Clinical effectiveness of patellar resurfacing, no resurfacing and selective resurfacing in primary total knee replacement: systematic review and meta-analysis of interventional and observational evidence

Abstract

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.

Morphological analysis of patellofemoral joint in haemophilic arthropathy: A case‐control study

“…The inclusion of patellar resurfacing in total knee arthroplasty remains a topic of ongoing debate, and a standardised approach has not been universally recommended for total knee prostheses performed in cases of haemophilic arthropathy. 28,29 Recognising the limitations of current implant designs in adequately restoring the anterior femoral anatomy, 30 it is predictable to anticipate that haemophilic arthropathies will also receive their share of the personalised surgical approach in the future. 31 One of the most striking data we found in our study were that the intercondylar depth decreased in the haemophilic group.…”

“…The inclusion of patellar resurfacing in total knee arthroplasty remains a topic of ongoing debate, and a standardised approach has not been universally recommended for total knee prostheses performed in cases of haemophilic arthropathy 28,29 . Recognising the limitations of current implant designs in adequately restoring the anterior femoral anatomy, 30 even in knees affected by gonarthrosis, and considering the alterations in patellar size, tilt and inclination observed in haemophilic knees, along with the standard trochlear sulcus in knee prostheses, patellar resurfacing should be kept in mind in order to achieve more predictable clinical outcomes.…”

What’s New in Adult Reconstructive Knee Surgery

“…In an RCT of patients who did not undergo patellar resurfacing, patellar rim denervation using electrocautery did not appear to provide clinically relevant benefits with regard to anterior knee pain compared with no denervation 44 . With regard to patellar resurfacing, a systematic review and meta-analysis of RCTs revealed that resurfacing reduced anterior knee pain and revision risk compared with no resurfacing 45 . A prospective study showed that 75% of patients reported thigh pain on postoperative day 1 regardless of tourniquet or intramedullary guide use during the surgical procedure, but, at 2 weeks postoperatively, tourniquet use appeared to increase the odds of a quadriceps strain 46 .…”

Should we replace the patella during total knee replacement?

“…High-quality randomized-controlled trials involving selective resurfacing, the most common strategy in the United Kingdom and other countries, are needed based on the fact that limited observational data suggest that selective resurfacing may not be effective over other strategies. [5] In a study, the degree of intraoperatively identified patellar cartilage loss did not affect the short-term outcomes following primary TKR without patellar resurfacing. [6] Clinical and radiographic outcomes were not significantly different between the two groups according to intraoperatively graded cartilage lesions based on the International Cartilage Repair Society (ICRS) system: Group 1, Grades 0-2 (n=110); Group 2, Grades 3-4 (n=102).…”

“…High-quality randomized-controlled trials involving selective resurfacing, the most common strategy in the United Kingdom and other countries, are needed based on the fact that limited observational data suggest that selective resurfacing may not be effective over other strategies. [ 5 ]…”