Revision Surgery for Patellofemoral Problems: Should We Always Resurface?

Abstract

Background Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear. Questions/purposes We asked whether (1) routine patellar resurfacing in TKAs resulted in lower cumulative revision rates compared to bicompartmental knee arthroplasties, (2) patella-friendly implants resulted in lower cumulative revision rates than earlier designs, and (3) bicompartmental knee arthroplasties revised to TKAs had higher cumulative revision rates than primary TKAs. Patients and Methods From a community-based joint registry, we identified 8135 patients treated with 9530 cemented, all-polyethylene patella TKAs and 627 bicompartmental knee arthroplasties without patellar resurfacing. We compared age, gender, year of index procedure, diagnosis, cruciate status, revision, and revision reason.

International Comparative Evaluation of Fixed-Bearing Non-Posterior-Stabilized and Posterior-Stabilized Total Knee Replacements

“…The higher failure rate associated with nonresurfaced posterior-stabilized knees compared with non-posterior-stabilized designs in the current study cannot be explained by our data. This outcome was not found in the study by Johnson et al 33 . Several other findings regarding resurfacing status during total hip arthroplasty involved female patients with patellar resurfacing, including a significantly lower risk of revision compared with male patients who did not undergo patellar resurfacing.…”

“…The rate of patella-only revision was also significantly higher: 4.8% compared with 0.8% at eighteen years. The authors were not able to demonstrate a significant difference in cumulative revision rates between non-posterior-stabilized and posterior-stabilized knee replacements with or without patellar resurfacing 33 . Clements et al, using what is believed to be the largest knee arthroplasty registry to date, including 134,799 arthroplasties, demonstrated a 1.33-times greater risk of revision for arthroplasties with no patellar resurfacing compared with resurfaced total knee arthroplasties 34 .…”

“…The results of our study indicate that the revision risk for posteriorstabilized knees is double that for non-posterior-stabilized knees in cases with nonresurfaced patellas. Johnson et al 33 found higher rates of revision for total knee arthroplasty performed without patellar resurfacing. In their community joint registry study, the cumulative revision rate for total knee arthroplasties with nonresurfaced patellas was 8.2% compared with 6.3% for resurfaced patellar cases at eighteen years.…”

“…Evidence from the study by Abdel et al indicates that this may not be important 11 . Significant differences in the surgical technique have been brought to light through this analysis 27,28,33 . Some registries contained relatively few posterior-stabilized procedures.…”

Influence of patellofemoral articular geometry and material on mechanics of the unresurfaced patella

“…The decision to resurface the patella during total knee replacement (TKR) remains a debatable issue in the literature (Swan et al, 2010;Meneghini, 2008;Forster, 2004;Holt and Dennis, 2003;Johnson et al, 2012); early studies reported poor success with unresurfaced patellae, prompting the initial development of patellar resurfacing procedures. However, more recent advances in implant design to develop 'patella friendly' femoral components, which typically have a more anatomic geometry, with a deep patellar groove and more prominent lateral flange (Johnson et al, 2012), have resulted in clinical outcomes on par with those reported for resurfaced patellae (O'Brien et al, in press;Hooper et al, 2009;Chalidis et al, 2011).…”