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The patella in TKA: The European perspective
Total knee replacement is always more advisable than subtotal knee replacement.
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The European perspective on the patella in total knee arthroplasty is basically centered on one question: Should we do patella replacement in total knee arthroplasty?
 Alexander Giurea, MD |
In my opinion, there are two ways to answer the question. First, you can refer to studies in the literature or you can speak from your own experiences. As it is said, “If you do not know what to do, do what you know or what you’re familiar with.”
In terms of the literature, there are four randomized clinical trials — Barrack in 2001, Wood in 2002, Mayman in 2003 and Burnett in 2004 — that overall investigated 500 knees with a mean follow-up of 6 years. The researchers found that the revision for anterior knee pain was significantly higher among the nonresurfaced group than the resurfaced group.
In the literature
Looking at the postoperative function, two of the four studies showed that there was no difference between the resurfaced and the nonresurfaced group, while the other two showed that the resurfaced group was superior in pain and patient satisfaction.
In the European literature, there are two randomized trials from Walters from England and Kordelle from Germany that included 525 knees in their prospective randomized trial with an average follow-up of more than 5 years. They found results similar to the North American literature, that revisions for anterior knee pain were much more common in their nonresurfaced group than in the resurfaced group. It is interesting that their absolute numbers are considerably lower in the European literature than in the American. For outcomes, both studies showed also that the resurfaced group was superior in pain and patient satisfaction. This was also noted in the Swedish National Registry, which includes 27,370 knees. Registry officials reported that there is no difference in the clinical outcome, but patient satisfaction is superior with resurfacing the patella.
Personal results
My personal results on 1,705 total knee arthroplasties performed from 2001 to 2007, all of them with patella resurfacing, from the orthopaedic department at the University of Vienna, found 287 revisions of total knee arthroplasty; 64 were revisions of the patellae in total knee arthroplasties.
When I looked closer at these cases, I found that 30% of the patella revisions were revisions of already resurfaced patella due to fractures, loosening, wear, extensor mechanisms, ruptures and so forth. This means that 70% were revisions of the nonresurfaced patellae cases that had been performed elsewhere. All these cases have been converted to resurfaced patellae.
In summary, without resurfacing the patella, we get 5% to 10% reoperation rate at 5 to 7 years and we have a higher rate of patient dissatisfaction. In other words, with primary resurfacing of the patella, we have a 0.44% to 4% revision rate of the patella at 5 to 7 years and a higher rate of patient satisfaction. With accurate femur component positioning, with accurate patella thickness restoration and proper joint line restoration, I think patella resurfacing is recommended. In general, total knee replacement seems more advisable than subtotal knee replacement.
For more information:
- Alexander Giurea, MD, professor of orthopaedic surgery, Department of Orthopaedics, Medical University of Vienna, can be reached at the Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; +43-1-40160-0; e-mail: a.giurea@gmx.at. He has no direct financial interest in any products or companies mentioned in this article.
References:
- Barrack RL, Bertot AJ, Wolfe MW, et al. 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(9):1376-1381.
- Bourne RB, Burnett RS. The consequences of not resurfacing the patella. Clin Orthop Relat Res.2004;(428):166-169.
- Kordelle J, Schleicher I, Kaltschmidt I, et al. Patella resurfacing in patients without substantial retropatellar knee pain symptoms? Z Orthop Ihre Grenzgeb.2003;141(5):557-562.
- Mayman D, Bourne RB, Rorabeck CH, et al. Resurfacing versus not resurfacing the patella in total knee arthroplasty: 8- to 10-year results. J Arthroplasty. 2003;18(5):541-545.
- Waters TS, Bently G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg (Am). 2003;Feb;85-A(2):212-217.
- Wood DJ, Smith AJ, Collopy D, White B, et al. Patellar resurfacing in total knee arthroplasty: a prospective, randomized trial. J Bone Joint Surg (Am). 2002;84(2):187-193.