Does Circumferential Patellar Denervation Result in Decreased Knee Pain and Improved Patient-reported Outcomes in Patients Undergoing Nonresurfaced, Simultaneous Bilateral TKA?

Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails

To investigate the effects of patellar denervation (PD) and non-patellar denervation (NPD) after primary total knee arthroplasty (TKA) without patellar resurfacing, this study conducted systematic electronic searches in November 2023 using PubMed, Embase, Web of Science, Cochrane, and Scopus, adhering to Cochrane Collaboration recommendations. Only randomized controlled trials (RCTs) were included. Additionally, a manual search was performed to identify potentially eligible studies from the reference lists of review articles. Two researchers independently conducted literature reviews, data extraction, and risk of bias assessments. The outcome analysis encompassed the incidence of anterior knee pain (AKP), visual analogue scale (VAS), range of motion (ROM), American Knee Society Score (KSS), Oxford Knee Score (OKS), patellar score (PS), complications, and reoperations. Meta-analysis was executed using RevMan 5.3 software. To enhance the credibility of the study, TSA v0.9 software was utilized to perform power analysis on the overall efficacy of primary and secondary outcomes. Twelve studies involving 1745 patients (1587 knees) were included, with 852 undergoing PD and 893 undergoing NPD. Results indicated a superior reduction in AKP incidence in the PD group compared to the NPD group. Statistically significant differences were observed between PD and NPD in KSS, OKS, and PS. However, the upper limit of the 95% confidence interval for each outcome fell below the minimal clinically important difference (MCID). No significant differences were found in VAS and ROM between PD and NPD. Additionally, PD was not associated with an increased incidence of complications or reoperations. Within 12 months and beyond, PD was proven to be a beneficial intervention in reducing AKP following TKA without patellar resurfacing, achieved without an increase in complications or reoperations. Regarding KSS, OKS, and PS, the minimal advantage achievable through PD may not be clinically significant.

Different modalities of patellar management in primary total knee arthroplasty: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

The primary management modalities for the patella in TKA include patellar resurfacing, patellar non-resurfacing, patellar resurfacing with denervation, and patellar non-resurfacing with denervation. Traditionally, meta-analyses have predominantly focused on examining comparisons between two management modalities. However, this study performed a network meta-analysis to compare all four patellar management interventions to identify the most optimal approach for patellar management in TKA.

METHODS

A computer-based search of PubMed, China National Knowledge Infrastructure (CNKI), The Cochrane Library, Web of science, Embase, and MEDLINE databases was performed to identify randomized controlled trials focusing on the four management interventions for the patella in TKA. Comparisons included two-by-two comparisons as well as those involving more than two concurrent comparisons. The search timeframe spanned from inception to June 30, 2023. Two independent authors extracted the data and evaluated the quality of the literature. The Cochrane Collaboration Risk of Bias (ROB) tool was used to evaluate the overall quality of the literature. Subsequently, a network meta-analysis was conducted using the "gemtc" package of the R-4.2.3 software. Outcome measures such as anterior knee pain (AKP), reoperation rate, and patient satisfaction rate were evaluated using odd ratio (OR) and 95% confidence intervals (CI). Additionally, the knee society score (KSS), function score (FS), and range of motion (ROM) were evaluated using mean differences (MD) with associated 95% CI. The different treatment measures were ranked using the surfaces under the cumulative ranking curves (SUCRA).

RESULTS

A total of 50 randomized controlled trials involving 9,283 patients were included in the analysis. The findings from this network meta-analysis revealed that patellar resurfacing exhibited significantly lower postoperative reoperation rate (OR 0.44, 95% CI 0.24-0.63) and AKP (OR 0.58, 95% CI 0.32-1) compared to non-resurfacing. Additionally, patellar resurfacing exhibited higher postoperative KSS clinical scores in comparison with non-resurfacing (MD: 1.13, 95% CI 0.18-2.11). However, for postoperative FS, ROM, and patient satisfaction, no significant differences were observed among the four management interventions.

CONCLUSION

Patellar resurfacing emerges as the optimal management modality in primary TKA. However, future studies should aim to reduce sources of heterogeneity and minimize the influence of confounding factors on outcomes.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023434418 identifier: CRD42023434418.

PCL retained is safe in medial pivot TKA-a prospective randomized trial

PURPOSE

Medial pivot (MP) designs resemble native knee kinematics and restore the "natural" kinematics of a knee after total knee arthroplasty (TKA). However, whether to preserve or resect the posterior cruciate ligament (PCL) is still under debate. We inquired whether sacrificing the PCL would improve range of motion, functional outcomes, and limb alignment compared to preserving the PCL in TKA using medial pivot implants (MP-TKA).

METHODS

This prospective, double-blinded, randomized controlled trial consisted of 33 patients (66 knees) undergoing bilateral simultaneous MP-TKA. In one knee, a PCL preservation technique was performed, and in the contralateral knee, the PCL was resected. The primary outcome was postoperative range of motion (ROM). The secondary outcomes were visual analogue scale (VAS) score for knee pain at walking, Knee Injury and Osteoarthritis Outcome Score for symptoms (KOOS-S) and quality of life (KOOS-QoL), Oxford knee score (OKS), and Forgotten Joint Score (FJS), and measurement of the mechanical femoral-tibial axis (mFTA) on X-ray images. All patients were followed up for a minimum of 2 years after surgery.

RESULTS

Patients who underwent MP-TKA with PCL preservation had a similar ROM at 2 years (125.45 ± 7.00 vs. 126.21 ± 6.73, p = 0.65) as those who underwent MP-TKAs with PCL resection. There was also no difference in VAS score (1.94 ± 0.79 vs. 2.00 ± 0.71, respectively, p = 0.51), OKS (39.97 ± 2.01 vs. 39.67 ± 2.03, respectively, p = 0.52), KOOS-S (84.41 ± 3.77 vs. 84.19 ± 3.57, respectively, p = 0.92), KOOS-QoL (82.94 ± 4.76 vs. 82.75 ± 4.70, respectively, p = 0.84), or FJS (72.66 ± 8.99 vs. 72.35 ± 8.64, respectively, p = 0.76) at the 2-year follow-up. No difference in the measurement of the mFTA was found between the two groups (180.27 ± 2.25 vs. 181.30 ± 2.13, respectively, p = 0.59).

CONCLUSION

This study demonstrated that both medial pivot TKA with PCL preservation and PCL resection achieved excellent results. There was no difference at the 2-year follow-up in terms of postoperative ROM, patient-reported outcomes, or radiographic evaluation.

LEVEL OF EVIDENCE

Therapeutic study, Level I.

Preoperative patellar bone marrow lesions with full thickness cartilage defects correlate with residual anterior knee pain in total knee arthroplasty without patellar resurfacing

PURPOSE

Residual anterior knee pain is one of the most common problems after total knee arthroplasty (TKA). However, the contributing factors affecting postoperative anterior knee pain (AKP) remain poorly understood. This study aimed to evaluate the effect of preoperative patellar bone marrow lesions (BMLs) and patellar cartilage defects on postoperative AKP after patellar non-resurfacing TKA.

METHODS

This retrospective study included 336 patients who underwent unilateral TKA without patella resurfacing. All patients underwent preoperative magnetic resonance imaging (MRI) to assess the presence of BMLs and the degree of cartilage defects in the patella. Patients were categorized into four groups according to the presence of BMLs (with or without BMLs) and the degree of cartilage defects (with or without full thickness cartilage defects). The Kujala Anterior Knee Pain Scale (AKPS) and the Hospital for Special Surgery Knee Rating Scale (HSS) scores at 2 years after TKA were compared among the groups.

RESULTS

Preoperative BMLs in the patella were found in 132 (39.3%) of 336 cases. Among the four groups, the group with both BMLs and full-thickness cartilage defects demonstrated significantly lower AKPS compared to the other groups at 2 years after TKA (p < 0.01), but no significant difference was shown in the HSS scores, between these groups. There were no significant differences in either AKPS or HSS scores among the other three patient groups.

CONCLUSIONS

The presence of preoperative BMLs with full-thickness cartilage defects in the patella was associated with worse postoperative AKP after TKA without patella resurfacing. Patella resurfacing should be considered in this patient group to minimize the risk of developing residual AKP after TKA.

LEVEL OF EVIDENCE

III.

What can we expect from patellar denervation in knee arthroplasty? An updated systematic review and meta-analysis

Denervation by electrocauterization was proposed to be efficient in preventing anterior knee pain (AKP) following arthroplasty. The purpose of this study was to evaluate the effects of patellar denervation (PD) in primary knee arthroplasty. Systematic search was performed in PubMed, ScienceDirect, Cochrane Library, and ClinicalKey databases until July 2022 for published articles. The quantitative analyses were carried out by Review Manager 5.4 software. Twenty-one studies were included. Overall incidence of AKP, visual analog scale (VAS), and knee society score were significantly superior in PD group. Denervation also showed better outcomes in incidence of AKP at each follow-up time point, and in VAS and range of motion (ROM) at ≤3 months. Subanalyses based on depth of electrocautery showed statistically better results with 2–3 mm depth in VAS and PS compared to ≤1 mm. This study concluded that PD might contribute to lower incidence of knee pain. Patients who expect quicker recovery in pain and ROM may benefit from this procedure.

Patellar Resurfacing in Total Knee Arthroplasty, a Never-Ending Controversy; Case Report and Literature Review

Total knee arthroplasty (TKA) remains a lifesaving procedure for advanced gonarthrosis. However, patella resurfacing (PR) in TKA remains a controversial procedure, leading to extensive discussions amongst orthopedic surgeons, regarding its indications and results. Based on these premises, we present a clinical case of a 70-year-old Caucasian woman admitted for pain, swelling and limitation of left knee joint mobility. Her medical history records an Ahlback stage IV gonarthrosis with simultaneous bilateral TKA surgery performed in different hospital, when two NexGen cemented total prostheses were implanted with patellar resurfacing being performed only on the right side. Our clinical (American Knee Society Score, Lonner and Feller scales) and radiological evaluations (CT scan and Xray) revealed left patellar arthrosis and a slight lateral subluxation of the patella. The chosen treatment plan was revision surgery for PR and patellar prosthesis with a cemented patellar component, cross-linked polyethylene, no 32 NexGen model with 8.5 mm thickness. The immediate and distant postoperative evolution was favorable. Extensive literature review shows that, at present, PR remains at surgeon's discretion mainly based on his previous results. Therefore, we believe there is an imperative need to develop high quality studies based on accurate scientific evidence to universally establish valid guidelines for PR in TKA.

Patellar management during total knee arthroplasty: a review

The optimal management of the patella during total knee arthroplasty (TKA) remains controversial and surgeons tend to approach the patella with one of three general mindsets: always resurface the patella, never resurface the patella, or selectively resurface the patella based on specific patient or patellar criteria.

Studies comparing resurfacing and non-resurfacing of the patella during TKA have reported inconsistent and contradictory findings.

When resurfacing the patella is chosen, there are a number of available patellar component designs, materials, and techniques for cutting and fixation.

When patellar non-resurfacing is chosen, several alternatives are available, including patellar denervation, lateral retinacular release, and patelloplasty. Surgeons may choose to perform any of these alone, or together in some combination.

Prospective randomized studies are needed to better understand which patellar management techniques contribute to superior postoperative outcomes. Until then, this remains a controversial topic, and options for patellar management will need to be weighed on an individual basis per patient.

Cite this article: EFORT Open Rev 2021;6:861-871. DOI: 10.1302/2058-5241.6.200156

Influence of patellar denervation on anterior knee pain and knee function following total knee replacement: A systematic review and meta-analysis

BACKGROUND

Previous studies have reached mixed results regarding the effects of patellar denervation with electrocautery (PD) on total knee replacement (TKR). This systematic review and meta-analysis aimed to summarize all available literatures to investigate the influence of PD on postoperative anterior knee pain (AKP) and knee function after TKR.

METHODS

Electronic databases, including PubMed, Cochrane Library and Embase, were searched from their inception to March 2021. Randomized controlled trials (RCT) and quasi-randomized controlled trials (quasi-RCT) comparing PD and non-patellar denervation (NPD) in TKR were selected, and the Cochrane risk of bias tool was used to assess the quality of included trials. AKP prevalence was defined as the primary outcome.

RESULTS

A total of 12 RCTs and one quasi-RCT enrolled 1895 knees proved eligible. PD knees had significantly lower AKP prevalence than NPD knees (odds ratio [OR] = 0.54; 95% confidence intervals [95% CI], 0.36-0.81; p = 0.003). There was no difference between PD and NPD in terms of visual analogue scale for knee pain and range of motion, American knee society knee score, American knee society function score, patellar feller score, Oxford knee score for knee function. The results of subgroup analysis based on follow-up duration and patella resurfacing were in accordance with the results. PD knees were not associated with a higher risk of complication or revision.

CONCLUSION

PD can significantly reduce the AKP prevalence following TKR without increasing the risk of complication and revision. Although the pain relief effect of PD may not be associated with improved knee function after TKR, this procedure is preferred in both patella resurfacing and patella non-resurfacing TKR.

Patellar Denervation Reduces Postoperative Anterior Knee Pain After Patellar Resurfacing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The benefit of patellar denervation (PD) in patellar resurfacing total knee arthroplasty (TKA) is still debatable. This prospective, randomized controlled trial investigated whether circumferential PD should be performed in patellar resurfacing TKA.

METHODS

A total of 241 patients who underwent unilateral TKA were randomized into PD or non-PD groups. Incidence, intensity, and presentation time of anterior knee pain (AKP) and clinical outcomes were evaluated at 3, 6, 9, 12, 18, and 24 months postoperatively.

RESULTS

The incidence of AKP was significantly lower in the PD group (6.4% vs 16.2%, P = .032). The intensity of AKP and patient satisfaction scores were significantly better in the PD group at 3 months but not after 3 months. The presentation time of AKP mostly occurs at 3 months after surgery. The Knee Society score, range of motion, Oxford score, patellar score, activity of daily living score, and visual analog scale of overall knee pain were not significantly different between the two groups during the follow-up period.

CONCLUSION

Given that PD can improve AKP and patient satisfaction at an early period postoperatively without jeopardizing clinical outcomes at no additional cost, this inexpensive procedure readily available in nearly every operation room is strongly recommended during primary TKA with patellar resurfacing.