A Case for Patellar Resurfacing in TKA
Kelly G. Vince, M.D.,
F.R.C.S.(C)
Assistant Clinical
Professor
University of California -
Irvine
Irvine, California
Associate Surgeon,
Kerlan-Jobe Orthopedic
Clinic,
Los Angeles, California
THE CASE FOR PATELLAR
RESURFACING?
à BETTER
RESULTS!
ADMISSION:
I come to this
debate from a position of ignorance. I have always resurfaced the patella and
this is why.
Consider:
 advantages of patellar
resurfacing
pain relief, poly more
durable than cartilage
risks of patellar
resurfacing
fracture, wear loosening,
instability, clunks
all patellar complications
are related to maltracking
advantages of patellar
non-resurfacing
faster surgery, avoid most
complications of resurfacing
risks of patellar
non-resurfacing
pain
Now
if you tell me that you choose not to resurface, because you want to avoid
the complications of patellar resurfacing…OK. I can understand that. Perhaps
we can talk about how to reduce the complication rate.
If
you say the results are the same, I am dubious. Are the results good enough
to discriminate? For example:
If average flexion in the
study is poor, perhaps no differences will be apparent.
How long is the follow up?
Will cartilage wear even as well as polyethylene?
BUT…
If
you tell me that you do not resurface because the results are better, then I am
confused. Perhaps we should stop resurfacing the femur or tibia as well.
What can the literature show us?
TI:
Patellofemoral complications in symmetrical total knee arthroplasty.
AU:
Harwin-SF
AD:
Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New
York, USA.
SO:
J-Arthroplasty. 1998 Oct; 13(7): 753-62
3-8 year follow up, 350
Kinemax TKR, all resurfaced, with 5
(1.4%) patellofemoral complications.
TI:
Contact areas and pressures between native patellas and prosthetic femoral
components.
AU:
Benjamin-JB; Szivek-JA; Hammond-AS; Kubchandhani-Z; Matthews-AI Jr;
Anderson-P
AD:
Department of Surgery, The University of Arizona Health Sciences Center, Tucson,
85724-5064, USA.
SO:
J-Arthroplasty. 1998 Sep; 13(6): 693-8
Mean native patellar
contact areas were found to be fourfold greater than seen with the prosthetic
patellar component
TI:
[Patellar resurfacing. Results of a prospective randomized study]
TO:
Der Patellaruckflachenersatz. Ergebnisse einer prospektiv randomisierten
Studie.
AU:
Schroeder-Boersch-H; Scheller-G; Synnatschke-M; Arnold-P; Jani-L
AD:
Orthopadische Universitatsklinik Mannheim, Klinikum Mannheim gGmbH, Fakultat der
Universitat Heidelberg.
SO:
Orthopade. 1998 Sep; 27(9): 642-50
Leaving the patella
unresurfaced was associated with a higher rate of anterior knee pain and
revision in our study
TI:
In vitro measurement of patellofemoral force after three types of knee
replacement.
AU:
Miller-RK; Goodfellow-JW; Murray-DW; O'Connor-JJ
AD:
Nuffield Orthopaedic Centre, Headington, Oxford, UK.
SO:
J-Bone-Joint-Surg-Br. 1998 Sep; 80(5): 900-6
ISSN:
0301-620X
PY:
1998
LA:
ENGLISH
CP:
ENGLAND
After arthroplasty with a
posterior-cruciate-retaining prosthesis and division of the anterior cruciate
ligament, the PFF decreased in extension and increased by 20% in flexion.
Implantation of a posterior stabilised prosthesis and division of both
cruciate ligaments produced a decrease in the PFF in extension but maintained
normal load in flexion.
TI:
Resurfacing of the patella in total knee arthroplasty. A prospective,
randomized, double-blind study [see comments]
CM:
Comment in: J Bone Joint Surg Am 1997 Aug;79(8):1119-20. Comment in: J Bone
Joint Surg Am 1998 Jun;80(6):925-6. Comment in: J Bone Joint Surg Am 1998
Jun;80(6):926. Comment in: J Bone Joint Surg Am 1998 Jun;80(6):926-7
AU:
Barrack-RL; Wolfe-MW; Waldman-DA; Milicic-M; Bertot-AJ; Myers-L
AD:
Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
rbarrac@tmcpop.tmc.tulane.edu
SO:
J-Bone-Joint-Surg-Am. 1997 Aug; 79(8): 1121-31
ISSN:
0021-9355
PY:
1997
LA:
ENGLISH
CP:
UNITED-STATES
During a two-year period,
eighty-nine patients who were scheduled to have a total knee arthroplasty for
the treatment of degenerative osteoarthrosis were randomly assigned to one of
two groups: resurfacing of the patella or retention of the patella. All patients
received the same posterior cruciate-sparing prosthesis, and all
operations were performed by, or under the direct supervision of, one of us.
Three patients died in the early postoperative period. The remaining
eighty-six patients (118 knees; fifty-eight that had had resurfacing of the
patella and sixty that had not) formed the study group. They were followed
for a mean of thirty months (range, twenty-four to forty-four months).
Evaluation was performed with use of the clinical scoring system of The Knee
Society, a patient-satisfaction questionnaire, specific questions regarding
patellofemoral symptoms and function, and radiographs. All clinical
evaluations were performed by the same research nurse, without the
involvement of a physician, in a blinded manner (neither the nurse nor the
patient had knowledge of whether the patella had been resurfaced).
Preoperatively, the mean Knee Society score, on a scale ranging from 0 to 200
points, was 89.7 points (range, 33 to 132 points); postoperatively, this score
improved to a mean of 172.7 points (range, 98 to 200 points). With the
numbers available for study, we could detect no significant difference
between the knees that had had patellar resurfacing and those that had not
with regard to the over-all score (p = 0.63), the subscore for pain (p =
0.56), or the subscore for function (p = 0.77). We also could detect no
difference between the treatment groups, with the numbers available, with
regard to patient satisfaction or the responses to questions involving the
function of the patellofemoral joint, including the ability to exit from an
automobile, to rise from a chair, and to climb stairs. Thirty-two patients
had bilateral total knee replacement with resurfacing of the patella in one
knee and retention of the patella in the other. These patients expressed no
clear preference for either knee. Eight (13 per cent) of the sixty knees that
had not had resurfacing were painful anteriorly compared with four (7 per
cent) of the fifty-eight that had; this was not a significant difference (p =
0.38), with the numbers available. The anterior pain that was noted
postoperatively was predominantly of new onset; it had not been observed
preoperatively in three of the four knees that had had resurfacing or in four
of the eight that had not. No additional treatment options were offered to
the patients who had anterior pain in the knee after resurfacing. However,
six (10 per cent) of the sixty knees that had not had resurfacing had it
subsequently, because of anterior pain in the knee, after the twelfth
postoperative month (range, fifteen to thirty-nine months). The pain
decreased in four of these knees. Thus, total knee arthroplasty with
retention of the patella yielded clinical results that were comparable with
those after total knee arthroplasty with patellar resurfacing, but it was
associated with a 10 per cent prevalence of the need for subsequent
resurfacing. The prevalence of anterior pain after total knee arthroplasty
was not influenced by whether or not the patella had been resurfaced. The
postoperative clinical scores, the postoperative development of anterior
pain, and the need for subsequent resurfacing were not predicted by the
presence of preoperative anterior pain, obesity, or the grade of
chondromalacia observed intraoperatively. Because of the short duration of
follow-up, these results should be considered preliminary. Additional
follow-up is planned.
TI:
Comparison of the results of bilateral total knee arthroplasty with and
without patellar replacement for rheumatoid arthritis. A follow-up note.
AU:
Kajino-A; Yoshino-S; Kameyama-S; Kohda-M; Nagashima-S
AD:
Department of Joint Disease and Rheumatism, Nippon Medical School, Tokyo,
Japan.
SO:
J-Bone-Joint-Surg-Am. 1997 Apr; 79(4): 570-4
ISSN:
0021-9355
PY:
1997
LA:
ENGLISH
CP:
UNITED-STATES
Simultaneous bilateral
total knee arthroplasty was performed in twenty-six patients who had
rheumatoid arthritis, and a patellar replacement was performed concurrently
in one randomly selected knee in each patient. A lateral retinacular release
was performed in all knees. The patients were followed for at least six years
(mean, 6.6 years; range, 6.0 to 7.5 years), and the postoperative status of
the patients was evaluated with the knee score of The Hospital for Special
Surgery. Pain on standing and on ascending or descending stairs as well as
tenderness of the patellofemoral joint also were assessed. The over-all score
and the individual scores for pain, function, range of motion, muscle
strength, flexion contracture, and instability were not significantly
different between the knees that had had a patellar replacement and those
that had not. However, pain on standing and on ascending or descending stairs
as well as tenderness of the patellofemoral joint were only noted in knees
that had not had a patellar replacement. These findings suggest that, in
order to diminish pain on standing and on using stairs, replacement of the
patella during total knee arthroplasty is preferable for patients who have
rheumatoid arthritis.
TI:
Patellar clunk syndrome in total knee arthroplasty without patellar
resurfacing.
AU:
Shoji-H; Shimozaki-E
AD:
Department of Orthopaedic Surgery, Loma Linda University, School of Medicine,
California, USA.
SO:
J-Arthroplasty. 1996 Feb; 11(2): 198-201
TI:
Radiographic changes in the patella after total knee arthroplasty without
resurfacing the patella. Comparison of osteoarthrosis and rheumatoid
arthritis.
AU:
Kawakubo-M; Matsumoto-H; Otani-T; Fujikawa-K
AD:
Department of Orthopaedic Surgery, School of Medicine, Keio University,
Tokyo, Japan.
SO:
Bull-Hosp-Jt-Dis. 1997; 56(4): 237-44
Fourteen patients (23.3%)
complained of postoperative peripatellar pain: 2 of the 17 patients with OA
(11.8%) and 12 of the 43 with RA (27.9%).
TI:
Advantages of patellar resurfacing in total knee arthroplasty. Two-year
results of a prospective randomized study.
AU:
Schroeder-Boersch-H; Scheller-G; Fischer-J; Jani-L
AD:
Orthopaedic Clinic Mannheim, University of Heidelberg, Germany.
SO:
Arch-Orthop-Trauma-Surg. 1998; 117(1-2): 73-8
ISSN:
0936-8051
PY:
1998
LA:
ENGLISH
CP:
GERMANY
Complications of patellar
resurfacing in total knee arthroplasty have rekindled the interest of many
surgeons in patellar retention. In a prospective study 20 randomly selected
patients of 40 underwent patellar resurfacing in combination with their total
knee arthroplasty. The other 20 patients were left with an unresurfaced
patella. Within 24 months of follow-up, the advantages of patellar
resurfacing could be seen according to the Knee Society Score. Especially in
advanced osteoarthritis of the knee joint, the patients achieved better
scores in climbing stairs and in function. The superior functional results
are arguments for patellar resurfacing, at least in knees with advanced
osteoarthritis.
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