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Patellar Resurfacing inCemented Total Knee Arthroplasty
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Patella Replacement inKnee
Arthroplasty: AJapanese
Perspective
AtsushiTakahashi
Contents
21.1 Introduction – 234
21.2 Patellofemoral Contact Stress inTKA – 234
21.2.1 Factors Correlated withPatellofemoral Contact Stress after TKA – 234
21.2.2 Eect ofPatellar Morphology onPostoperative
Patellofemoral Contact Stress – 235
21.2.3 Eect ofComponent Geometry onPostoperative
Patellofemoral Contact Stress – 236
21
21.3 Complications Associated withthePatellofemoral
Joint inTKA – 236
21.3.1 Patellar Fracture – 236
21.3.2 Osteonecrosis ofthePatella – 239
21.3.3 Patellar Clunk Syndrome andCrepitus – 239
21.3.4 Anterior Knee Pain after TKA – 240
21.4 Surgical Technique andStrategies that Can
Reduce Anterior Knee Pain – 241
References – 243
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_21
234
Registry trends in patellar resurfacing
HealthEast
Year of report
Percentage resurfaced
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A. Takahashi
21.1 Introduction
The use of patellar resurfacing versus retention in total
knee arthroplasty (TKA) has long been controversial.
There are signicant differences in the rates of patellar
resurfacing among countries (. Fig. 21.1) (Fraser and
Spangehl 2017). Hence, whether this procedure should
be performed remains unclear. Patellar retention is
advantageous because it is less invasive to the extensor
mechanism, can preserve the bone, and has a short operative time. Moreover, it is benecial for revision surgery
particularly in cases of infection. The treatment of patellar fracture after patellar resurfacing is challenging, with
a high complication rate and low satisfaction outcome
(Chalidis etal. 2007; Ortiguera and Berry 2002). However,
patellar retention has disadvantages, which include anterior knee pain and a high rate of revision surgery
(. Fig.21.2). Grassi etal. revealed that a higher risk of
re-surgery after patellar retention should be interpreted
with caution due to the methodological limitations of
previous meta-analyses on search criteria, heterogeneity,
and inherent bias of the indication for reoperation when
the patella is not resurfaced (Grassi et al. 2018).
Considering these factors, patellar retention could be a
better option if anterior knee pain is managed.
21.2 Patellofemoral Contact Stress inTKA
21.2.1 Factors Correlated
withPatellofemoral Contact
Stress after TKA
> High-contact pressure in the patellofemoral joint
causes postoperative anterior knee pain (Becher etal.
2009; Whiteside and Nakamura 2003).
Moreover, it induces degenerative changes in the
patella, which may be associated with pain around the
patellofemoral joint (Rodriguez-Merchan and GomezCardero 2009; Sawaguchi etal. 2010). To date, several
studies have reported about numerous factors affecting
patellofemoral contact pressure which include the following:
5 The design of the femoral component (Whiteside
and Nakamura 2003; Browne etal. 2005)
5 Rotational alignment (Kessler etal. 2008; Merican
etal. 2011; Verlinden etal. 2010) and
5 Use of either a mobile-bearing insert (Sawaguchi
etal. 2010) or highly conforming inlays (Heyse etal.
2010)
21
100
90
80
70
60
50
40
. Fig. 21.1 International rates of patellar resurfacing in primary total knee arthroplasty (Fraser and Spangehl 2017) based on the Ameri-
can Joint Replacement Registry
30
20
10
0
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Australia
Sweden
Denmark
Norway
England
AJRR
Kaiser
Risk of reoperation
aran et al.
Reoperations related to PF join
Reoperations not related to PF join
C
Anterior k
Knee pain score (SMD
V
P
Knee Scores (SMD
IKS scor
KSS scor
KSS func
Satisfactio
In
Pa
Pa
g
Patella Replacement inKnee Arthroplasty: AJapanese Perspective
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t
t
omplications related to PF joint
nee pain
)
AS for pain
ain during stairs climbing
)
e
e
tion score
n
fections
tellar tilt
tellar shift
235
Nizard et al.
Parvizi et al.
Pakos et al.
Li et al.
Pavlou et al.
He et al.
Fu et al.
Pilling et al.
Chen et al.
Arirachak
21
. Fig. 21.2 Use of the Jadad algorithm to select the best quality of evidence (Grassi etal. 2018)
> Patellar morphology and femoral component geome-
try are signicant factors correlated with patellofemoral contact stress in total knee arthroplasty without
patellar resurfacing (Takahashi etal. 2012).
21.2.2 Eect ofPatellar Morphology
onPostoperative Patellofemoral
Contact Stress
In general, the mineral density of the subchondral bone
reects the distribution of stress caused by joint contact
over a long period of time (Noble and Alexander 1985).
The measurement of mineral density is a convenient
method for assessing biomechanical stress within the bone
in clinical practice. Hence, subchondral bone mineral density can be used as a clinical indicator of patellofemoral
joint contact stress. Based on this point of view, osteosclerosis was classied to assess patellofemoral contact stress
after TKA without patellar resurfacing (Takahashi etal.
2012). Pre- and postoperative axial radiograph images
Not reported
No dierences
obtained 1year after surgery were compared. Then, they
Favour resurfacing
Favour not-resurfacin
were evaluated according to the grade of newly diagnosed
osteosclerosis, which were as follows:
5 None (grade 0)
5 Slight (grade 1)
5 Moderate (grade 2)
5 Severe (grade 3) (.
Fig.21.3)
The patellae signicantly vary in terms of morphology.
Some have a steep facet angle and others are at. The
medial-to-lateral facet length ratio also varies. The
patellar facet angle is a radiographic parameter that
expresses patellar atness (. Fig. 21.4). The Wiberg
classication is the most well-known classication system for patellar shape (Wiberg 1941). However, it is not
correlated with the occurrence of osteosclerosis of the
patella after surgery. Osteosclerosis is commonly
observed in patellae with a small facet angle, and the
results were statistically signicant (. Fig.21.5). Moreover, patient-specic nite element analyses revealed a
negative correlation between the patellar facet angle and
the peak von Mises stress inside the patella (. Fig.21.6).
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A. Takahashi
. Fig. 21.3 Grade of newly diagnosed osteosclerosis after surgery (Takahashi etal. 2012)
was higher than that in either xed-bearing CR or
mobile- bearing designs (Wyatt et al. 2013). Some
authors reported that the prosthetic design did not
inuence the patellofemoral clinical outcome in TKA
(Johnson etal. 2012; Pavlou etal. 2011). However, in
their studies, most of the new prostheses were considered as patella-friendly. In contrast, our study compared new prostheses with different designs of the
femoral trochlea (. Fig.21.7). Results showed that the
signicance of the patellofemoral contact stress patterns differed even in modern implants (Takahashi etal.
2012). In this study, the maximum von Mises stress val-
ues were signicantly lower in both the LCS and
NexGen groups than in the Genesis II group, and the
stress distribution pattern within the patella coincided
. Fig. 21.4 Measurement of the patellar facet angle (Takahashi
etal. 2012). C is a point on the central ridge, M is a point bisecting
the medial facet, and L is a point bisecting the lateral facet. The
patellar facet angle is the angle formed using lines MC and LC
> Based on these findings, patellae with a large facet
angle (flat patellae) do not require patellar resurfacing. Hence, the preoperative patellar facet angle can
be used as an indicator for selective patellar resurfacing.
with the localization of osteosclerosis, which was conrmed on radiography (. Fig. 21.8). To date, several
studies have used the term “patella- friendly”. However,
it does not have a clear denition (Montonen et al.
2018; Wyatt et al. 2013; Johnson et al. 2012; Pavlou
etal. 2011; Atzori etal. 2015; Koh etal. 2018; Roessler
etal. 2018).
> The result of our study showed that a deep trochlea
could be patella-friendly.
21.2.3 Eect ofComponent Geometry
onPostoperative Patellofemoral
Contact Stress
As mentioned in 7 Sect. 21.1, previous studies comparing patellar resurfacing and retention have different
results. One possible explanation for this discrepancy is
21
that these studies used various implants with different
geometries. For example, Montonen etal. reported that
Triathlon cruciate retaining (CR) had a higher risk for
patellar revision than Nexgen CR Flex (Montonen
etal. 2018). Moreover, Wyatt etal. showed that the rate
of revision for secondary resurfacing of the patella in
the xed-bearing posterior-stabilized (PS) TKA designs
21.3 Complications Associated
withthePatellofemoral Joint inTKA
21.3.1 Patellar Fracture
Chlidis etal. showed that the incidence rate of patellar
fracture was 1.19% (range: 0.15–12%) (Chalidis et al.
2007). Moreover, approximately 99% of patellar frac-
tures occurred after patellar resurfacing, and 88% were
not associated with a traumatic event and identied during the follow-up examination within the rst 2 years
after TKA.Bone thickness <12mm after patellar resurfacing was considered a risk factor for patellar fracture
Patella Replacement inKnee Arthroplasty: AJapanese Perspective
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. Fig. 21.5 Relationship between postoperative osteosclerosis grade and patellar facet angle. Patients with high-grade osteosclerosis had a
small facet angle (**p<0.01, *p<0.05)
regardless of preoperative patellar thickness (Hamilton
etal. 2017). Moreover, other risk factors include body
mass index >30kg/m2, male gender, large preoperative
varus, and intraoperative lateral release (Meding etal.
ful in 92% of cases, and the nal outcome was poor
(Chalidis etal. 2007). Avascular fracture fragments have
minimal healing potential, and the surgical complication rate is extremely high.
2008). Ortiguera and Berry classied patellar fracture as
follows (Ortiguera and Berry 2002):
Classication of Patellar Fractures (Ortiguera and
Berry 2002)
5 Type 1: Stable implant and intact extensor mecha-
nism
5 Type 2: Disruption of the extensor mechanism
5 Type 3: Loose patellar component with an intact
extensor mechanism
– Type 3a: Indicated reasonable remaining bone
stock
– Type 3b: Poor bone stock
> Hence, simple ORIF should not be routinely
recommended.
Considering these factors, Putman et al. summarized
the management of post-TKA patellar fractures as follows (Putman etal. 2019):
Management of Post-TKA Patellar Fractures (Putman
z
etal. 2019)
5 Type 1: Nonoperative treatment (splint, cast) is used.
5 Type 2 with a stable implant: In this condition, the
fracture involves either the proximal or the distal
pole of the patella. The implant is left in place to
prevent the fragilization of the residual bone, and the
Patellar fracture after TKA often occurs without
trauma, and lateral retinacular release is considered a
risk factor for patellar fracture (Chalidis et al. 2007;
Meding etal. 2008). Thus, hypovascularity or osteonecrosis of the patella has been considered the etiology of
this type of fracture. Chalidis etal. reported that open
reduction and internal xation (ORIF) was not success-
extensor apparatus is reconstructed.
5 Type 2 with a loose implant: Surgery is usually
required, with the primary objective of restoring a
continuous extensor apparatus (trans-osseous suture,
hamstring graft augmentation, and allogeneic graft).
The patellar implant must be removed.
5 Type 3: Removal of the patellar implant is sufcient.
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A. Takahashi
21
. Fig. 21.6 Relationship between von Mises stress inside the patella and patellar facet angle (Takahashi etal. 2012)
. Fig. 21.7 Comparison of the femoral trochlea of different prostheses. Genesis II has a relatively shallow trochlea whereas LCS has a deep
trochlea
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21
. Fig. 21.8 Osteosclerosis conrmed on radiography and simu-
lated stress distribution within the patella. The right column shows
an equivalent stress distribution within the patella model created
using the data of the same patient. In the nite element analysis,
21.3.2 Osteonecrosis ofthePatella
As described 7 Sect. 21.3.1, most patellar fractures
after patellar resurfacing is associated with hypovascularity or osteonecrosis of the patella. Osteonecrosis-like
lesion after TKA was also observed in non-resurfaced
patellae, which had radiological similarities to those of
spontaneous osteonecrosis of the knee (. Fig. 21.9)
(Takahashi etal. 2014). In this study, the major osteoporotic fracture risk assessed using the World Health
Organization fracture risk assessment tool was signicantly higher in the osteonecrosis group than in the control group. In addition, the average patellar facet angle
in the radiolucent group was signicantly smaller than
that in the control group (. Fig.21.10). As described in
7 Sect. 21.3.1, a small patellar facet angle was associ-
ated with stress concentration (. Fig.21.6).
both the LCS and NexGen implants had a high stress concentration
on the lateral facet where osteosclerosis was observed (arrowhead).
Both high stress concentration and osteosclerosis are observed on
the central ridge in the Genesis II implant
> Therefore, both underlying osteoporosis and stress
concentration may play an important role in the
pathogenesis of the radiolucent zones in the patellae
after TKA without patellar resurfacing.
Based on the author’s experience, this condition might
cause mild-to-moderate anterior knee pain. However, it
can be treated conservatively.
21.3.3 Patellar Clunk Syndrome
andCrepitus
Hozack etal. rstly proposed the patellar clunk syndromeas patellofemoral pain due to an unusual suprapatellar brous nodule after posterior-stabilized (PS) TKA,
which is characterized by catch or clunk on extension of
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A. Takahashi
. Fig. 21.9 The radiolucent zone of the patella a has a radiological similarity to that of spontaneous osteonecrosis of the knee b (Taka-
hashi etal. 2014)
. Fig. 21.10 Comparison between patients with and without osteonecrosis. Patients with osteonecrosis had a small facet angle (**p<0.01)
the knee (Hozack etal. 1989). The synovial entrapment
is caused by hypertrophic synovial tissue at the superior
pole of the patella (. Fig.21.11) (Pollock etal. 2002).
> When treating patellar clunk syndrome, more than
half will improve with time under conservative treatment (Ip etal. 2004; Gholson etal. 2017).
This condition is commonly observed in PS knees particularly when prostheses have an intercondylar box
ratio >0.7 (Fukunaga etal. 2009). Other risk factors are
previous surgeries, small femoral component size, thick
polyethylene bearing, and patella baja (Conrad and
Arthroscopic resection of the suprapatellar nodule has
good outcomes, with a low rate of recurrence (Costanzo
etal. 2014).
Dennis 2014).
21
To prevent patellar crepitus and clunk, the removal
21.3.4 Anterior Knee Pain after TKA
of brosynovial tissues at the border of the superior
pole of the patella and distal quadriceps tendon was recommended at the time of primary TKA (Conrad and
Dennis 2014).
Anterior knee pain after TKA is a multifactorial problem. When treating anterior knee pain, known causes
such as patellar fracture, patellar clunk, loosening of the
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. Fig. 21.11 Knees with synovial entrapment syndromehave hypertrophic tissue proximal to the patella (arrows) (Pollock etal. 2002)
patellar implant, asymmetric patellar cut, lateral patellar
facet impingement, and component malrotation, should
be ruled out (Putman etal. 2019; Antinol etal. 2018).
> Importantly, successful repair of the MPFL after
using the medial parapatellar approach in TKA could
reduce anterior knee pain (Keshmiri etal. 2017).
Lateral patellofemoral impingement or lateral patellar
facet impingement is a cause of treatable pain after TKA
(Nikolaus et al. 2014; Cercek et al. 2011). An axial
weight-bearing radiographic view (. Fig. 21.12) while
21.4 Surgical Technique andStrategies that
Can Reduce Anterior Knee Pain
the patient is in semi-squatting position is occasionally
useful to detect impingement (Baldini etal. 2007).
> Although there are some cementless patellar compo-
> Lateral patellar facet impingement after TKA could
be treated with lateral facetectomy, with relatively
good outcomes (Nikolaus etal. 2014; Cercek et al.
2011). Lateral facetectomy is a useful preparation
method of the patella in primary TKA with patellar
retention (Kim etal. 2017).
nents available, cement xation is the gold standard
for patellar replacement.
When resurfacing the patella, a at surface during bone
resection should be made. The patellar thickness should
be similar to or slightly thinner than the original thickness. Multiple small anchor holes are necessary only
Moreover, patellar denervation and patelloplasty are techniques used to reduce anterior knee pain in patellarretaining TKA.Xie etal. showed that patellar denervation
can signicantly reduce the incidence of anterior knee
pain and improve early clinical outcomes after TKA (Xie
etal. 2015). However, after a prolonged follow- up period,
this advantage may not be observed. Cerciello et al.
reported that the outcome of patelloplastyis superior to
that of isolated osteophyte removal and denervation, with
a lower rate of anterior knee pain (Cerciello etal. 2016).
when the patella is eburnated. An adequate component
size must be selected, and the position slightly should be
medialized. Lateral partial facetectomy is recommended
to prevent lateral patellar facet impingement. Dry the
bone surface before starting cement xation. Apply
cement on to both the implant and bony surfaces, and
compression force should be applied until cement
polymerization is complete.
The author used the following strategies to reduce
anterior knee pain in primary TKA:
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