Are orthopedic surgeons providing value by routinely resurfacing the patella?
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Click here to read the Cover Story, "'No correct answer' exists to guide patella resurfacing decision"
Flaws with routine patella resurfacing
While the majority of surgeons in the United States routinely resurface patellae during every TKA, the data and modern understanding of TKA fail to support this practice.
Routine patella resurfacing is rooted in surgeon training and historical studies that report a greater incidence of anterior knee pain and revision patella resurfacing in a small percentage of patients. However, the overwhelming majority of these studies were performed prior to the modern understanding of flexion instability, which is now known to be the number one cause of anterior knee pain and a leading cause of early TKA revision. This likely explains historical data where about 50% of patients who underwent subsequent revision patella resurfacing after TKA fail to obtain pain relief and supports that many of those patients had undiagnosed flexion instability. In one of the largest, randomized controlled trials of patellar resurfacing, functional outcome, reoperation rate and total health care cost 5 years after primary TKA were unaffected by patellar resurfacing.
Further, patella resurfacing is not without risk and associated complications, some of which are devastating. Patellar fracture, avascular necrosis, fragmentation, bone loss and implant loosening, as well as patella and quadriceps tendon disruption from patella resurfacing can result in catastrophic extensor mechanism disruption. Therefore, based on equivocal functional results and outcomes, the added cost and surgical time, and potential catastrophic complications, the practice of routinely resurfacing every patella in TKA is flawed. Further research to elucidate the specific criteria for selective patella resurfacing is desperately warranted.
- References:
- Breeman S, et al. J Bone Joint Surg Am. 2011;doi:10.2106/JBJS.J.00725.
- Meneghini RM. J Arthroplasty. 2008;doi:10.1016/j.arth.2008.06.009.
- For more information:
- R. Michael Meneghini, MD, is the director of Indiana University Health Hip and Knee Center, professor of clinical orthopedic surgery at Indiana University School of Medicine in Fishers, Indiana, and an Orthopedics Today Editorial Board Member.
Cost of patella resurfacing
Surgeons will likely always argue about resurfacing the patella or not resurfacing the patella. I like to selectively resurface the patella; however, I understand how the argument could be made about potential cost savings when the surgeon avoids using a patellar implant in every case. However, I think a great counterargument exists around the costs that are created when a patient goes back to the OR for a second trip to have the patella resurfaced. We can say that the predictability of a surgery like that is not ideal, but we all know that it does happen. The unhappy patient will find someone to do that procedure.
- For more information:
- Michael P. Bolognesi, MD, is a professor and chief of the division of adult reconstruction at Duke University Medical Center in Durham, North Carolina.
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