; critical revision of the article for important intellectual content. Masaki Iguchi: data analysis and interpretation; critical revision of the article for important intellectual content. The author(s) read and approved the final manuscript.

Ethics approval

This study was conducted in accordance with the principles of the Declaration of Helsinki. Our institutional ethics committee approved the study (date: December 26, 2024; ID: 83).

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not‐for‐profit sectors.

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