Patellarückflächenersatz bei Patienten ohne wesentliche retropatellare Beschwerdesymptomatik?

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta-analysis and Trial Sequential Analysis of 50 Randomized Controlled Trials

OBJECTIVE

During total knee arthroplasty, femur and tibia parts are regularly replaced, while resurfacing the patellar or not is an ongoing discussion. To compare revision rate, anterior knee pain rate, patient-reported outcome measures, complication, radiographic, and clinical outcomes after patellar resurfacing versus non-resurfacing in total knee arthroplasty.

METHODS

PubMed, Medline, EMBASE, CENTRAL, and CINAHL databases were searched on 25 April 2021 to enroll randomized controlled trials that compared patellar resurfacing versus non-resurfacing. We used the grading of recommendations assessment, development and evaluation (GRADE) framework to assess the certainty of evidence. Our primary outcome was revision rate and secondary outcomes was anterior knee pain rate. Outcomes were pooled using the random-effect model and presented as risk ratio (RR), or mean difference (MD), with 95% confidence interval (CI).

RESULTS

Fifty studies (5586 knees) were included. Significant reductions in patellar revision rate (RR 0.41, 95% CI [0.19, 0.88]; P = 0.02; I²  = 24.20%) and non-patellar revision rate (RR 0.64, 95% CI [0.55, 0.75]; P < 0.001; I²  = 0%) were seen after patellar resurfacing. Patellar resurfacing significantly reduced the anterior knee pain rate than nonresurfacing (RR 0.72, 95% CI [0.57, 0.91]; P = 0.006; I²  = 69.5%). Significant differences in patient-reported outcome measures were found. However, these differences were inconsistent and lacked clinical importance. Patellar resurfacing resulted in a significant lower rate of patellar clunk (RR 0.58, 95% CI [0.38, 0.88]; P = 0.01; I²  = 0%), a higher patellar score (MD 1.24, 95% CI [0.67, 0.81]; P < 0.001; I²  = 73.8%), but prolonged surgical time (MD 8.59, 95% CI [5.27, 11.91]; P < 0.001; I²  = 88.8%).

CONCLUSIONS

The clear relationship is that patellar resurfacing reduces revisions, anterior knee pain, and patellar clunk. It will be interesting to compare the initial cost with the revision cost when required and cost-utility analysis with long-term results in future studies.

Resurfacing versus not-resurfacing the patella in one-stage bilateral total knee arthroplasty: a prospective randomized clinical trial

Purpose

Resurfacing the patella in one-stage bilateral total knee arthroplasty (TKA) remains debatable. This study aimed to assess the mid-term outcomes of patients after one-stage bilateral TKA performed with and without patellar resurfacing, respectively, with at least five years of follow-up.

Methods

Sixty-six patients (132 knees) scheduled for first-ever one-stage bilateral TKA due to osteoarthritis received patellar resurfacing and retention, respectively, on one knee and the other, randomly selected. All patients received Scorpio NRG knee prostheses and were evaluated by radiology (anteroposterior, lateral, and axial views) pre-operatively and yearly post-operatively, for at least five years. Knee Society Score and Feller Score values were measured. Anterior knee pain, patellar clunk, and patient satisfaction were assessed.

Results

One patient died within five years of operation and four were lost to follow-up. One patient developed severe dementia and could not be constructively questioned. Therefore, 60 patients (120 knees) were finally analyzed. There were significantly improved Knee Society and Feller scores (P < 0.001) in the resurfacing group compared with the non-resurfacing group post-operatively. Anterior knee pain and patellar clunk rates were lower on the resurfaced side compared with the non-resurfaced side (P < 0.001). Meanwhile, 47% and only 7% patients preferred the resurfaced and non-resurfaced sides, respectively, at final follow-up. No revision was performed for patellofemoral complications, and no significant differences were found between the two groups in radiographic outcomes.

Conclusions

Using the Scorpio NRG knee prosthesis, patellar resurfacing is superior to non-resurfacing in patients with osteoarthritis observed for ≥ five years.

Registration trials number

NCT03600922

Key Points

• Findings Patellar resurfacing is superior to non-resurfacing in osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) with the Scorpio NRG knee prosthesis.

• Implications Patellar resurfacing should be performed in OA patients during TKA.

• Caution Several prosthesis types should be assessed in the same study setting, and multicenter studies are required before generalizability of the present findings.

Electronic supplementary material

The online version of this article (10.1007/s00264-019-04361-7) contains supplementary material, which is available to authorized users.

Patellar resurfacing versus patellar retention in primary total knee arthroplasty: a systematic review of overlapping meta-analyses

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.

Dutch translation of the Kujala Anterior Knee Pain Scale and validation in patients after knee arthroplasty

PURPOSE

To translate and validate the Kujala Anterior Knee Pain Scale (AKPS) in patients who have undergone total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) and evaluate the internal consistency, construct validity and ceiling or floor effect.

METHODS

After standard forward and backward translation was performed, 302 patients who have received a TKA or UKA filled out the AKPS together with Hospital for Special Surgery (HSS) patella score, visual analogue score (VAS) for pain, the Oxford 12-item questionnaire and the SF-36 at follow-up. The internal consistency was tested using Cronbach's α coefficient. The construct validity was assessed using Spearman's rank correlation (R) to test for correlations between the AKPS and VAS HSS, HSS patella score, VAS month, Oxford 12-item questionnaire and SF-36 subscales. Ceiling or floor effects are given in percentage of patients giving a maximum or minimum score.

RESULTS

The internal reliability of the AKPS is acceptable with a Cronbach's α of 0.81 in patients after TKA or UKA. A high correlation was found between the AKPS and the Oxford 12-item questionnaire (R = 0.81). Moderate correlations were found with the VAS month (R = 0.63), HSS patella score (R = 0.51) and SF-36 subscales physical functioning (R = 0.59), role-physical (R = 0.59), bodily pain (R = 0.57). Other correlations were poor, therefore indicating a good convergent and divergent validity. Ceiling effects were observed for the HSS patella score (31 %), VAS HSS (51 %), VAS pain (19 %), SF36-RP (46 %), SF36-RE (80 %) and SF36-BP (24 %). No ceiling or floor effect was found for the AKPS, Oxford 12-item and the other SF36 domains.

CONCLUSIONS

The AKPS appears to be reliable and valid in patients after knee arthroplasty, with no ceiling and floor effects, and can be used to assess anterior knee pain in patient who underwent joint replacement surgery.

Is patellar resurfacing superior than nonresurfacing in total knee arthroplasty? A meta-analysis of randomized trials

Conflicting results from abundant studies have made it unclear whether the patella should be resurfaced during total knee replacement. A meta-analysis was undertaken to pool the results of randomized controlled studies (RCTs) and to compare the outcomes and postoperative complications after total knee arthroplasty with patellar resurfacing or nonresurfacing. Sixteen RCTs including 3034 knees between 1966 and December 2009 were analyzed. Reoperation for patellofemoral problems was significantly more likely in the nonresurfacing group (P = 0.03). There was no difference between the two groups in terms of anterior knee pain rate, knee pain score, knee society score and knee function score. The results indicate that patellar resurfacing would reduce the risk of reoperation after total knee replacement, but it seems that the benefits are limited on other aspects, and the analysis of high-quality studies shows no advantage of resurfacing over nonresurfacoing group, even in the aspect of reoperation risk. More carefully and scientifically designed RCTs are beneficial and necessary to further prove the results.

Systematic review of patellar resurfacing in total knee arthroplasty

Controversies existing over resurfacing the patella in total knee arthroplasty remain in the literature. The purpose of this review was to evaluate the effectiveness of resurfacing versus nonresurfacing the patella in total knee arthroplasty. We searched the Cochrane Library, MEDLINE and EMBASE for published randomised clinical trials relevant to patellar resurfacing. The relative risk of reoperation was significantly lower for the patellar resurfacing group than for the nonresurfacing group (relative risk 0.57, 95% confidence interval 0.38-0.84, P =0.004). The overall incidence of postoperative anterior knee pain of the 1,421 knees included was 12.9% in the patellar resurfacing group and 24.1% in the nonresurfacing group. The existing evidence indicates that patellar resurfacing can reduce the risk of reoperation with no improvement in postoperative knee function or patient satisfaction over total knee arthroplasty without patellar resurfacing. Whether it can decrease the incidence of anterior knee pain remains uncertain.

Resurfacing versus nonresurfacing the patella in total knee arthroplasty: a critical appraisal of the available evidence

A systematic literature search for evidences comparing treatment effect and harm of resurfacing versus nonresurfacing the patella in total knee arthroplasty was conducted and yielded five meta-analysis (MA), one systematic review (SR) and six randomized controlled trials not included in previous MAs/SR. The evidence suggests that patellar resurfacing would reduce the risk of anterior knee pain, as well as the risk of patella-related reoperation. Furthermore, patients not undergoing patella resurfacing would experience more knee pain during stair climbing and be less satisfied with surgery. No significant difference in range of motion can be expected with or without patellar resurfacing. Importantly, methodological limitations were observed in all retrieved studies and evidences about potential adverse events related to patellar resurfacing are presently undetermined.