Controversy: supporting patellar resurfacing in total knee arthroplasty - do it

Patella is rarely resurfaced during primary total knee arthroplasty in clinical trials conducted in Greece: a systematic review

PURPOSE

The aim of the present study was to report the approach of Greek surgeons regarding patellar management and provide the outcomes and the rate of the need for secondary patella resurfacing.

METHODS

Following the PRISMA guidelines, PubMed, Scopus, and The Cochrane Central Register of Controlled Trials (CENTRAL) databases were accessed in January 2024. Clinical studies evaluating the outcomes of patients undergoing primary TKA were considered eligible for this systematic review if the following predefined criteria were fulfilled: (1) published in English, (2) were conducted in Greece, and had a minimum of 2-year follow-up. The methodological quality and publication bias were assessed using the Modified Coleman Methodology Score (mCMS) and ROBIS tool, respectively. Data was presented in tables using absolute values from individual studies. Pooled data were presented as means, ranges, and percentages.

RESULTS

Six clinical studies with a total of 1084 TKAs were included. Four studies were retrospectives, and two studies were prospective. Patella was only resurfaced in 0.6% of total TKAs. TKA without patellar resurfaced, which resulted in an improvement in functional outcome. Among studies, the overall need for revision incidence was 7.6% (68 out of 892 TKAs). Additionally, Aseptic loosening (2.4%) was the most common reason for revision due to patellofemoral joint complications, followed by secondary patellar resurfacing (2.1%) and deep infection (1.3%). The mean mCMS demonstrated a fair methodological quality level, and the ROBIS toll a low risk of bias in all four domains.

CONCLUSION

The available evidence supports that Greek surgeons mainly do not resurface the patella. However, patellar non-resurfacing yields good functional outcomes and presents relatively low revision rates for secondary patellar resurfacing.

LEVEL OF EVIDENCE

IV.

Intraoperative and Postoperative Outcomes of Patients Undergoing Total Knee Arthroplasty With Prior Anterior Cruciate Ligament Reconstruction: A Matched Cohort Analysis

Background

Previous anterior cruciate ligament (ACL) injury is a risk factor for the development of knee osteoarthritis. Despite advances in ACL reconstruction (ACLR) techniques, many patients with history of ACLR develop end-stage osteoarthritis necessitating total knee arthroplasty (TKA). The purpose of this study was to investigate the impact of prior ACLR on intraoperative and postoperative outcomes of TKA.

Methods

This was a single-centre matched cohort study of all patients with prior ACLR undergoing primary TKA from January 2000 to May 2022. Patients were matched 1:1 to patients undergoing TKA with no prior ACL injury based on age, sex, and body mass index. Outcomes investigated included TKA procedure duration, soft-tissue releases, implant design, and complications requiring reoperation.

Results

Forty-two ACLR patients were identified and matched to controls. Mean follow-up was 6.8 years and 5.0 years in the ACLR and control cohorts, respectively (P = .115). ACLR patients demonstrated longer procedure durations (122.8 minutes vs 87.0 minutes, P < .001) and more frequently required soft-tissue releases (40.5% vs 14.3%, P = .007), stemmed implants (23.8% vs 4.8%, P = .013), and patellar resurfacing (59.5% vs 26.2%, P = .002). There were no significant differences in postoperative clinical or surgical outcomes between groups. Ten-year implant survivorship was 92% and 95% in the ACLR and control cohorts, respectively (P = .777).

Conclusions

TKA is an effective procedure for the management of end-stage osteoarthritis with prior ACLR. The care team should be prepared for longer operative times and the utilization of advanced techniques to achieve satisfactory soft-tissue balance and implant stability.

Patellar resurfacing might not be mandatory in contralateral second total knee replacement even if performed during replacement of the first knee

INTRODUCTION

The appropriateness or necessity of patellar resurfacing in total knee arthroplasty (TKA) is not clearly established. The objective of the present study was to compare the clinical and functional results of patients with bilateral involvement, operated on in one knee by TKA with patellar resurfacing and in the other knee by TKA without resurfacing. The hypothesis was that there was no difference in results between the two sides.

METHOD

This was a retrospective cohort of patients operated on by TKA without patellar resurfacing in a second osteoarthritic knee after contralateral TKA with patellar resurfacing. Twenty consecutive patients who underwent second primary TKA constituted their own control group (40 knees). Iwano scores were comparable. Mean age was 75.9±6.2years. Mean time between the two procedures was 20.6±11.9months.

RESULTS

There were no differences in SF-36, KOOS or Lille patellofemoral scores between the right and left knees. Sixty-five percent of patients were unable to differentiate the performance of their knees in activities of daily living.

CONCLUSION

The present study did not differentiate results according to patellar resurfacing, showing the limitations of resurfacing for early functional gain after primary TKA. Resurfacing might thus not be essential, even if it was performed in replacement of the first knee.

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Outcomes and Survivorships of Total Knee Arthroplasty Comparing Resurfaced and Unresurfaced Patellae

BACKGROUND

The decision to resurface the patella in total knee arthroplasty (TKA) is controversial. While there is some consensus that leaving the patella unresurfaced increases risk of reoperation, there is conflicting evidence about patient reported outcomes or indications for resurfacing. This study sought to determine recent rates of patellar resurfacing, examine factors affecting rates of resurfacing, and analyze the associations between patellar resurfacing and both revision rates and patient-reported outcome measures (PROMs).

METHODS

The American Joint Replacement Registry was used to identify primary TKAs performed for osteoarthritis between 2012 and 2021. Cases were classified as resurfaced patella and unresurfaced patella (URP). Outcomes analyzed included trends in patellar resurfacing, factors influencing rate of resurfacing, revision rates, operative time, and 2 PROMs.

RESULTS

Rates of patellar resurfacing decreased and rates of URP increased significantly faster in ambulatory surgery centers and among high volume surgeons. Operative time was significantly lower in URP versus resurfaced patella (88.15 versus 89.90 minutes). The URP were significantly more likely to require revision surgery (odds ratio = 1.206 (1.078, 1.35), P = .0011). There was no significant difference in the likelihood of achieving the minimal clinically important difference in PROMs between resurfaced and nonresurfaced TKAs at 1 year (odds ratio = 1.060 (0.710, 1.581), P = .7755).

CONCLUSION

There was no difference in minimal clinically important difference between resurfaced and URPs and no clinically relevant difference in operative time. However, URPs were more likely to require revision surgery. Therefore, the decision not to resurface should be made carefully considering the known risk of revision and the uncertain benefit.

Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review

BACKGROUND

Difficulty kneeling following total knee arthroplasty (TKA) remains highly prevalent, and has cultural, social, and occupational implications. With no clear evidence of superiority, whether or not to resurface the patella remains debatable. This systematic review examined whether resurfacing the patella (PR) or not (NPR) influences kneeling ability following TKA.

METHODS

This systematic review was conducted by following PRISMA guidelines. Three electronic databases were searched utilizing a search strategy developed with the aid of a department librarian. Study quality was assessed using MINROS criteria. Article screening, methodological quality assessment and data extraction were performed by two independent authors, and a third senior author was consulted if consensus was not reached.

RESULTS

A total of 459 records were identified, with eight studies included in the final analysis, and all deemed to be level III evidence. The average MINORS score was 16.5 for comparative studies and 10.5 for non-comparative studies. The total number of patients was 24,342, with a mean age of 67.6 years. Kneeling ability was predominantly measured as a patient-reported outcome measure (PROM), with two studies also including an objective assessment. Two studies demonstrated a statistically significant link between PR and kneeling, with one demonstrating improved kneeling ability with PR and the other reporting the opposite. Other potential factors associated with kneeling included gender, postoperative flexion, and body mass index (BMI). Re-operation rates were significantly higher in the NPR cohort whereas PR cohorts had higher Feller scores, patient-reported limp and patellar apprehension.

CONCLUSION

Despite its importance to patients, kneeling remains not only under-reported but also ill-defined in the literature, with no clear consensus regarding the optimum outcome assessment tool. Conflicting evidence remains as to whether PR influences kneeling ability, and to clarify the situation, large prospective randomized studies are required.

Anterior Knee Pain Following Primary Unilateral Total Knee Arthroplasty With Posterior-Stabilized Prosthesis and Patellar Resurfacing: Prevalence and Clinical Implications

BACKGROUND

Anterior knee pain following total knee arthroplasty (TKA) is associated with patient dissatisfaction. Factors related to postoperative anterior knee pain and its impact on patient outcomes are poorly understood. The following are the aims of this study: (1) to report the prevalence of anterior knee pain before and after TKA using a posterior-stabilized prosthesis with routine patellar resurfacing; (2) to investigate the association of preoperative clinical factors with the presence of anterior knee pain after TKA; and (3) to explore the association of postoperative anterior knee pain with postoperative self-reported function and quality of life.

METHODS

This retrospective study included 506 patients who had undergone elective primary unilateral TKA with a posterior-stabilized prosthesis and patellar resurfacing. Outcome measures prior to and 12 months after TKA included self-reported anterior knee pain, knee function, and quality of life.

RESULTS

Prevalence of anterior knee pain was 72% prior to and 15% following TKA. Patients who had preoperative anterior knee pain had twice the risk of experiencing anterior knee pain after TKA than patients who did not have preoperative anterior knee pain (risk ratio: 2.37, 95% CI 1.73-2.96). Greater severity of preoperative anterior knee pain and worse self-reported function were associated with the presence of postoperative anterior knee pain (rho = 0.15, P < .01; rho = 0.13, P < .01, respectively). Preoperative age, gender, and quality of life were not associated with postoperative anterior knee pain. Greater severity of postoperative anterior knee pain was associated with worse knee function at 12 months postoperative (rho = 0.49, P < .01).

CONCLUSION

One in 7 patients reported anterior knee pain 12 months following posterior-stabilized and patella-resurfaced TKA. The presence of preoperative anterior knee pain and worse self-reported function are associated with postoperative anterior knee pain.

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.

Does Choice of Patellar Implant in Total Knee Arthroplasty Matter?: A Randomized Comparative Trial of 3 Commonly Used Designs

BACKGROUND

There is currently a lack of evidence to identify the optimal patellar implant design in total knee arthroplasty (TKA). The aim of this study was to assess clinical, intraoperative, radiographic, and scintigraphic differences between inlay (IN), onlay round (OR), and onlay oval (OO) patellar implants.

METHODS

A parallel-group, double-blinded, randomized trial compared IN, OR, and OO patellar implants using the same posterior-stabilized TKA prosthesis for each. Patient outcomes were prospectively followed for a minimum of 2 years, with survivorship outcomes followed for a mean of 5 years. The primary outcome was the between-group differences in the mean Kujala score change from preoperatively to 2 years postoperatively. The secondary outcomes included differences in other knee-specific and general health outcomes, intraoperative characteristics, radiographic parameters, patellar vascularity, and implant survivorship.

RESULTS

A total of 121 participants (40 in the IN group, 41 in OR group, 40 in the OO group) were allocated to 1 of 3 implant designs. At 2 years postoperatively, there were no significant differences in Kujala score changes between groups (p = 0.7; Kruskal-Wallis test). Compared with the IN group, the OR group showed greater improvements in Knee injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living and in KOOS Quality of Life compared with the OO group. However, the OO design exhibited better bone coverage and lower lateral facetectomy rates compared with the IN and OR designs. The IN group had more lateral contact compared with the OO group (p = 0.02; Fisher exact test), but the overall value for lateral contact was not significant (p = 0.09; chi-square test). There were no differences in postoperative scintigraphic vascularity (p = 0.8; chi-square test). There was 1 revision for infection at 3 years postoperatively in the OO group, and no revision in the other groups.

CONCLUSIONS

Patellar design did not influence patellofemoral outcomes or survivorship. However, OR implants showed improvements in some secondary patient-reported outcome measures, and OO implants exhibited superior bone coverage and improvements in several intraoperative, radiographic, and scintigraphic outcomes. These findings, combined with superior long-term implant survivorship from previous studies, add support for the use of onlay designs in TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association between type of anesthesia and length of hospital stay in primary unilateral total knee arthroplasty patients: a single-center retrospective study

Objective

This study explored the risk factors influencing the length of hospital stay (LOS) and establish whether the type of anesthesia is independently associated with the LOS in patients after primary unilateral total knee arthroplasty (TKA).

Methods

In this retrospective cohort study, 2309 patients undergoing unilateral TKA were recruited between January 2013 and June 2014 in a tertiary academic medical center in Singapore. Univariate and multivariate linear regression analyses were used to identify the independent risk factors associated with LOS. Besides, subgroup and interaction analyses were performed to evaluate the relationship between the type of anesthesia and LOS.

Result

In total, 2309 patients were identified. Out of these, 791 patients underwent general anesthesia, whereas 1518 patients underwent regional anesthesia. Multivariate regression analyses revealed that prolonged LOS was significantly associated with age ≥ 65 years (β = 0.48; 95% CI, 0.09–0.87; P = 0.015), diabetes mellitus (DM) (β = 0.8; 95% CI, 0.33–1.27; P = 0.001), congestive cardiac failure (CCF) (β = 4.1; 95% CI, 2.02–6.17; P < 0.001), perioperative blood transfusion (β = 5.71; 95% CI, 4.86–6.56; P < 0.001), creatinine > 2 mg/dL (β = 4.54; 95% CI, 2.46–6.62; P < 0.001), ASA status (III) (β = 1.72; 95% CI, 0.72–2.71; P = 0.001), general anesthesia (β = 0.78; 95% CI, 0.41–1.66; P < 0.001). The LOS further decreased among participants receiving regional anesthesia at advanced age (age ≥ 65 years) (β = − 1.12; 95% CI, − 1.66 to − 0.58; P < 0.001), patients with BMI ≤ 25 kg/m² (β = − 1.92; 95% CI, − 2.73 to − 1.11; P < 0.001) or ≥ 30 kg/m² (β = − 0.58; 95% CI, − 1.1 to − 0.06; P = 0.029).

Conclusion

Our findings demonstrated that age ≥ 65 years, DM, CCF, perioperative blood transfusion, creatinine > 2 mg/dL, ASA status (III), general anesthesia are associated with a prolonged LOS after primary TKA. Elderly patients (age ≥ 65 years) and patients with BMI ≤ 25 kg/m² or ≥ 30 kg/m² receiving regional anesthesia have a further reduced LOS. Therefore, when TKA is performed, priority for regional anesthesia is given to the elderly patients (age ≥ 65 years old) and those with BMI ≤ 25 kg/m² or ≥ 30 kg/m².

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02817-4.

Secondary Patellar Resurfacing in TKA: A Combined Analysis of Registry Data and Biomechanical Testing

The German Arthroplasty registry (EPRD) has shown that different prosthesis systems have different rates of secondary patellar resurfacing: four years after implantation, the posterior-stabilized (PS) Vega prosthesis has a 3.2% risk of secondary patellar resurfacing compared to the cruciate-retaining (CR) Columbus prosthesis at 1.0% (both Aesculap AG, Tuttlingen, Germany). We hypothesized that PS implants have increased retropatellar pressure and a decreased retropatellar contact area compared to a CR design, which may lead to an increased likelihood of secondary patellar resurfacing. Eight fresh frozen specimens (cohort 1) were tested with an established knee rig. In addition, a possible influence of the registry-based patient collective (cohort 2) was investigated. No significant differences were found in patient data–cohort 2-(sex, age). A generally lower number of PS system cases is noteworthy. No significant increased patella pressure could be detected with the PS design, but a lower contact area was observed (cohort 1). Lower quadriceps force (100°–130° flexion), increased anterior movement of the tibia (rollback), greater external tilt of the patella, and increasing facet pressure in the Vega PS design indicate a multifactorial cause for a higher rate of secondary resurfacing which was found in the EPRD patient cohort and might be related to the PS’ principle function.