No clinically meaningful differences between PCL preservation and sacrifice in medial pivot total knee arthroplasty: A systematic review and meta‐analysis

Purpose The decision to preserve or sacrifice the posterior cruciate ligament (PCL) during medial pivot total knee arthroplasty (TKA) remains controversial. This systematic review and meta‐analysis evaluated postoperative functional outcomes and complications in patients undergoing medial pivot TKA with and without PCL preservation. Methods Eight databases were systematically searched eight databases through July 2025 following PRISMA guidelines. Studies comparing PCL preservation (cruciate‐retaining [CR]) versus sacrifice (cruciate‐sacrificing [CS]) in medial pivot TKA with minimum 2‐year follow‐up were included. Primary outcomes were functional scores and complication rates. Due to substantial heterogeneity ( I 2 > 75%) in key outcomes, we emphasized qualitative synthesis over pooled estimates for affected outcomes. Statistical analysis employed random‐effects models with prediction intervals for highly heterogeneous outcomes. Results Seven cohort studies (957 patients) were included. For outcomes with acceptable heterogeneity, quantitative pooling showed no statistically significant differences: Knee Society Score (KSS) (mean difference: 0.39, 95% confidence interval [CI]: −0.5, 1.27, I 2 = 60.4%) and Forgotten Joint Score (FJS) (mean difference: 0.77, 95% CI: −0.25, 1.79, I 2 = 23%). However, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score and range of motion demonstrated extremely high heterogeneity ( I 2 = 89.6%–99.4%), precluding reliable pooled estimates. Qualitative synthesis of individual studies consistently showed no clinically meaningful differences between approaches, it is important to note that the extremely high heterogeneity for most functional outcomes severely limits the reliability of these conclusions and prevents definitive recommendations. Complication rates were similar between groups (9% CS vs. 6% CR, p = 0.57, I 2 = 21%). Conclusions Based on low to moderate certainty evidence with significant study heterogeneity, PCL management strategy does not result in clinically meaningful differences in functional outcomes or complication rates in medial pivot TKA. Level of Evidence Level III.