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Park DY, Chung JY, Jin YJ, Yoon HS, Min BH, Park JY, Lim S. Lateral Retinacular Release During Medial Unicompartmental Knee Arthroplasty in the Presence of Patello-Femoral Joint Arthritis Relieves Patello-Femoral Joint Pressure and Improves Associated Symptoms. J Arthroplasty 2023; 38:2288-2294. [PMID: 37271229 DOI: 10.1016/j.arth.2023.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND This study evaluated the effects of concomitant lateral patellar retinacular release (LPRR) during medial unicompartmental knee arthroplasty (UKA). METHODS We retrospectively analyzed 100 patients who had patello-femoral joint (PFJ) arthritis who underwent medial UKA with (n = 50) and without (n = 50) LPRR who had ≥2 years follow-up. Radiological parameters associated with lateral retinacular tightness, including patellar tilt angle (PTA), lateral patello-femoral angle (LPFA), and congruence angle, were measured. Functional evaluation was performed using the Knee Society Pain Score, Knee Society Function Score (KSFS), Kujala Score, and the Western Ontario McMaster Universities Osteoarthritis Index score. Intraoperative patello-femoral pressure evaluation was performed on 10 knees to evaluate the pressure changes before and after LPRR. Mann-Whitney U-tests were used for statistical analyses. RESULTS Demographic data did not differ between the LPRR(+) and LPRR(-) groups. A decrease in PTA and an increase in LPFA were observed in the LPRR(+) group compared to those in the LPRR(-) group (PTA; -0.54 versus -1.74, P = .002, LPFA; 0.51 versus 2.01, P = .010). The LPRR(+) group showed significantly better KSFS and Kujala scores than the LPRR(-) group (KSFS: 90 versus 80, P = .017; Kujala score: 86 versus 79, P = .009). Intraoperative patello-femoral pressure analysis showed a 22.6% reduction in the PFJ contact pressure and an 18.7% reduction in PFJ peak pressure after LPRR. (P = .0015, P < .0001, respectively) CONCLUSION: A LPRR during UKA may be a simple and useful adjunct procedure to relieve PFJ symptoms with concomitant PFJOA.
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Affiliation(s)
- Do Young Park
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea; Cell Therapy Center, Ajou University Medical Center, Suwon, Korea
| | - Jun Young Chung
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea
| | - Yong Jun Jin
- Cell Therapy Center, Ajou University Medical Center, Suwon, Korea
| | - Ha Seung Yoon
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea
| | - Byoung-Hyun Min
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea; Cell Therapy Center, Ajou University Medical Center, Suwon, Korea; Department of Molecular Science and Technology, Ajou University, Suwon, Korea
| | - Jae-Young Park
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Sumin Lim
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea
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Verma A, Lalchandani R. Prospective comparative study of intraoperative "Towel clip test" and "Vertical patella test" assessing lateral retinaculum tightness in patients undergoing TKA. J Clin Orthop Trauma 2019; 10:995-998. [PMID: 31528083 PMCID: PMC6739461 DOI: 10.1016/j.jcot.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/05/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Proper patellar tracking is one of the most important aspect of TKA to ensure good functional outcome. A patellar tracking problem noted intraoperatively serves as a warning sign and should prompt the surgeon to reassess position of each component. Various tests are there to assess lateral retinaculum tightness viz. "No thumb test", "Towel clip test". A new test "Vertical patella test" is described to assess lateral retinaculum tightness. A study was conducted to assess the effectiveness, correlation and validity of two techniques. MATERIALS & METHODS Patients >50 years of age and with diagnosis of Osteoarthritis knee having less than 30 varus and flexion deformity going in for primary TKA were selected with a sample size of 100 knees in a tertiary care centre. Revision cases or patients with flexion contracture more than 30, complex knee surgery; with pre existing patellar tilt were excluded from study. RESULTS Results of both tests were found to correlate in 75% of case with sensitivity of 96.65% and specificity of 75.00%. Kappa came out to be 0.634 which shows good agreement of vertical patella test and towel clip test. Result was computed using excel and SPSS and was found to be significant with p value< 0.05. Lateral retinaculum release was done in 8 knees. CONCLUSIONS Vertical patella test correlates with towel clip test, is easy to perform and saves time. The limitation of our study was small sample size.
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Affiliation(s)
| | - Rajesh Lalchandani
- Corresponding author at: 182, Ekta Apartments, Pocket 1 & 2, Near DPS Dwarka, Sector 3 Dwarka, New Delhi, 110075, India.
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Maiti R, Cowie RM, Fisher J, Jennings LM. The influence of malalignment and ageing following sterilisation by gamma irradiation in an inert atmosphere on the wear of ultra-high-molecular-weight polyethylene in patellofemoral replacements. Proc Inst Mech Eng H 2017; 231:634-642. [PMID: 28661229 PMCID: PMC5495427 DOI: 10.1177/0954411917696112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complications of patellofemoral arthroplasty often occur soon after implantation and, as well as other factors, can be due to the design of the implant or its surgical positioning. A number of studies have previously considered the wear of ultra-high-molecular-weight polyethylene patellae following suboptimal implantation; however, studies have primarily been carried out under a limited number of degrees of freedom. The aim of this study was to develop a protocol to assess the wear of patellae under a malaligned condition in a six-axis patellofemoral joint simulator. The malalignment protocol hindered the tracking of the patella centrally in the trochlear groove and imparted a constant 5° external rotation (tilt) on the patella button. Following 3 million cycles of wear simulation, this condition had no influence on the wear of ultra-high-molecular-weight polyethylene patellae aged for 4 years compared to well-positioned non-aged implants (p > 0.05). However, under the malaligned condition, ultra-high-molecular-weight polyethylene patellae aged 8-10 years after unpacking (following sterilisation by gamma irradiation in an inert atmosphere) and worn ultra-high-molecular-weight polyethylene components also aged 4 years after unpacking (following the same sterilisation process) exhibited a high rate of wear. Fatigue failure due to elevated contact stress led to delamination of the ultra-high-molecular-weight polyethylene and in some cases complete failure of the patellae. The results suggest that suboptimal tracking of the patella in the trochlear groove and tilt of the patella button could have a significant effect on the wear of ultra-high-molecular-weight polyethylene and could lead to implant failure.
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Affiliation(s)
- Raman Maiti
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | - Raelene M Cowie
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | - John Fisher
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | - Louise M Jennings
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
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Should the position of the patellar component replicate the vertical median ridge of the native patella? Knee 2017; 24:82-90. [PMID: 27836693 DOI: 10.1016/j.knee.2016.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND In total knee arthroplasty (TKA), the position of the patellar component can affect patellar tracking. However, the patellar component cannot always replicate the original high point of the patella because of anatomical variance. This study investigated whether altering the highest point of the patella can affect outcomes of primary TKA, especially in patients having a patella with a far-medialized median ridge. METHODS A retrospective review was performed for 177 knees (143 patients) treated with primary TKA between July 2011 and March 2014. Group 1 (34 knees) had the patellar component displaced over three millimeters from the median ridge, while Group 2 (143 knees) had the patellar component placed on the original median ridge position. The one-year follow-up outcomes were reviewed, including: patellar tilt angle, Knee Society Score, Feller Patellar Score, and modified Kujala Anterior Knee Pain Score. RESULTS Mean (±standard deviation) displacement of the patellar component in Group 1 was 3.97±0.97mm lateral to the original position of the median ridge, with a significant decrease in lateral patellar tilt angle (P<0.001). Lateral patellar tilt showed a positive correlation with the medialization of the patellar component (P<0.001, r=0.401). Ability to rise from a chair was better in Group 1 (P=0.025). There were no other between-group differences in other clinical outcomes. CONCLUSIONS There should be no need for the patellar component to replicate the original highest point of the native patella in primary TKA.
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King JJ, Chakravarty R, Cerynik DL, Black A, Johanson NA. Decreased ratios of lateral to medial patellofemoral forces and pressures after lateral retinacular release and gender knees in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2013; 21:2770-8. [PMID: 23052108 DOI: 10.1007/s00167-012-2200-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To demonstrate that lateral to medial patellofemoral force and pressure ratios could be a surrogate marker of retinacular tension and patellar tracking. METHODS The patellofemoral forces of six knees from three fresh-frozen half-body female cadavers were evaluated with a capacitive sensor under simulated operative conditions in six staged clinical scenarios: native knees, knee arthroplasty without patellar resurfacing, resurfaced knee and patella, resurfaced knee and patella with lateral release, gender-specific knee arthroplasty with patella resurfacing, and gender-specific knee arthroplasty with lateral release. Maximum force and peak pressure were simultaneously recorded during three to four ranges of motion. Average values were compared between lateral and medial patellofemoral compartments as an objective measure of patellar tracking for the different settings. RESULTS Significant differences in lateral and medial force and pressure differentials were seen in most scenarios despite clinically normal patellar tracking. Lateral to medial ratios of maximum force and peak pressure significantly increased after TKA (2.9, 2.1) and after patella resurfacing (2.8, 2.6) compared to the native knee (1.6, 1.8). Addition of a lateral release in resurfaced knees decreased the ratio of lateral to medial patellofemoral forces and pressures as did gender knee arthroplasty (1.5 and 1.1, 2 and 1.3, respectively). Pressure and force values most closely resembled the native knee in the resurfaced knee/resurfaced patella with lateral release and in the gender knee arthroplasty scenarios. CONCLUSIONS Use of lateral to medial patellofemoral force ratios as a surrogate objective marker for patellar tracking was validated in this study by decreasing ratios observed after lateral release in TKA and with gender-specific implants.
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Affiliation(s)
- Joseph J King
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 215 North Broad Street, MS 420, Philadelphia, PA, 19106, USA
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Vasconcelos JW, Leite LMDS, Sousa JCA, Sousa JOMD, Santos e Santos MF. Medium-term evaluation of total knee arthroplasty without patellar replacement. Rev Bras Ortop 2013; 48:251-256. [PMID: 31214541 PMCID: PMC6565877 DOI: 10.1016/j.rboe.2012.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 02/08/2012] [Indexed: 11/29/2022] Open
Abstract
Objective To mid-term evaluate patients who were submitted to total knee arthroplasty without patellar resurfacing. Methods It was realized a retrospective cross-sectional study of patients who were submitted to total knee arthroplasty without patellar resurfacing. In all patients clinical examination was done based on the protocol of the Knee Society Scoring System, which assessed pain, range of motion, stability, contraction, knee alignment and function, and radiological evaluation. Results A total of 36 patients were evaluated. Of these, 07 were operated only on left knee, 12 only on right knee and 17 were operated bilaterally, totaling 53 knees. Ages ranged from 26 to 84 years. Of the 53 knees evaluated, 33 (62.26%) had no pain. The maximum flexion range of motion averaged 104.7°. No knee had difficulty in active extension. As to the alignment for anatomical axis twelve knees (22.64%) showed deviation between 0° and 4° varus. Thirty-nine (75.49%) knees showed pace without restriction and the femorotibial angle ranged between 3° varus and 13° valgus with an average of 5° valgus. The patellar index ranged from 0.2 to 1.1. Conclusion Total knee arthroplasty whitout patellar resurfacing provides good results in mid-term evaluation.
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Affiliation(s)
- José Wanderley Vasconcelos
- PhD in Surgery; Associate Professor, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brazil
- Corresponding author. Av. dos Holandeses, quadra 19, Residencial Monet, ap. 1202, São Luís, MA, Brazil. CEP: 65.065-180. Tel.: +55 98 8119 0794/55 98 2107 5858.
| | | | - José Carlos Amaral Sousa
- Head of the Orthopedics and Traumatology Service, Hospital Universitário, Universidade Federal do Maranhão (HU-UFMA) São Luís, MA, Brazil
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Vasconcelos JW, Leite LMDS, Sousa JCA, Sousa JOMD, Santos e Santos MF. Avaliação em médio prazo da artoplastia total de joelho sem substituição da patela. Rev Bras Ortop 2013. [DOI: 10.1016/j.rbo.2012.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lateral patellar facetectomy had improved clinical results in patients with patellar-retaining total knee arthroplasty. J Arthroplasty 2012; 27:1442-7. [PMID: 22325960 DOI: 10.1016/j.arth.2011.12.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 12/16/2011] [Indexed: 02/01/2023] Open
Abstract
To evaluate the functional outcome of a partial lateral facetectomy in patellar-retaining total knee arthroplasty (TKA), we retrospectively analyzed 63 knees of 59 patients who underwent TKA for primary knee osteoarthritis with (32 knees of 30 patients, group 1) or without (31 knees of 29 patients, group 2) patellar facetectomy from September 2005 to July 2007. All cases were followed up for a minimum of 36 months. Although there was no significant differences between the 2 groups in preoperative patellar score, Western Ontario and McMaster Universities score, knee and function scores, postoperatively, group 1 showed more significant improvements in the scores and fewer lateral patellar osteophytes in radiographs than group 2. A partial lateral facetectomy is an effective way to improve the function of patellar-retaining TKA in patients with primary osteoarthritis.
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Khan A, Pradhan N. Results of total knee replacement with/without resurfacing of the patella. ACTA ORTOPEDICA BRASILEIRA 2012; 20:300-2. [PMID: 24453622 PMCID: PMC3718441 DOI: 10.1590/s1413-78522012000500011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 12/19/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the difference of post-op patellofemoral pain, clunk and crepitus in patients with/without resurfacing at 5 years who had pre-op patellofemoral pain. To study the incidence of post-operative patellofemoral pain, clunk and crepitus following patelloplasty in both the groups. METHODS Retrospective review of 765 patients who had total knee replacement with/without resurfacing.Patients were asked about both pre-operative pain and also post-operative pain 5 years after the operation. Patients were examined by a specialist nurse at 5 years post-operatively to check for any patellofemoral clunk/crepitus. CONCLUSION In patients with pre-op PF pain, there is significant (p<0.005) higher incidence of post-op clunk in the R group. In patients without pre-op PF pain, there is significantly (p<0.005) higher incidence of post-op crepitus in the R group. In patients with/without pre-op PF pain, the incidence of post-op PF pain, clunk and crepitus is lower than in patients who underwent patelloplasty when compared to the other members of the NR group (statistically significant p<0.005). LEVEL OF EVIDENCE Type 4, Case series .
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Affiliation(s)
- Abdul Khan
- Department of Trauma & Orthopaedics, Warrington Hospital, Warrington, Cheshire
| | - Nikhil Pradhan
- Department of Trauma & Orthopaedics, Warrington Hospital, Warrington, Cheshire
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Cho WS, Woo JH, Park HY, Youm YS, Kim BK. Should the 'no thumb technique' be the golden standard for evaluating patellar tracking in total knee arthroplasty? Knee 2011; 18:177-9. [PMID: 20510617 DOI: 10.1016/j.knee.2010.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 04/27/2010] [Accepted: 04/29/2010] [Indexed: 02/02/2023]
Abstract
We checked intraoperative patellar tracking with both 'towel clip technique' and the 'no thumb technique' on 97 patients (167 knees) who underwent primary total knee arthroplasty to decide whether to do or not to do lateral retinacular release. Patellar tracking was assessed under pneumatic tourniquet with the no thumb technique first and re-evaluated with the towel clip technique. The tracking was graded as total contact, good contact, lateral contact and subluxation. The knees graded as total or good contact with the no thumb technique were classified into group A; those graded lateral contact or subluxation by the no thumb technique but total or good contact by the towel clip technique were classified into group B; and those graded lateral contact or subluxation by both techniques were classified into group C; in which lateral releases were performed. One hundred three, 53 and 11 knees were classified into groups A, B and C respectively. Of the 167 knees, 64 (38.3%) showed poor tracking (lateral contact or subluxation) with the no thumb technique alone. Re-evaluation of these knees with the towel clip technique significantly reduced the number with poor tracking to 11 (6.6%) knees requiring lateral retinacular release (p < 0.05). The patients were followed up for 1 year without any patella-related complications occurring. Assessment of the patellar tracking using only the no thumb technique may overestimate the need for lateral retinacular release. The use of the no thumb technique as a screening test, and re-evaluation with the towel clip technique may reduce unnecessary lateral retinacular release.
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Affiliation(s)
- Woo-Shin Cho
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, Republic of Korea
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Di Martino A, Franceschi F, Papalia R, Marini M, Prossomariti G, Maffulli N, Denaro V. Increased bone mineral density in the non-resurfaced patella after total knee arthroplasty: a clinical and densitometric study. Surgeon 2011; 10:20-4. [PMID: 22233553 DOI: 10.1016/j.surge.2011.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2010] [Accepted: 01/03/2011] [Indexed: 11/28/2022]
Abstract
We report the results of a longitudinal study of 40 patients with osteoarthritis who had primary prosthetic replacement without patellar resurfacing, and were followed at 6 months postoperatively with a densitometric study and clinically at a minimum follow-up of 2 years. Densitometric analysis showed a mean preoperative density at the affected knee of 0.69 g/cm(2) (CI: 0.62-0.76), compared to 0.86 g/cm(2) (CI: 0.79-0.93) for the opposite knee (p = 0.002). In our study population, the return to load and motion to the retained patella led to a significant increase in patellar bone density as measured by densitometry studies. This observation correlated with significant improvement in knee functional score.
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Affiliation(s)
- Alberto Di Martino
- Department of Orthopaedics and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
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Rodríguez-Merchán EC, Gómez-Cardero P. The outerbridge classification predicts the need for patellar resurfacing in TKA. Clin Orthop Relat Res 2010; 468:1254-7. [PMID: 19844770 PMCID: PMC2853678 DOI: 10.1007/s11999-009-1123-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Patellar resurfacing (PR) in total knee arthroplasty (TKA) is controversial. The Outerbridge classification of cartilage defects in the patella is commonly used in the literature. The purpose of this study was to determine if the Outerbridge classification can predict the need for PR as part of total knee arthroplasty. Between 1995 and 2000, we performed a prospective, randomized study of 500 TKAs. We carried out PR depending on the Outerbridge classification of the patella at the time of surgery. Patients with Outerbridge Grades I, II, and III formed Group A, whereas patients with Grade IV formed Group B. Within each group, resurfacing was completed on half of the patients. Group A had 328 patients (164 with PR, 164 without PR). In Group B, there were 172 patients (86 with PR, 86 without PR). An identical prosthetic design was used for both groups. The minimum followup was 5 years (average, 7.8 years) for both Group A and Group B. At the end of followup, we assessed the number of patients in each group that required secondary resurfacing as a result of patellofemoral pain. Patients in Group A required fewer revisions for PF pain. In Group A, only one patient required a secondary PR (0.6% rate), whereas in Group B, 10 patients needed PR (11.6% rate). In Group B, the risk of need of a patellar resurfacing was 21.5 times greater than in Group A. On the basis of these findings, we recommend PR in Outerbridge Grade IV patellae, but not in Grades I, II, and III. LEVEL OF EVIDENCE Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- E Carlos Rodríguez-Merchán
- Department of Orthopaedics, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain.
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A technique of staged lateral release to correct patellar tracking in total knee arthroplasty. J Arthroplasty 2009; 24:735-42. [PMID: 18534447 DOI: 10.1016/j.arth.2008.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 02/10/2008] [Indexed: 02/01/2023] Open
Abstract
Optimal patellar tracking and component alignment are important in achieving a well-functioning total knee arthroplasty (TKA). The patella is constrained partly by design of the prosthetic trochlear groove, and patellar tracking is governed by a combination of static and dynamic factors. Maltracking may result from excessive or unbalanced tension in the surrounding soft tissues. This article describes a staged progressive lateral release of the patellar retinaculum in TKA, which is classified into 6 stages. Stage 1 transects the deep lateral patellofemoral ligament; stages 2 to 6 extend the lateral patellar incision distally from vastus lateralis to the tibial tubercle. This technique was used in a series of 96 primary TKAs. We report the rates of the various stages of lateral release and the variables that might affect the decision to perform such a release.
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Nizard RS, Biau D, Porcher R, Ravaud P, Bizot P, Hannouche D, Sedel L. A meta-analysis of patellar replacement in total knee arthroplasty. Clin Orthop Relat Res 2005:196-203. [PMID: 15738822 DOI: 10.1097/01.blo.0000150348.17123.7f] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
From individual randomized studies it is unclear whether the patella should be replaced during total knee replacement. We did a meta-analysis to provide quantitative data to compare patellar resurfacing with nonresurfacing during total knee arthroplasty. Only randomized, controlled trials reported between January 1966 and August 2003 comparing patellar replacement with patella retention were included for a total of 12 studies. Two reviewers assessed trial quality and extracted data from papers. The outcomes identified were reoperations for patellar problems, anterior knee pain, knee scores, stair climbing, and patient satisfaction. The resurfaced patella performed better, and we found an increased relative risk (defined by the ratio of the risk of the event in the resurfaced group on the risk of the event in the nonresurfaced group) for reoperation, for significant anterior knee pain, and for significant pain during stair climbing when the patella was left unresurfaced. No differences were observed between the two groups for International Knee Society function score, Hospital for Special Surgery score, and for patient satisfaction. Despite these general findings, forming a definitive conclusion is difficult because many confounding factors, such as component design, surgeon experience, and technical aspects of the surgery, might influence the result in a patient.
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Abstract
BACKGROUND The decision to resurface the patella or not during total knee replacement (TKR) is a controversial issue. During primary TKR some surgeons routinely resurface the patella, others operate a selective policy and a third group never resurfaces the patella. AIM This study attempts to investigate the relationship of patellofemoral knee pain and TKR. MATERIALS AND METHODS This was a prospective, non-randomised, multi-centre outcome study of 638 primary Insall Burstein II total TKRs, and their effect upon patellofemoral pain. Of those enrolled 378 knees had pre-operative patellofemoral pain; 236 of these underwent patella resurfacing and 142 did not. There were no statistically significant differences in the post-operative incidence of patellofemoral pain between the groups treated with resurfacing of the patella and those in which the patella was left intact. In those knees that developed patellofemoral pain after TKR there was no significant difference as to whether the knee had had resurfacing done or not. CONCLUSION Given that the cost of patella resurfacing is not insubstantial and that there are well-known complications resulting from it, we conclude that the role of patellar resurfacing for patellofemoral pain in knee arthritis remains unclear.
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Affiliation(s)
- J E Arbuthnot
- Department of Orthopaedics and Trauma, Warwick Hospital, Lakin Road, Warwick.
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Healy WL, Iorio R, Warren P. Mesh expansion release of the lateral patellar retinaculum during total knee arthroplasty. J Bone Joint Surg Am 2004; 86-A Suppl 1:193-200. [PMID: 15466759 DOI: 10.2106/00004623-200409001-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Release of the lateral patellar retinaculum can be used to treat patellofemoral instability and to balance the extensor mechanism during knee replacement operations. However, conventional lateral release disrupts the integrity of the lateral knee capsule, may damage the blood supply to the patella, and is associated with several other potential complications. Mesh expansion release of the lateral patellar retinaculum was developed to achieve the goal of lateral release and to reduce the potential for postoperative morbidity. METHODS Thirteen consecutive knees in eleven patients were treated with mesh expansion lateral release during a total knee arthroplastyand were evaluated after a minimum duration of follow-up of two years. The mesh release technique consisted of multiple, longitudinal, parallel 5 to 10-mm stab incisions to mesh and expand the lateral patellar retinaculum and thereby medialize the patella in the trochlear groove of the femoral implant. RESULTS Mesh expansion lateral release balanced the extensor mechanism in each knee, maintained the mechanical integrity of the lateral capsule, and avoided disruption of the lateral genicular blood supply to the patella. After a minimum duration of follow-up of two years, no complications had been noted in association with mesh expansion lateral release. CONCLUSIONS Mesh expansion release of the lateral patellar retinaculum effectively balanced the patellofemoral joint during total knee arthroplasty, maintained the integrity of the lateral capsule, and preserved the lateral genicular blood supply.
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Affiliation(s)
- William L Healy
- Department of Orthopaedic Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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Karnezis IA, Vossinakis IC, Rex C, Fragkiadakis EG, Newman JH. Secondary patellar resurfacing in total knee arthroplasty: results of multivariate analysis in two case-matched groups. J Arthroplasty 2003; 18:993-8. [PMID: 14658103 DOI: 10.1016/s0883-5403(03)00286-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Although patellofemoral symptoms after patellar-retaining knee arthroplasty are common, no evidence has been published in the literature on the potential benefit from patellar resurfacing at a later stage. This study evaluates the effect of secondary (delayed) patellar resurfacing using comparisons between 2 case-matched groups of patients with primary and secondary patellar resurfacing. Furthermore, multivariate statistical methods were applied to study factors that may influence the final outcome. Our results suggest that although significant clinical improvement was seen after delayed patella resurfacing, the outcome of secondary patellar resurfacing is inferior to that expected for a similar group of patients with primary resurfacing. Furthermore, the timing (delay period) of the secondary resurfacing procedure appears to negatively affect the final outcome. This suggests that secondary patellar resurfacing, when indicated, should be considered at an early stage.
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Affiliation(s)
- Ioannis A Karnezis
- Department of Orthopaedic Surgery, University of Bristol, Bristol, United Kingdom
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Healy WL, Iorio R, Warren P. Mesh expansion release of the lateral patellar retinaculum during total knee arthroplasty. J Bone Joint Surg Am 2003; 85:1909-13. [PMID: 14563797 DOI: 10.2106/00004623-200310000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Release of the lateral patellar retinaculum can be used to treat patellofemoral instability and to balance the extensor mechanism during knee replacement operations. However, conventional lateral release disrupts the integrity of the lateral knee capsule, may damage the blood supply to the patella, and is associated with several other potential complications. Mesh expansion release of the lateral patellar retinaculum was developed to achieve the goal of lateral release and to reduce the potential for postoperative morbidity. METHODS Thirteen consecutive knees in eleven patients were treated with mesh expansion lateral release during a total knee arthroplasty and were evaluated after a minimum duration of follow-up of two years. The mesh release technique consisted of multiple, longitudinal, parallel 5 to 10-mm stab incisions to mesh and expand the lateral patellar retinaculum and thereby medialize the patella in the trochlear groove of the femoral implant. RESULTS Mesh expansion lateral release balanced the extensor mechanism in each knee, maintained the mechanical integrity of the lateral capsule, and avoided disruption of the lateral genicular blood supply to the patella. After a minimum duration of follow-up of two years, no complications had been noted in association with mesh expansion lateral release. CONCLUSION Mesh expansion release of the lateral patellar retinaculum effectively balanced the patellofemoral joint during total knee arthroplasty, maintained the integrity of the lateral capsule, and preserved the lateral genicular blood supply.
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Affiliation(s)
- William L Healy
- Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts 01805, USA
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Abstract
BACKGROUND Anterior knee pain following total knee arthroplasty is a common complaint and typically is attributed to the patellofemoral joint. The purpose of the present study was to compare the outcome of resurfacing and nonresurfacing of the patella, particularly with regard to anterior knee pain, and to clarify the indications for patellar resurfacing at the time of total knee arthroplasty. METHODS We performed a prospective, randomized study of 514 consecutive primary press-fit condylar total knee replacements. The patients were randomized to either resurfacing or retention of the patella. They were also randomized to either a cruciate-substituting or a cruciate-retaining prosthesis as part of a separate trial. The mean duration of follow-up was 5.3 years (range, two to 8.5 years), and the patients were assessed with use of the Knee Society rating, a clinical anterior knee pain score, and the British Orthopaedic Association patient-satisfaction score. The assessment was performed without the examiner knowing whether the patella had been resurfaced. At the time of follow-up, there were 474 knees. Thirty-five patients who had a bilateral knee replacement underwent resurfacing on one side only. RESULTS The overall prevalence of anterior knee pain was 25.1% (fifty-eight of 231 knees) in the nonresurfacing group, compared with 5.3% (thirteen of 243 knees) in the resurfacing group (p < 0.0001). There was one case of component loosening. Ten of eleven patients who underwent secondary resurfacing had complete relief of anterior knee pain. The overall postoperative knee scores were lower in the nonresurfacing group, and the difference was significant among patients with osteoarthritis (p < 0.01). There was no significant difference between the resurfacing and nonresurfacing groups with regard to the postoperative function score. Patients who had a bilateral knee replacement were more likely to prefer the resurfaced side. CONCLUSIONS As the present study showed a significantly higher rate of anterior knee pain following arthroplasty without patellar resurfacing, we recommend patellar resurfacing at the time of total knee replacement when technically possible.
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Affiliation(s)
- T S Waters
- Institute of Orthopaedics, The Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom.
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Wood DJ, Smith AJ, Collopy D, White B, Brankov B, Bulsara MK. Patellar resurfacing in total knee arthroplasty: a prospective, randomized trial. J Bone Joint Surg Am 2002; 84:187-93. [PMID: 11861723 DOI: 10.2106/00004623-200202000-00004] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The management of the patella in total knee arthroplasty is still problematic. We aimed to identify differences in the clinical outcome of total knee arthroplasty according to whether or not patellar resurfacing had been performed in a prospective, randomized study of 220 osteoarthritic knees. METHODS Two hundred and twenty total knee arthroplasties in 201 patients were randomly assigned to be performed with either resurfacing or retention of the patella, and the results were followed for a mean of forty-eight months (range, thirty-six to seventy-nine months) in a double-blind (both patient and clinical evaluator blinded), prospective study. Evaluation was performed annually by an independent observer and consisted of assessment with the Knee Society clinical rating system, specific evaluation of anterior knee pain, a stair-climbing test, and radiographic examination. RESULTS Fifteen (12%) of the 128 knees without patellar resurfacing and nine (10%) of the ninety-two knees with patellar resurfacing underwent a revision or another type of reoperation related to the patellofemoral articulation. This difference was not significant (chi square with one degree of freedom = 0.206, p = 0.650). At the time of the latest follow-up, there was a significantly higher incidence of anterior pain (chi square with one degree of freedom = 5.757, p = 0.016) in the knees that had not had patellar resurfacing. CONCLUSIONS Patients who underwent patellar resurfacing had superior clinical results in terms of anterior knee pain and stair descent. However, anterior knee pain still occurred in patients with patellar resurfacing, and nine (10%) of the ninety-two patients in that group underwent a revision or another type of reoperation involving the patellofemoral joint. Weight but not body mass index was associated with the development of anterior knee pain in the patients without patellar resurfacing, a finding that suggests that patellofemoral dysfunction may be a function of joint loading rather than obesity.
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Affiliation(s)
- David J Wood
- Division of Orthopaedics, Department of Surgery, University of Western Australia, Nedlands, Western Australia, Australia
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Abstract
Total knee replacement (TKR) presumably is replacement of the total knee articular surface. Sometimes it is and sometimes it is not. It is this author's firm conviction that the patella should be resurfaced in the vast majority of cases. Such advocacy must be critically justified and the potential drawbacks and alternatives examined.
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Affiliation(s)
- J Noble
- Department of Orthopaedic Surgery, University of Manchester Medical School, Hope Hospital, Eccles Old Road, Salford, Greater, Manchester, UK
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Wachtl SW, Jakob RP. Patella osteotomy for lateral retinaculum decompression in total knee arthroplasty. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:522-4. [PMID: 11186413 DOI: 10.1080/000164700317381252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- S W Wachtl
- Department of Orthopaedic Surgery, H pital Cantonal, Fribourg, Switzerland.
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Ogata K, Ishinishi T, Hara M. Evaluation of patellar retinacular tension during total knee arthroplasty. Special emphasis on lateral retinacular release. J Arthroplasty 1997; 12:651-6. [PMID: 9306216 DOI: 10.1016/s0883-5403(97)90138-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Tension of a suture placed to the patella to close the medial capsule during 35 primary total knee arthroplasties was measured. The increase in tension with flexion after arthrotomy was significantly smaller in 10 knees with a subvastus incision (subvastus group) than in 25 knees with a standard medial parapatellar incision (standard group). With the prosthesis in place, the patella showed maltracking with the no-thumb technique in 1 knee (10%) of the subvastus group and in 9 knees (36%) of the standard group. A lateral retinacular release was performed in 5 of these 10 knees but not in the remaining 5 knees because the increase in tension was a minimum. There was no case of patellar maltracking at an average follow-up period of 2.1 years after surgery, suggesting that a lateral release is not always needed if retinacular tension shows no significant increase, even cases where the patella dislocates with the no-thumb technique.
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Affiliation(s)
- K Ogata
- Fukuoka University Hospital, Japan
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AYERS DAVIDC, DENNIS DOUGLASA, JOHANSON NORMANA, PELLEGRINI VINCENTD. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Common Complications of Total Knee Arthroplasty*†. J Bone Joint Surg Am 1997. [DOI: 10.2106/00004623-199702000-00018] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Abstract
A consecutive series of 289 Miller-Galante (Zimmer, Warsaw, IN) total knee arthroplasties were studied, with particular reference to the patellofemoral joint. Sixteen knees were initially excluded; the remaining 273 arthroplasties were followed for 14 to 44 months. Thirty patients (11%) had patellofemoral pain. Twenty patients (7.3%) had revision patellofemoral surgery. Fourteen patients had revision surgery for patellar maltracking, of which 10 had resolution of their symptoms, 2 were improved, 1 had no change, and 1 developed a prosthetic infection. Six patients who had no evidence of patellar maltracking had revision surgery with a cemented metal-backed patellar component. Only two of these patients had symptom improvement from their revision surgery. A higher than usual incidence of patellar maltracking (5%) is reported. The first-generation Miller-Galante femoral component may contribute to the relative instability of patellofemoral tracking. Those patients with patellar maltracking were greatly improved by revision surgery; the results of revision surgery for anterior knee pain without associated patellar maltracking were disappointing.
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Affiliation(s)
- D G Campbell
- Department of Orthopaedic Surgery, Queen Elizabeth Hospital, Adelaide, South Australia
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Abstract
One hundred patients with primary osteoarthritis of the knee were prospectively randomized to assess the clinical outcome between two contemporary knee designs, namely the Anatomic Modular Knee (AMK, DePuy, Warsaw, IN) and the Miller Galante I (MG I, Zimmer, Warsaw, IN). In addition, patients were stratified by surgeon. While the clinical outcome measured by the Hospital for Special Surgery knee scores was similar for both groups, there was a difference in the number of complications requiring further surgery. Extensor mechanism complications requiring further surgery occurred in four patients (3 MG I and 1 AMK); three patients in the MG I group required a distal realignment procedure for patellar dislocation, while none of the AMK patients had this complication. There was, however, one patellar fracture in the AMK group that required an open reduction. The authors postulate that the major difference contributing to patellofemoral complications relates to the patellofemoral design and patellar tracking, with the more anatomic AMK femoral component having better patellar tracking and stability clinically.
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Affiliation(s)
- P G Kirk
- University Hospital, University of Western Ontario, London, Canada
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