Posterior cruciate ligament management in medial pivot total knee arthroplasty: a systematic review and meta-analysis

Abstract Introduction Medial pivot total knee arthroplasty (TKA) was designed to replicate physiological tibiofemoral kinematics, yet the role of posterior cruciate ligament (PCL) management in this setting remains controversial. This systematic review and meta-analysis aimed to compare the clinical and functional outcomes, as well as revision rates, between PCL retention and resection in medial pivot TKA. Methods A comprehensive search of PubMed, Web of Science, Embase, and Google Scholar was conducted in August 2025, following the PRISMA guidelines. Comparative and non-comparative clinical studies reporting outcomes of medial pivot TKA with either PCL retention or resection were included. Outcomes of interest were Knee Society Score (KSS) and its functional subscale (KSS-F), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS), range of motion (ROM), and revision rates. Results Twenty-seven studies involving 3380 patients were included, of whom 1209 underwent medial pivot total knee arthroplasty (TKA) with posterior cruciate ligament (PCL) retention and 2171 with PCL resection. Baseline characteristics were comparable, except for follow-up duration and sex distribution. At the final follow-up, both groups achieved similar outcomes for the Knee Society Score (KSS), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS), and range of motion (ROM). The PCL-retained cohort exhibited slightly higher functional and clinical scores, yet the magnitude of difference remained below the threshold of minimal clinical significance. Revision rates were low and comparable between the two groups. Conclusion PCL retention and resection in medial pivot TKA yield statistically different but clinically equivalent results. The small numerical advantages observed for the retained group in certain functional outcomes do not appear to represent a meaningful clinical improvement. Both strategies can therefore be considered viable, and adequate alignment, balancing, and soft-tissue management remains pivotal. Further high-quality comparative studies involving well-matched populations are warranted to clarify whether subtle functional trends associated with PCL retention have consistent long-term clinical significance. Level of evidence Level III.