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Purpose Patellar resurfacing in total knee arthroplasty (TKA) remains controversial as recent meta-analyses have not shown its clear superiority; however, most authors recommend it because it is associated with less frequent anterior knee pain and need for reoperation. We aimed to clarify the changes in patellar cartilage thickness in no patellar resurfacing TKA using a ceramic femoral component on magnetic resonance imaging (MRI). Methods Between 2009 and 2014, 40 consecutive patients (59 knees) were included in this study. All patients underwent TKA using zirconia ceramic femoral implants without patellar resurfacing. Indications for no patellar resurfacing TKA were absence of anterior knee pain, patellar compression pain, and osteoarthritic changes in the patellofemoral joint on plain radiography. The mean postoperative follow-up duration was 81.5 months (range, 25–131 months). Clinical and radiological evaluations were performed preoperatively and 5 years after TKA. Patellar cartilage thickness was evaluated preoperatively and every year for 5 years after TKA using MRI T2-weighted imaging. The patellar cartilage was divided into three regions of interest: medial, central, and lateral. To standardise the variation in patellar thickness among patients, the percent cartilage thickness was calculated. Results The implant’s position was appropriate in all cases. Compared to preoperative scores, 5 years postoperatively, the Japanese Orthopedic Association score and Oxford knee score significantly improved from 52.1 to 84.7; mean tilting angle and congruence angle did not change significantly; mean lateral shift ratio significantly increased from 7.1% to 14.6%; cartilage thickness significantly decreased ( P  < 0.05); and the percentage cartilage thickness of the central, medial, and lateral cartilage zones gradually thinned to less than half. Four patients underwent conversion to patellar resurfacing due to anterior knee pain, without loosening the femoral and tibial implants. Conclusion The patellar cartilage thickness decreased to less than half its preoperative level within 5 years after no patellar resurfacing TKA; this would led to clinical problems and conversion to patellar resurfacing. Level of evidence Level III.

Background The primary management modalities for the patella in TKA include patellar resurfacing, patellar non-resurfacing, patellar resurfacing with denervation, and patellar non-resurfacing with denervation. Traditionally, meta-analyses have predominantly focused on examining comparisons between two management modalities. However, this study performed a network meta-analysis to compare all four patellar management interventions to identify the most optimal approach for patellar management in TKA. Methods A computer-based search of PubMed, China National Knowledge Infrastructure (CNKI), The Cochrane Library, Web of science, Embase, and MEDLINE databases was performed to identify randomized controlled trials focusing on the four management interventions for the patella in TKA. Comparisons included two-by-two comparisons as well as those involving more than two concurrent comparisons. The search timeframe spanned from inception to June 30, 2023. Two independent authors extracted the data and evaluated the quality of the literature. The Cochrane Collaboration Risk of Bias (ROB) tool was used to evaluate the overall quality of the literature. Subsequently, a network meta-analysis was conducted using the “gemtc” package of the R-4.2.3 software. Outcome measures such as anterior knee pain (AKP), reoperation rate, and patient satisfaction rate were evaluated using odd ratio (OR) and 95% confidence intervals (CI). Additionally, the knee society score (KSS), function score (FS), and range of motion (ROM) were evaluated using mean differences (MD) with associated 95% CI. The different treatment measures were ranked using the surfaces under the cumulative ranking curves (SUCRA). Results A total of 50 randomized controlled trials involving 9,283 patients were included in the analysis. The findings from this network meta-analysis revealed that patellar resurfacing exhibited significantly lower postoperative reoperation rate (OR 0.44, 95% CI 0.24–0.63) and AKP (OR 0.58, 95% CI 0.32–1) compared to non-resurfacing. Additionally, patellar resurfacing exhibited higher postoperative KSS clinical scores in comparison with non-resurfacing (MD: 1.13, 95% CI 0.18–2.11). However, for postoperative FS, ROM, and patient satisfaction, no significant differences were observed among the four management interventions. Conclusion Patellar resurfacing emerges as the optimal management modality in primary TKA. However, future studies should aim to reduce sources of heterogeneity and minimize the influence of confounding factors on outcomes. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023434418 identifier: CRD42023434418

Purpose Despite numerous well-conducted studies and meta-analyses, the management of the patella during total knee arthroplasty (TKA) remains controversial. The aim of our study was to compare the clinical and radiological outcomes between patients with and without patellar resurfacing and to determine the influence of resurfacing on patellar tracking with a “patella-friendly” prosthesis. Methods A single-centered prospective randomized controlled study was performed between April 2017 and November 2018. Two hundred and forty-five consecutive patients (250 knees) scheduled for TKA were randomized for patellar resurfacing or patella non-resurfacing. All patients received the same total knee prosthesis and were evaluated clinically and radiologically, including the International Knee Society Score (KSS knee and function), Forgotten Joint Score (FJS), anterior knee pain (AKP), pain when climbing stairs, patellar tilt, and patellar translation. Results Two hundred and twenty-nine knees were available for clinical evaluation and 221 knees for radiographic analysis. The revision rate for patellofemoral cause was 3.1% (7 cases) with no difference between the groups ( p  = 0.217). There was no difference in survival rate between patellar resurfacing (88.3%) and non-resurfacing (85.3%) after 24 months ( p  = 0.599). There were no differences in KSS functional component ( p  = 0.599), KSS knee component ( p  = 0.396), FJS ( p  = 0.798), and AKP ( p  = 0.688) at a mean follow-up of 18 months. There was twice as much stair pain for the non-resurfacing group (17.1% versus 8.5%) ( p  = 0.043). There was patellar tilt in 43% of resurfaced knees ( n  = 50/116) versus 29% in non-resurfaced knees ( n  = 30/105) ( p  = 0.025); however, there was more patellar translation in the non-resurfaced group (21.0% versus 7.8%) ( p  < 0.001). There were no specific complications attributed to the patellar resurfacing procedure. There were four secondary patellar resurfacing procedures (3.6%) in the non-resurfaced group after a mean of 10 ± 7 months (1–17) postoperatively. Conclusion There is no superiority of patellar resurfacing or non-resurfacing in terms of clinical or radiological outcomes at mid-term. Secondary patellar resurfacing is rare. There is not enough evidence to recommend systematic patellar resurfacing with a “patella-friendly” prosthesis. Level of evidence 1.

Purpose The need of patellar resurfacing in total knee arthroplasty (TKA) is a subject of debate. This systematic review of overlapping meta-analyses aimed to assess and analyze current evidence regarding patellar resurfacing and non-resurfacing in TKA. Methods A systematic literature search was performed in March 2017 in PubMed, CINAHL and Cochrane Library. Inclusion criteria were meta-analysis of randomized controlled trials that compared TKA with and without patellar resurfacing considering as outcomes re-operations rate, complications, anterior knee pain, functional scores. The quality of meta-analyses was evaluated with AMSTAR score and the most relevant meta-analysis was determined by applying the Jadad algorithm. Results Ten meta-analyses, published between 2005 and 2015, were included in the systematic review. Two studies found a significantly increased Knee Society Score in the resurfacing group. According to four meta-analyses, anterior knee pain incidence was lower in resurfacing group. Six of the included studies described a greater risk of re-intervention in the non-resurfacing groups. The overall quality of included studies was moderate. The most relevant meta-analysis reported no differences in functional scores and incidence of anterior knee pain between the groups. Conclusions Comparable outcomes were found when comparing patellar resurfacing and non-resurfacing in TKA. The higher risk of re-operations after non-resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses regarding search criteria, heterogeneity and the inherent bias of easier indication to reoperation when the patella is not resurfaced. There is no clear superiority of patellar resurfacing compared to patellar retention. Level of evidence Level II, systematic review of meta-analyses.

Background Patellar resurfacing is optional during total knee replacement (TKR). Some surgeons always resurface the patella, some never resurface, and others selectively resurface. Which resurfacing strategy provides optimal outcomes is unclear. We assessed the effectiveness of patellar resurfacing, no resurfacing, and selective resurfacing in primary TKR. Methods A systematic review and meta-analysis was performed. MEDLINE, Embase, Web of Science, The Cochrane Library, and bibliographies were searched to November 2021 for randomised-control trials (RCTs) comparing outcomes for two or more resurfacing strategies (resurfacing, no resurfacing, or selective resurfacing) in primary TKR. Observational studies were included if limited or no RCTs existed for resurfacing comparisons. Outcomes assessed were patient reported outcome measures (PROMs), complications, and further surgery. Study-specific relative risks [RR] were aggregated using random-effects models. Quality of the evidence was assessed using GRADE. Results We identified 33 RCTs involving 5,540 TKRs (2,727 = resurfacing, 2,772 = no resurfacing, 41 = selective resurfacing). One trial reported on selective resurfacing. Patellar resurfacing reduced anterior knee pain compared with no resurfacing (RR = 0.65 (95% CI = 0.44–0.96)); there were no significant differences in PROMs. Resurfacing reduced the risk of revision surgery (RR = 0.63, CI = 0.42–0.94) and other complications (RR = 0.54, CI = 0.39–0.74) compared with no resurfacing. Quality of evidence ranged from high to very low. Limited observational evidence (5 studies, TKRs = 215,419) suggested selective resurfacing increased the revision risk (RR = 1.14, CI = 1.05–1.22) compared with resurfacing. Compared with no resurfacing, selective resurfacing had a higher risk of pain (RR = 1.25, CI = 1.04–1.50) and lower risk of revision (RR = 0.92, CI = 0.85–0.99). Conclusions Level 1 evidence supports TKR with patellar resurfacing over no resurfacing. Resurfacing has a reduced risk of anterior knee pain, revision surgery, and complications, despite PROMs being comparable. High-quality RCTs involving selective resurfacing, the most common strategy in the UK and other countries, are needed given the limited observational data suggests selective resurfacing may not be effective over other strategies.

BackgroundTotal knee arthroplasty (TKA) is a feasible and cost-effective procedure. However, resurfacing of the patella sparks a heated debate. Anterior knee pain after TKA was supposed to be correlated to the patellofemoral joint, and the resurface of the patella was believed to be effective to avoid this complication.AimA meta-analysis was performed to update current evidence concerning the outcomes of patellar resurfacing versus retaining for total knee arthroplasty. The first outcomes of interest were to compare the rate of anterior knee pain and revision surgeries.Material and methodsThis study was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). A comprehensive review of the literature was conducted accessing the main databases: Embase, Google Scholar, PubMed, Scopus. All the prospective clinical trials comparing the outcomes between patellar resurfacing versus retaining were included in this study. Only articles classified as level of evidence I to II were considered for inclusion. Only studies reporting a minimum 24 months follow-up were included. The following data were extracted: demographic baseline, anterior knee pain, reoperations, clinical scores (HSS, KSS and related subscales) and range of motion (ROM). Studies solely reporting quantitative data under the outcomes of interest were included.ResultsIn favor of the resurfacing group, we observed a statistically significant reduced rate of anterior knee pain (odd ratio 1.73) and reoperation (odd ratio 3.24). In the resurfacing group, a prevalence of anterior knee pain of 11.15% was detected, whereas in the retaining group it amounted to 17.39%. Furthermore, a greater KSS pain (+ 0.97%), KSS clinical (+ 0.23%), KSS functional (+ 2.44%), KSS overall (+ 2.47%) and HSS (+ 5.64%) were reported. In the retaining group, we found a better range of motion (+ 3.09°).ConclusionBased on the main findings of this meta-analysis, patellar resurfaced TKA was demonstrated to have performed superior overall. Patellar resurfacing detected a lower rate of postoperative anterior knee pain and reoperation. Moreover, the resurfacing group showed greater value of the HSS, KSS and related subscales. In favor of the retaining group, a slightly better ROM was evidenced.Level of evidenceLevel II, meta-analysis of prospective clinical trials

IntroductionThe role of secondary patellar resurfacing (SPR) in anterior knee pain (AKP) is still debated in literature. A regional arthroplasty registry was investigated, aiming to: (1) assess the survival rate of SPR; and (2) compare SPR to tricompartmental TKA.Materials and methodsThe regional arthroplasty registry RIPO was investigated about all SPRs performed after bicompartmental arthroplasty. The survival rates and the reasons for revision were assessed as any other factor that could have influenced implants failure. SPR survivorship was compared to tricompartmental TKAs.Results406 SPRs performed after bicompartmental arthroplasty were analyzed. The survival rates were 80.6% (CI 95% 75.9–84.5) at 5 years and 77.6% (CI 95% 72.4–82) at 7 years. Half of the SPRs was performed 0.9–2.4 years after the index bicompartmental arthroplasty. SPR achieved lower survival than tricompartmental TKA (80.6% vs 96.7%, p < 0.001), with an adjusted hazard ratio for failure of 5.5 (CI 95% 4.2–7.1, p < 0.001). SPRs performed within 2 years after primary implant had a significantly higher rates of failure when compared to tricompartmental TKA (HR: 6.4, CI 95% 4.8–8.4, p < 0.001).ConclusionSPR after bicompartmental knee arthroplasty showed modest 5- and 7-year survival rates, worse than primary tricompartmental TKA. When SPRs are performed within 2 years after primary arthroplasty, a significant higher risk of failure should be expected, highlighting than appropriate pre-operative work-up and patient selection is crucial for SPR successful outcome.Level of evidenceIII, therapeutic study.

Purpose Patellar component positioning and patellofemoral kinematics are of great importance in total knee arthroplasty (TKA). The factors influencing patellar tilt are femoral rotation and lateral patellar release. However, the effect of patellar component size remains unknown. The aim of this study was to evaluate the intra-operative risk factors for patellar tilt, particularly the effect of the patellar component size. The hypothesis was that increasing the patellar component size would reduce the risk of patellar tilt. Methods 878 primary TKAs with patellar resurfacing were included between January 2015 and October 2018. Analysis was performed at 1-year postoperatively on patients categorized into two groups: patellar tilt (PT) and no patellar tilt (NPT). A multivariate analysis was performed for the effect of patellar component size, femoral rotation, femoral overbuilding, patellar thickness and lateral release on patellar tilt risk. Secondary analysis was performed for any difference in clinical outcomes and revision rates between groups. Results Multivariate analysis showed that increasing the patellar component size decreased the risk of patellar tilt by 37% ( p  < 0.001). Placing the femoral component at 3° of external rotation decreased the risk of patellar tilt by 67% ( p  < 0.001). Secondary analysis showed better clinical outcomes in the NPT group, especially regarding global satisfaction, and KSS objective and subjective scores. The revision for any cause was less in the NPT group ( p  = 0.019). The cause for TKA revision was related to the patellar in 11% of cases in the NPT group and 65% in the PT group ( p  < 0.001). Conclusion Increased patellar component size and positioning the femoral component in external rotation decreases the risk of patellar tilt, improves clinical outcomes and decreases the rate of surgical revision. Level of evidence III.

PurposeThe aim of this study was to investigate whether increased patellar thickness after resurfacing decreased knee flexion angle and had any effect on functional outcomes comparing with patellar thickness restoration (patelloplasty) in patients undergoing primary total knee arthroplasty (TKA) or not.MethodsWe retrospectively reviewed 220 patients undergoing primary TKA: 110 patients undergoing patelloplasty and 110 patients received overstuffed patellar resurfacing using subchondral bone cut at lateral facet technique were recruited. The mean increase in patellar thickness after resurfacing equal to 2 ± 1.2 mm. The outcomes were postoperative knee flexion angle and modified Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score at minimum 2 year after surgery.ResultsThe mean postoperative knee flexion angles were similar between overstuffed resurfacing group and patelloplasty group (132 ± 7° vs. 134 ± 8°, 95% confidence interval [CI] − 6.9–1.8°, p = 0.1). The mean increase in postoperative knee flexion was 13° in both groups (p = 0.94). The mean change of overall modified WOMAC score was also similar between the two groups (42 ± 12 vs. 39 ± 9 points, 95% CI − 1.7–9.4 points, p = 0.17).ConclusionThis study demonstrated that increased patellar thickness has no effect on postoperative knee flexion angle and functional outcomes in TKA. The finding clarified the misunderstanding principle of native patellar thickness restoration after resurfacing which had made many surgeons to refrain from resurfacing especially in patient who had thin patella.