The Challenge of Managing the “Third-Space” in Total Knee Arthroplasty: Review of Current Concepts

Abstract

Total knee arthroplasty (TKA) is the best treatment for advanced knee osteoarthritis and it has proven to be durable and effective. Anterior knee pain (AKP) is still one of the most frequent complications after TKA, but sometimes no recognized macroscopic causes can be found. The correct treatment of patella is considered the key for a proper management of AKP. The inclusion of patellar resurfacing during TKA has been described as a potential method for the reduction of AKP. After surgeons started to resurface the patella, new complications emerged, such as component failure, instability, fracture, tendon rupture, and soft tissue impingement. Patelloplasty has been proposed as a good alternative to resurfacing but whether or not to resurface the patella is still a controversial topic in the literature. Therefore, patellofemoral joint is a complex critical aspect in TKA and choosing between the several options of treatment of patella could not be sufficient. In this review, evidence-based studies do not succeed in resolving this difficult argument. The accurate management of the so-called “third space” should include an accurate assessment of cartilage layers, balance of soft tissue, preoperative anterior tracking, and positioning of the femoral and tibial components. In fact, the selection of suitable implants and adherence to proper surgical technique are the fundamental principles for the success of TKA.

Sexual dimorphism and racial diversity render bone–implant mismatch inevitable after off-the-shelf total knee arthroplasty: a systematic review and meta-analysis

“…Based on these thresholds, there was a greater risk of clinically relevant overall mediolateral under-coverage as opposed to overhang in both East Asian and Caucasian knees. When considering anterior mediolateral coverage, the risk of overhang was higher, thereby increasing the potential for patellofemoral soft-tissue impingement, which might explain why some patients have anterior knee pain following TKA [68].…”

Patellar management during total knee arthroplasty: a review

“…When choosing not to resurface the patella, surgeons may perform a patelloplasty, defined as any surgical intervention aimed at improving the congruency between the native patella and the trochlea of the femoral component. 136 , 137 This definition is fairly non-specific and may include patellar decompression, lateral patellectomy, patellar reshaping with or without resection of the cartilage layer, osteophyte removal, or some combination of these procedures. 136 , 138 This lack of standardization can make it challenging to compare results between studies.…”