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Morrison R, Mandalia V. Current outcomes of patellofemoral arthroplasty for isolated patellofemoral arthritis - A narrative review. J Orthop 2023; 46:156-160. [PMID: 37997600 PMCID: PMC10663639 DOI: 10.1016/j.jor.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 11/25/2023] Open
Abstract
Patellofemoral (PFJ) arthritis can be primary, or secondary to underlying trochlea dysplasia and patellofemoral malalignment. Although primary PFJ osteoarthritis affects an older patient population, just like tibiofemoral arthritis, it is common for younger patients to present with isolated PFJ arthritis secondary to an abnormal PFJ. PFJ arthroplasty (PFJA) has many benefits including being less invasive, associated with lower blood loss, is more cost-effective, and leaves the kinematics of the tibiofemoral joint undisturbed. As a result, there are arguably better functional outcomes associated with PFJA, however the historical revision rate of this procedure is high. Although registry outcome data associated with the first generation of PFJ implants shows a higher revision rate compared to TKA, the comparison of PFJ outcomes with TKA is not always age-matched and there is limited comparison on functional and patient-reported outcomes, something which is more important and relevant in a younger patient cohort. Improvements in implant design, instrumentation, surgical technique, and better patient selection has now resulted in outcomes which are comparable to that of TKA, and in some cases even better. This narrative review outlines the current outcomes of PFJA including highlighting factors which need to be considered in optimising outcomes, as well as discussing advanced techniques of robotic assisted PFJA.
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Affiliation(s)
- Rory Morrison
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5DW, UK
| | - Vipul Mandalia
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5DW, UK
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Bond EC, Stauffer TP, Hendren S, Amendola A. Modern Patellofemoral Arthroplasty. JBJS Rev 2023; 11:01874474-202309000-00002. [PMID: 37656827 DOI: 10.2106/jbjs.rvw.23.00071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
INTRODUCTION The ideal procedure for isolated patellofemoral arthritis is a controversial topic. Patellofemoral arthroplasty (PFA) is an option that aims to restore normal kinematics to the knee while preserving bone. PFA has been shown to have benefits compared with total knee arthroplasty (TKA) in this patient population but has historically had a high failure rate. Revision rates are improving with modern implants and tight indications but still remain higher than TKA. This review summarizes current thinking around PFA using modern implants and techniques in 2023, provides an implant-specific analysis, and assesses how we can improve outcomes after PFA based on the current literature. The aim was to provide an outline of the evidence around PFA on which surgeons can make decisions to optimize patient outcome in this young and active population. METHODS Four databases (MEDLINE, Embase, Scopus, and SPORTDiscus) were searched for concepts of patellofemoral joint arthroplasty. After abstract and text review, a screening software was used to assess articles based on inclusion criteria for studies describing indications, outcomes, and techniques for isolated PFA using modern implants, with or without concomitant procedures. RESULTS A total of 191 articles were included for further examination, with 62 articles being instructional course lectures, systematic reviews, technique articles, narrative reviews, expert opinions, or meta-analyses. The remaining articles were case reports, trials, or cohort studies. Articles were used to create a thorough outline of multiple recurrent topics in the literature. CONCLUSIONS PFA is an appealing option that has the potential to provide a more natural feeling and functioning knee for those with isolated PF arthritis. The high rate of revision is a cause for concern and there are several technical details that should be stressed to optimize results. The uncertain outcome after revision to TKA also requires more investigation. In addition, the importance of strict selection criteria and firm indications cannot be stressed enough to optimize longevity and attempt to predict those who are likely to have progression of tibiofemoral osteoarthritis. The development of new third-generation implants is promising with excellent functional outcomes and a much lower rate of maltracking and implant complications compared with earlier generations. The impact of these implants and improvement in surgical techniques on the revision rate of PFA will be determined from longer-term outcomes.
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Affiliation(s)
- Elizabeth C Bond
- Division of Orthopedic Surgery, Duke University, Durham, North Carolina
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Yamawaki Y, Kuriyama S, Watanabe M, Nakamura S, Ohkoshi Y, Matsuda S. Internal Rotation, Varus, and Anterior Femoral Component Malalignments Adversely Affect Patellofemoral Joint Kinematics in Patellofemoral Arthroplasty. Arthroplast Today 2023; 21:101124. [PMID: 37012933 PMCID: PMC10066524 DOI: 10.1016/j.artd.2023.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/26/2022] [Accepted: 02/14/2023] [Indexed: 04/05/2023] Open
Abstract
Background Patellofemoral arthroplasty (PFA) is reported to provide nearly normal PF joint kinematics but only with adequate surgical techniques. This study evaluated the effects of various femoral component settings on patellar component biomechanics. Methods A dynamic musculoskeletal computer simulation analyzed normal knee and standard PFA models, as well as 8 femoral component malposition models: 5° internal or external rotation, 5° valgus or varus, 5° extension or flexion, and 3-mm or 5-mm anterior positioning. Mediolateral patellar translation, lateral patellar tilt, and contact force and stress at the PF joint were measured in each model during gait. Results The patella in the standard PFA model was shifted up to 5.0 mm laterally near heel off and was tilted up to 3.0° laterally at heel strike compared to the normal knee model. The patella in the external rotation model translated more laterally in the direction of the femoral component setting than in the standard model. However, in the internal rotation and varus alignment models, the patellar lateral shift occurred largely in the opposite direction of the femoral component setting. The patella in most models was tilted in the same direction as the femoral component setting. The PF contact force was increased, especially in the anterior femoral position models, by up to 30 MPa compared with 20 MPa in the standard model. Conclusions Internal rotation, varus, and anterior femoral component settings during PFA should be avoided to reduce postoperative complications, whereas external rotation might be appropriate only for cases with lateral patellar instability.
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Affiliation(s)
- Yusuke Yamawaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kuriyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Corresponding author. Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. Tel.: +81 75 751 3366.
| | - Mutsumi Watanabe
- Department of Orthopaedic Surgery, Tamatsukuri Hospital, Shimane, Japan
| | - Shinichiro Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasumitsu Ohkoshi
- Department of Orthopaedic Surgery, Hakodate Orthopaedic Clinic, Hakodate, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Vasta S, Rosi M, Tecame A, Papalia R, Adravanti P. Aiming for anatomical femoral axis on the coronal plane leads to good-to-excellent short-term outcomes in isolated patellofemoral arthroplasty. Knee 2020; 27:1003-1009. [PMID: 32192817 DOI: 10.1016/j.knee.2020.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 01/27/2020] [Accepted: 02/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND In patellofemoral replacement (PFR) coronal alignment is mostly influenced by local condylar anatomy. However, there is still a lack of consensus regarding references to follow intraoperatively for the optimal positioning of the trochlear component. The aim of this study was to assess whether aiming for the anatomical femoral axis on the coronal plane leads to improved clinical outcomes and whether coronal alignment correlates with clinical outcomes. METHODS Forty-two patients who underwent PFR were retrospectively evaluated at a minimum one-year follow-up using Kujala and Knee Society Score (KSS). Moreover, patients underwent an anteroposterior hip-to-knee X-ray to evaluate the coronal alignment of the trochlear component with respect to the femoral anatomic and mechanical axis. Prosthesis coronal alignment, Kujala, and KSS were assessed for possible correlation. RESULTS Mean follow-up time: 29.1 months. Mean KSS for pain: 90 (±8.9), for function: 93.7 (±15.9); mean Kujala: 89.2 (±13.6). Mean prosthesis coronal alignment was 3.3 ± 2.3° in valgus with respect to the femoral anatomic axis and 7.4 ± 2.6° in valgus with respect to the femoral mechanical axis. No correlations were found between coronal alignment and KSS or Kujala scores. CONCLUSIONS Results from the current study showed that PF replacement with a third-generation implant led to good-to-excellent outcomes. In addition, the surgical technique used for aligning femoral component in this study resulted in reduced coronal alignment variability and achieved good short-term clinical outcomes.
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Affiliation(s)
- Sebastiano Vasta
- Department of Orthopaedics and Trauma Surgery, University Campus Bio-Medico of Rome, Rome, Italy.
| | - Massimiliano Rosi
- Department of Orthopaedics and Trauma Surgery, University of Messina, Messina, Italy
| | - Andrea Tecame
- Orthopaedic Department, Clinic "Città di Parma", Parma, Italy
| | - Rocco Papalia
- Department of Orthopaedics and Trauma Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Paolo Adravanti
- Orthopaedic Department, Clinic "Città di Parma", Parma, Italy
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Metcalfe AJ, Ahearn N, Hassaballa MA, Parsons N, Ackroyd CE, Murray JR, Robinson JR, Eldridge JD, Porteous AJ. The Avon patellofemoral joint arthroplasty: two- to 18-year results of a large single-centre cohort. Bone Joint J 2018; 100-B:1162-1167. [PMID: 30168762 DOI: 10.1302/0301-620x.100b9.bjj-2018-0174.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims This study reports on the medium- to long-term implant survivorship and patient-reported outcomes for the Avon patellofemoral joint (PFJ) arthroplasty. Patients and Methods A total of 558 Avon PFJ arthroplasties in 431 patients, with minimum two-year follow-up, were identified from a prospective database. Patient-reported outcomes and implant survivorship were analyzed, with follow-up of up to 18 years. Results Outcomes were recorded for 483 implants (368 patients), representing an 86% follow-up rate. The median postoperative Oxford Knee Score (0 to 48 scale) was 35 (interquartile range (IQR) 25.5 to 43) and the median Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, 0 to 100 scale) was 35 (IQR 25 to 53) at two years. There were 105 revisions, 61 (58%) for progression of osteoarthritis. All documented revisions were to primary knee systems without augmentation. The implant survival rate was 77.3% (95% confidence interval (CI) 72.4 to 81.7, number at risk 204) at ten years and 67.4% (95% CI 72.4 to 81.7 number at risk 45) at 15 years. Regression analysis of explanatory data variable showed that cases performed in the last nine years had improved survival compared with the first nine years of the cohort, but the individual operating surgeon had the strongest effect on survivorship. Conclusion Satisfactory long-term results can be obtained with the Avon PFJ arthroplasty, with maintenance of patient-reported outcome measures (PROMs), satisfactory survival, and low rates of loosening and wear. Cite this article: Bone Joint J 2018;100-B:1162-7.
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Affiliation(s)
- A J Metcalfe
- Warwick Medical School, Warwick University, Coventry, UK
| | - N Ahearn
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - M A Hassaballa
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - N Parsons
- Warwick Medical School, Warwick University, Coventry, UK
| | - C E Ackroyd
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - J R Murray
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - J R Robinson
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - J D Eldridge
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - A J Porteous
- The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Femoral component rotation in patellofemoral joint replacement. Knee 2018; 25:485-490. [PMID: 29551276 DOI: 10.1016/j.knee.2018.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Clinical outcomes in patellofemoral joint replacement may be related to femoral component rotation. Assessment of rotational alignment is however difficult as patients with isolated patellofemoral osteoarthritis often have trochlear dysplasia. The use of the medial malleolus as a landmark to guide rotation has been suggested. The purpose of our study was to evaluate this technique with regard to femoral component rotation, and to correlate rotation with clinical outcomes at one-year follow-up. METHODS Forty-one knees in 39 patients had patellofemoral joint replacement using the Zimmer Gender-Solutions patellofemoral prosthesis. Intraoperatively, we determined femoral component rotational alignment using an extramedullary rod aimed at the inferior tip of the medial malleolus. Postoperatively, we measured the angle between the femoral component and the anatomical transepicondylar axis using CT. The amount of rotation was correlated with clinical outcomes at one-year follow-up. RESULTS Forty knees in 38 patients were available for one-year follow-up. Mean femoral component rotation relative to the anatomical transepicondylar axis was 1.4° external rotation (range, -3.8 to 5.7°). We found no statistically significant correlation between femoral component rotation and change from baseline KOOS subscales at one-year follow-up. CONCLUSIONS Our findings show that when using the medial malleolus as a landmark to guide rotation, the femoral component of the patellofemoral prosthesis was oriented in external rotation relative to the anatomical transepicondylar axis in 80% of knees. Our study did not show a relation between the amount of external rotation and clinical outcomes. LEVEL OF EVIDENCE Level III.
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Saffarini M, Müller JH, La Barbera G, Hannink G, Cho KJ, Toanen C, Dejour D. Inadequacy of computed tomography for pre-operative planning of patellofemoral arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018; 26:1485-1492. [PMID: 28271370 DOI: 10.1007/s00167-017-4474-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the accuracy of preoperative planning for patellofemoral arthroplasty (PFA) by comparing: (1) virtual implant positioning simulated on pre-operative images versus (2) real implant positioning from post-operative images. METHODS The authors prospectively studied 15 patients that received a PFJ implant (Tornier, Montbonnot France). A pre-operative planning software was established to determine the size and position of the trochlear component. Pre-operative scans were used to perform virtual implantations by two different operators, which were then compared to the post-operative scans to calculate errors (ε) in implant positioning and intra-class correlation coefficients (ICC) for intra- and inter-observer repeatability. RESULTS Analysis was performed for 13 patients, for whom agreement between virtual and real surgery was excellent for anteroposterior (AP) position (ICC = 0.84; ε max = 3.5 mm), fair for proximodistal (PD) position (ICC = 0.50; ε max = 9.5 mm), and poor for mediolateral (ML) position (ICC = 0.07; ε max = 9.0 mm). It was fair for flexum-recurvatum (FR) alignment (ICC = 0.53; ε max = 8.2°), poor for varus-valgus (VV) alignment (ICC = 0.34; ε max = 10.0°), and internal-external (IE) rotation (ICC = 0.34; ε max = 10.6°). CONCLUSIONS Pre-operative planning was insufficiently accurate to follow intra-operatively, the greatest errors being angular alignment (VV and FR). The clinical relevance of these findings is that PFA is difficult to plan pre/operatively due to non-visibility of cartilage on CT scans and to trochlear dysplasia in most cases. LEVEL OF EVIDENCE Prospective evaluation of operative tools on consecutive patients, Level III.
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Affiliation(s)
- Mo Saffarini
- ReSurg SA, 35 ch. de la Vuarpillière, 1260, Nyon, Switzerland.
| | - Jacobus H Müller
- Department of Mechanical and Mechatronic Engineering Stellenbosch University, Private Bag X1, Matieland, 7600, Stellenbosch, South Africa
| | - Giuseppe La Barbera
- Lyon-Ortho-Clinic, Clinique de la Sauvegarde, 8 Avenue Ben Gourion, 69009, Lyon, France
| | - Gerjon Hannink
- Orthopaedic Research Laboratory, Radboud University Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Kyung Jin Cho
- Department of Mechanical and Mechatronic Engineering Stellenbosch University, Private Bag X1, Matieland, 7600, Stellenbosch, South Africa
| | - Cécile Toanen
- Lyon-Ortho-Clinic, Clinique de la Sauvegarde, 8 Avenue Ben Gourion, 69009, Lyon, France
| | - David Dejour
- Lyon-Ortho-Clinic, Clinique de la Sauvegarde, 8 Avenue Ben Gourion, 69009, Lyon, France
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Westerbeek RE, Derks RPH, Zonneveld BJGL, van Jonbergen HPW. Femoral component rotation in patellofemoral joint replacement: a study protocol for a prospective observational study. Open Orthop J 2015; 9:45-8. [PMID: 25861405 PMCID: PMC4384222 DOI: 10.2174/1874325001509010045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/20/2015] [Accepted: 02/15/2015] [Indexed: 11/22/2022] Open
Abstract
Patellofemoral joint replacement is a successful treatment option for isolated patellofemoral osteoarthritis. The
short and mid-term outcomes are related to malposition and unexplained pain. Whether external rotation of the femoral
component in isolated patellofemoral joint replacement is required is unclear. The primary aim of this study is to
determine the CT-measured femoral component rotation of patellofemoral joint replacement relative to the
transepicondylar axis. The secondary aim is to correlate the CT-measured femoral component rotation with the clinical
outcomes at 1-year follow-up as assessed with the KOOS questionnaire. We designed a prospective observational study with medical research ethics committee and institutional review board
approval. A total of 40 patients who will be treated with patellofemoral joint replacement for isolated patellofemoral
osteoarthritis will be included. Intra-operatively, rotation of the femoral component will be assessed using anatomical
landmarks including the epicondylar axis, Whiteside’s line, and lower leg axis. The aim is to insert the femoral component
between 3 and 6 degrees external rotation relative to the transepicondylar axis. Two experienced musculoskeletal
radiologists will measure the angle between the transepicondylar axis and the femoral component, two to three days after
surgery. The primary outcome is the CT-based femoral component rotation of the prosthesis relative to the
transepicondylar axis. The secondary outcome is the patient reported KOOS questionnaire at 1-year follow-up. Successful completion of this study will provide data on the actual amount of femoral component rotation in
patellofemoral joint replacement, and its relationship with clinical results. (Netherlands Trial Register NTR4175).
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Affiliation(s)
- Robin E Westerbeek
- Department of Radiology, Deventer Hospital, PO Box 5001, 7400 GC Deventer, The Netherlands
| | - Rosalie P H Derks
- Department of Radiology, Deventer Hospital, PO Box 5001, 7400 GC Deventer, The Netherlands
| | - Bas J G L Zonneveld
- Department of Radiology, Deventer Hospital, PO Box 5001, 7400 GC Deventer, The Netherlands
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