Selective Patella Resurfacing and Total Knee Arthroplasty Jay R - PowerPoint PPT Presentation

Selective Patella Resurfacing and Total Knee Arthroplasty Jay R Lieberman MD Professor and Chairman Department of Orthopaedic surgery Keck School of Medicine of USC

Disclosures • Consultant – DePuy Inc – Royalties (Knee) • Research support – NIH • Stock – Hip Innovation Technology • Boards – AAHKS, WOA, MTF

Patella Management in TKA • Always resurface • Never resurface • Selectively resurface

Resurfacing vs. Nonresurfacing Resurfacing Nonresurfaced • Less anterior knee • Better tracking pain • No implant • Decreased secondary complications resurfacing • Improved function • Higher patient satisfaction

Problems Associated with Patellar Resurfacing • Over-resection - fracture • Under-resection – overstuffing (ROM) • Oblique resection - maltracking • AVN

Other Patellar Problems • Lateral facet pain • Loosening • Crepitus

Non Resurfacing: Advantages • Similar results overall results • Lower risk of some patella complications – Loosening – Fracture • Less expense • But increased rate of anterior knee pain

Primary TKA and Patella Usage Australian Registry 2017

Percent Revision of TKA by Patella Usage Australian Registry 2017

Cumulative Percent Revision by Stability and Patella Usage Both with minimally stabilized and posterior stabilized TKA there is higher revision rate with no patella resurfacing at 16 years Australian Registry 2017

Percent Revision After TKA: Stability and Patella Use Australian Registry 2017

Nonresurfaced Patella and TKA • Meta analysis – 14 studies • Increased anterior knee pain • Secondary resurfacing – 8.7% • ? Less patient satisfaction Parvizi et al Clin Orthop 2005

Multiple RCTs Resurfacing Vs Nonresurfacing • Some studies resurfacing better • Some studies nonresurfacing better • Most studies are underpowered

• Meta analysis – Most RCTs – variable quality • 16 randomized trials • 3465 TKAs – – Resurfaced – 1710 – Non-resurfaced – 1755 • Outcomes – knee score, anterior knee pain, complications, re-operations Pilling et al, JBJS, 2012

Meta Analysis: Results • 16 studies – 6 – re-surfacing better, 9 – re-surfacing not better, 1 – equivocal • Patient satisfaction – 90% - No difference • X-ray (patella tilt) – No difference (18% vs 17.8%) • Anterior knee pain – No difference (13.4% vs 23.5%) • Complications (exclude anterior knee pain) – No difference – Resurfacing 1.3% vs. Non-resurfacing – 1.1% Pilling et al, JBJS, 2012

Meta Analysis: Patellofemoral Issues • The chance of undergoing further surgery for anterior knee pain was 1% if patella resurfaced versus 6% • Rate of re-operation because of anterior knee pain and rate of re-operation for any patellofemoral complication – Significantly higher in non-resurfaced group Pilling et al, JBJS, 2012

50 year old w R knee pain

64 year old female with severe left knee

67 year old with severe L knee pain

Selective Resurfacing • Observational study (1985-2010) – 20,969 resurfaced TKAs; 402 unresurfaced TKA • Reasons for not resurfacing – nl cartilage, young pt, thin patella, surgeon choice • Adjust for implant type and diagnosis - no difference in results for resurfaced vs. non- resurfaced patellae – Thin patellae higher revision rate but for infection • Selective resurfacing not scientific process but intuition works Maradit-Kremers et al, JOA, 2017

Nonresurfacing • Young active patient with nl cartilage • Large patient with minimal to no disease • Thin patella • Shared decision making with patient – Increased risk of anterior knee pain

AAOS Guideline

Parvizi Study