The Impact of Preoperative Coronal Alignment on the Outcomes of Bicruciate-Retaining Total Knee Arthroplasty - 03/11/26

Doi : 10.1016/j.otsr.2026.104977

Maroun Rizkallah ^a,⁎ , Paul-Andre Synnott ^b, Dominic Cadoret ^b, Fidaa Al-Shakfa ^c, Frederic Lavoie ^c

^a Centre de Formation Medicale du Nouveau Brunswick, Orthopedic Surgery Department, Dr. Georges-L-Dumont University Hospital, Sherbrooke University, Moncton, New Brunswick, Canada

^b University of Montreal, Montreal, Quebec, Canada

^c Department of Orthopedic Surgery, University of Montreal Health Center, Montreal, Quebec, Canada

^⁎ Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Tuesday 03 November 2026

Abstract

Background

Bicruciate-retaining (BCR) total knee arthroplasty (TKA) aims to replicate native knee kinematics by preserving both cruciate ligaments. Yet, controversy persists over its suitability in patients with significant coronal deformities, as current literature lacks clarity on alignment thresholds. This study addresses this gap by evaluating whether preoperative coronal alignment influences implant survivorship, function and range of motion outcomes after a BCR-TKA performed with a gap-balancing technique.

Hypothesis

Preoperative coronal alignment does not impact mid-term survivorship, postoperative range of motion or functional outcomes when a gap-balancing technique is used.

Patients and methods

In this retrospective monocentric study, we analysed 172 BCR-TKA (163 patients, mean age 65.8 ± 9.2 years) performed by a single surgeon. Knees were grouped by preoperative coronal alignment based on the hip-knee-ankle angle: severe varus (≤170 °), moderate varus (170°–175 °), mild varus (175°–180 °), and valgus (>180 °). The primary outcome was 5-year implant survival (presented as Estimate ± Standard Error); secondary outcomes included range of motion, the Knee injury and Osteoarthritis Outcome Score and the Knee Society Score (presented as Estimate ± Standard Deviation). Subgroup analysis evaluated failure-risk factors in valgus knees.

Results

Twenty revisions (11.6%) occurred, with a 5-year survival of 91.4% ±5.2%. Survival was 97.5% ±2.2% in severe varus, 94.1% ±3.1% in moderate varus, 89.5% ±6.5% in mild varus. Valgus knees (71.8% ±8.7%) were significantly lower than in all varus groups (p = 0.016). Knees with post-operative varus alignment showed a higher risk of failure(p = 0.02), whereas valgus severity didn’t impact survival. At the latest follow-up, maximum knee flexion angle was comparable between all groups (116.8 ⁰ to 123 ⁰,p = 0.257) as well as the Knee injury and Osteoarthritis Outcome Score and Knee Society Score functional score.

Discussion

Severe pre-operative varus coronal alignment should not be considered a contraindication for BCR-TKA when using a gap-balancing technique. In contrast, valgus knees showed significantly lower survival when overcorrected to varus, therefore partially contradicting the study hypothesis. Efforts should be directed towards preserving the pre-operative alignment in the valgus knees to reduce the failure rate.