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Our findings suggest that guided-motion BCS TKA normalizes MCL strain. In this study, no significant differences were observed in the mean and peak strain measurements between native and guided-motion BCS-TKA knees at any flexion angle. The MCL provides restraint against anterior tibial translation in ACL-deficient knees [28]. Multiple previous studies have reported that MCL strain was significantly higher in post-TKA knees than in native knees [14,15,18] and postoperative MCL laxity was also higher in post-TKA knees than in native knees [16,17]. Our findings, when taken into account with previous studies, suggest that guided-motion BCS TKA successfully restored MCL strain to the level found in native knees. Additionally, free nerve endings that serve as a nociceptive system were reported to be the most commonly observed mechanoreceptors in the MCL [29]. Our findings, when taken into account with this anatomical detail, suggest that guided-motion BCS TKA may provide more normal feelings of the knee, which is strongly associated with patient satisfaction [11,12,30]. However, future studies that evaluate the MCL strain thresholds necessary to perceive the differences between normal and prosthetic knees are needed. Our findings also indicated that the standard deviations of the peak MCL strain were much higher than those of the mean MCL strain. One plausible explanation is that the difference in measuring area may affect MCL strain. In this study, the mean MCL strain was determined by measuring the strain over the whole MCL area and the peak MCL strain was found at one-fourth of the entire MCL area, and the distribution of MCL strain was evaluated at each of ROIs. Therefore, the surface strains measured at a smaller area, such as the peak MCL strain and strain at ROIs, are more susceptible to specimen-specific anatomical conditions, such as the bone contour underneath the measured MCL area and the soft tissues connected soft tissues to the MCL, than those measured at the entire MCL. 153554b96e

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