Patellar Resurfacing Compared with Nonresurfacing in Total Knee Arthroplasty :A Concise Follo

w-up of a Randomized Trial

J Bone Joint Surg Am ,2009 Nov

Presented by R4 李偉群Tutor: 翁怡然 醫師

Indications for patella resurfacingIndications for patella resurfacing ObesityObesity Preoperative anterior pain in the kneePreoperative anterior pain in the knee moderate or severe chondromalaciamoderate or severe chondromalacia patellar tilt or deformitypatellar tilt or deformity

OKU4OKU4

Without resurfacing will somewhat increase risk Without resurfacing will somewhat increase risk anterior knee pain but decrease serious patellar anterior knee pain but decrease serious patellar complication. (loosening and fracture)complication. (loosening and fracture)

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Indications for patellar resurfacingIndications for patellar resurfacing

Reoperation for anterior knee pain in unresurfacing grouReoperation for anterior knee pain in unresurfacing group:p:10%10% (resurfacing:2%) (resurfacing:2%)

Pain relief is not a predictor for resurfaciPain relief is not a predictor for resurfacing. ng.

Well tracking extensor mechanism,miniWell tracking extensor mechanism,minimal patellar arthritis and patellar friendlmal patellar arthritis and patellar friendly femoral component y femoral component not resurfacingnot resurfacing

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Resurfacing of patella: complication Resurfacing of patella: complication

Postoperative anterior pain in the kneePostoperative anterior pain in the knee Subluxation, dislocationSubluxation, dislocation OsteonecrosisOsteonecrosis Patellar fracture Patellar fracture Patellar clunkPatellar clunk ranged from 4 % to 50 % ranged from 4 % to 50 %

JBJS-A,1997JBJS-A,1997

January 1992 and December 1993, 86 patients/118kneesJanuary 1992 and December 1993, 86 patients/118kneesInclusion criteria:Inclusion criteria: degenerative osteoarthrosis degenerative osteoarthrosisExclusion criteria:Exclusion criteria:1.Previous tibial osteotomy or operation involving the extensor mech1.Previous tibial osteotomy or operation involving the extensor mechanismanism2.History of septic osteoarthrosis or osteomyelitis2.History of septic osteoarthrosis or osteomyelitis3.Severe medical disability that limited the ability to walk3.Severe medical disability that limited the ability to walk4.Disabling disease involving other joints of the lower extremities4.Disabling disease involving other joints of the lower extremities5.Inflammatory arthropathy5.Inflammatory arthropathy6.Severe deformity (varus angulation, valgus angulation, or 6.Severe deformity (varus angulation, valgus angulation, or flexion contracture of more than 15 degrees)flexion contracture of more than 15 degrees)

86 patients/118 knees86 patients/118 knees

Patella resurfacePatella resurface

58 knees58 knees

Non-resurface,patelloplastyNon-resurface,patelloplasty

60 knees60 kneesF/U 30 monthsF/U 30 months

•Miller-Galante-II, Zimmer ,CR •Patella- all PE

F/U 30 monthsF/U 30 months - Clinical result - Clinical result The Knee Society score : Pain The Knee Society score : Pain (P=0.56)(P=0.56) ,Function ,Function (p=0.77)(p=0.77)

Patient-satisfaction questionnairePatient-satisfaction questionnaire Specific questions regarding patellofemoral symptoms and funSpecific questions regarding patellofemoral symptoms and fun

ction. ction. (P>0.64)(P>0.64)

Obesity Obesity (P>0.1)(P>0.1)

Resurface Resurface

(n=58)(n=58)

Non-resurfaceNon-resurface

(n=60)(n=60)

Post –op anterior knee pain Post –op anterior knee pain 44 6 (all revision and 5 6 (all revision and 5 still feel pain but decstill feel pain but decreased )reased )

Resurface Resurface

(n=58)(n=58)

Non-resurfaceNon-resurface

(n=60)(n=60)

P valusP valus

Op timeOp time 128mins128mins 115 mins115 mins 0.040.04

Lateral retinacular releLateral retinacular releasease

31%31% 18%18% >0.1>0.1

Patellar thicknessPatellar thickness 24.424.4 23.423.4 >0.1>0.1

Chondromalacia Chondromalacia

(Grade III+IV)(Grade III+IV)

63%63% 60%60% >0.1>0.1

post-op patella tiltpost-op patella tilt lessless moremore P<0.01P<0.01

F/U 30 monthsF/U 30 months-Operative data-Operative data

Chondromalacia Patellae and post-op pain ,P=0.35Chondromalacia Patellae and post-op pain ,P=0.35

ChondromalaciaChondromalacia

～ Outerbridge , 1961

GradeGrade

II Light brown-yellow discoloration,Light brown-yellow discoloration, softeningsoftening, no fragmentation or , no fragmentation or fissuring. fissuring.

IIII Fragmentation and Fragmentation and fissuringfissuring in an area of 1.3 cm or less. The siin an area of 1.3 cm or less. The size of the lesion was estimated by scanning the ze of the lesion was estimated by scanning the

patella surface with the lens close to the cartilage.patella surface with the lens close to the cartilage.

IIIIII FragmentationFragmentation and fissuring in an area of more than 1.3 cm and fissuring in an area of more than 1.3 cm

IVIV Erosion of the articular cartilage down to the Erosion of the articular cartilage down to the subchondral bonesubchondral bone..

F/U 30 months- conclusionF/U 30 months- conclusion

Obesity, the grade of patellar chondromalaObesity, the grade of patellar chondromalacia, and preoperative anterior pain in the kcia, and preoperative anterior pain in the kneenee

– – Not resurfacing indicatorNot resurfacing indicator Prospective ,Randomized, Double-Blind StProspective ,Randomized, Double-Blind St

udyudy

Preliminary study Preliminary study No intermediate-term or long–term result No intermediate-term or long–term result

86 patients/118 knees86 patients/118 knees

Patella resurfacePatella resurface

58 knees58 knees

Non-resurface,patelloplastyNon-resurface,patelloplasty

60 knees60 kneesF/U 30 monthsF/U 30 months

Patella resurfacePatella resurface

38 knees38 knees

Non-resurface, patelloplastyNon-resurface, patelloplasty

40 knees40 kneesF/U 10 yearsF/U 10 years

1 loosening1 loosening

1 ON1 ONfracturefracture

4 anterior knee pain 4 anterior knee pain

7 knees (12%) resurface :7 knees (12%) resurface :

6 6 2-4 yrs 2-4 yrs

1 1 5-7 yrs5-7 yrs

VAS 8 VAS 8 2.3 (post-revision) 2.3 (post-revision) 7.4 (last F/U)7.4 (last F/U)

The Knee Society score The Knee Society score Patient-satisfaction questionnaire:Patient-satisfaction questionnaire:

Resurfacing (94%) v.s. Nonresurfacing (98%)Resurfacing (94%) v.s. Nonresurfacing (98%) Specific questions regarding patellofemoral symptomSpecific questions regarding patellofemoral symptom

s and function. s and function.

no difference in two groupsno difference in two groups

F/U 10 years F/U 10 years - Clinical result - Clinical result

～ Clinical Sports Medicine, 3rd ed , 2006

7 knees (12%) resurface finally in Non-resurfacing group:7 knees (12%) resurface finally in Non-resurfacing group:VAS: pre-op 4.5 VAS: pre-op 4.5 8 8 2.3 (post-revision) 2.3 (post-revision) 7.4 (last F/U)7.4 (last F/U)

4 anterior knee pain (8%) did not revise in Resurfacing group4 anterior knee pain (8%) did not revise in Resurfacing group

CORR,2001

•102 knees, F/U 5 years • 5° of combined tibial and femoral internal malrotation will increase anterior knee pain .• But no tilt or subluxation in X-ray

ConclusionConclusion

With the type of TKA used, similar resWith the type of TKA used, similar results may be achieved with and without ults may be achieved with and without resurfacing of the patella. resurfacing of the patella.

Resurface the patella only in inflammResurface the patella only in inflammatory condition of the knee. atory condition of the knee.

Thanks!!Thanks!!

Patellar resurfacing - Late complicatPatellar resurfacing - Late complicationion

Osteonecrosis of the patellaOsteonecrosis of the patella Aseptic looseningAseptic loosening Patellar fragmentationPatellar fragmentation Periprosthetic fracturePeriprosthetic fracture Failure of the extensor mechanismFailure of the extensor mechanism