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At Issue: To surface or not resurface?

Orthopedics Today asks surgeons: When deciding whether or not to resurface the patella during a primary total knee replacement surgery, what main factors do you consider?

Issue: March 2006

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Douglas W. Jackson, MD

I am sure that in the United States, we resurface more patellae than is absolutely necessary.

Some reasons include: It is currently the standard of community practice, there is an absence of scientific articles that define the indications of which patients will do well without resurfacing the patella, and there is concern for the expressed opinions of other doctors if a patient has any anterior knee complaints following knee replacement in which resurfacing of the patella was not done.

Douglas W. Jackson, MD, can be reached at Memorial Ortho. Surgical Group, 2760 Atlantic Ave, Long Beach, CA 90806-2755; 562-424-6666; fax: 562-989-0027; e-mail: JACKSONDW@aol.com.

Gurdev S. Gill, MD

In my opinion, if the cartilage on the patella looks good and there is congruency between the patella and the femoral component, then I might consider not replacing it. Also, in the past I have tended not to replace the patella in morbidly obese patients. In my practice of almost 6000 total knee replacements, in the past I did not replace the patella in about 5% of the patients.

However, as I have followed them over the years, I have found that they do get limited osteoarthritis, with pain, of the patellofemoral joint. These patients mostly ended up having the patella component replaced later. Usually this happens between six and 10 years post primary total knee arthroplasty. In my current practice, I replace all patellae regardless, because of the experience that I have gained over the past thirty years.

Gurdev S. Gill, MD, can be reached at 3601 22nd Place, Lubbock, TX 79410; 806-797-9119; 806-797-7669.

John M. Keggi, MD

At this point I am not resurfacing any patellae during primary or revision TKR. Instead, I use a patella-friendly component, debride the osteophytes and perform a peri-patellar neurectomy (as described by Keblish). Anterior knee pain after this procedure is less common than the complications of resurfacing. When pain occurs, it is almost always associated with pre-existing quadriceps weakness or obesity and is retinacular rather than articular. This technique applies to rheumatoid patients as well. I have not had problems with persistent inflammatory arthropathy or with anterior pain from very degenerated articular surfaces against the prosthetic trochlear groove.

John M. Keggi, MD, director, department of orthopedics; assistant director, Joint Replacement Center, Waterbury Hospital, Waterbury, Conn.

Michael A. Mont, MD

This remains a tremendously controversial issue in primary total knee arthroplasty surgery. At one point in my career, I would selectively resurface only very arthritic patellae, leaving the native patella in patients with minimal cartilage damage. I then read with great interest the article by Barrack et al, and went full circle, not resurfacing any but the most severe knees with patella arthritis. After review of my own cases that appeared years down the line, where some patients had anterior knee pain and required a previously un-resurfaced patella to be resurfaced, I started reconsidering my choices.

At the present time, I believe that there is a number that may be up to 10% of patients that will need an un-resurfaced patella eventually resurfaced. To me, this 10% revision rate is not worth not resurfacing the patella and now I perform resurfacings on all total knee replacements. I still believe arguments can be made for selectively not resurfacing many patellae, however, at the present time it is not predictable who will come to need a further revision procedure. Therefore, my decision remains to resurface all patellae during primary total knee replacement.

Michael A. Mont, MD, Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore.

References:

• Barrack RL, Bertot AJ, Wolfe MW, Waldman DA, Milicic M, Myers L. Patellar resurfacing in total knee arthroplasty. A prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am. 2001;83:1376-81.

Thomas P. Schmalzried, MD

The main factor for me is that resurfacing the patella is the standard of care in the U.S. as part of doing a total knee replacement. In this country, there may be liability issues if a patient has post-op pain and the patella was not resurfaced. Another surgeon might support the position that the patient’s pain was due to the unresurfaced patella, and the patient may have to have a second surgery to address this “deficiency.”

Thomas P. Schmalzried, MD, can be reached at the Joint Replacement Institute, 2400 S. Flower St., Los Angeles, CA 90007; 213-742-1075; fax: 213-744-1175; e-mail: schmalzried@earthlink.net.

Peter Sharkey, MD

I always resurface the patella. I published a meta-analysis in CORR last year clearly demonstrating the results of resurfacing are superior.

Peter Sharkey, MD, can be reached at The Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107; 267-339-3500; information@rothmaninstitute.com.

References:

• Parvizi J, Rapuri VR, Saleh KJ, et al. Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery. Clin Orthop. 2005; 438:191-196.

Alfred J. Tria Jr., MD

I try to resurface the patella in all primary total knee arthroplasties. On occasion there may be a patella that has been previously fractured and the remaining bone bed is deficient and will not accept a prosthetic device. In that type of case I will not resurface the remaining bone.

Some knees have a patella that is less than 10 mm in total thickness and it is not possible to remove the surface and implant the prosthesis, and these cases also have to go without resurfacing. However, the complications of patellar resurfacing are so small now that it makes little sense not to resurface.

Years ago with symmetric femoral prostheses and poor patellofemoral contact, the incidence of patellofemoral complications was as high as 3% or 4%. Now that is not the case and patellofemoral resurfacing makes good sense.

Alfred J. Tria, Jr., MD, is a clinical professor of orthopedic surgery at St. Peters University Hospital, New Brunswick, N.J.