EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
Abdullatif
PATELLAR PAIN AFTER TOTAL KNEE ARTHROPLASTY
COMPARISON OF THE RESULTS OF TOTAL KNEE
ARTHROPLASTY WITH AND WITHOUT RESURFACING
OF THE PATELLA.
By
Mohamed Fouad Abdullatif
Department of Orthopedics, El-Minia Faculty of Medicne
ABSTRACT:
This study included 43 patients with 56 knees in whom the patella was not
severely deformed and whom had primary total knee arthroplasty (TKA) for
osteoarthritis of the knee, the operation was done by the same team of surgeons using
one type of prothesis (PFC). The study and follow-up of the patients was done through
years 2000-2004, at Baraha Hospital UAE. The patients were randomly allocated
either to have the patella retained (36 knees) or resurfaced with a cemented, all
polyethelyne component regardless of the state of the patellar articular cartilage (20
knees). Apart from removal of osteophytes, patelloplasty was done on the retained
patellae. The aim of the study was to compare the clinical results with total knee
arthroplasty with patellar resurfacing and those after total knee arthroplasty with
retension of the patella. The patients were followed for 3 years (mean, 38 months),
and the postoperative status of the patients was evaluated with use of the clinical
scoring system of the knee society, a patient satisfaction questionnaire, specific
questions regarding patello-femoral symptoms and function, and radiograph findings.
Preoperatively, the mean Knee Society Score, on a scale ranging from 0 to 100 points,
was a mean of 47.6 (range, 45.0 to 49.7 points); postoperatively, this score improved
to a mean of 81.6 points (range, 56.6-93.9 points). With the number available for the
study we could detect a significant difference between the knees that had patellar
resurfacing with the mean of 91.6 points (range, 89.5 to 93.9 points); and those
without with the mean of 70.7 points (range, 56.1 to 65.7 points). Eight (22.2%) of the
36 knees with retained patella had anterior knee pain compared with 1 knee (5%) of
the 20 kness with resurfaced patella; this was a significant difference (P<0.05). The
findings suggest that, in order to diminish pain on the patellofemoral joint,
replacement of the patella during total arthroplasty is preferable.
KEY WORDS:
Arthroplasty
Patellofemoral
Joint Resurfacing
status of the patients was evaluated by
the use of the Clinical Scoring System
of the Knee Society,1 whereas
complications such as patellar fracture,
osteonecrosis, and loosening may
occur after a patellar replacement.2
Complications related to the patella
was major cause of reoperations after
total knee arthroplasty, the reported
INTRODUCTION:
There is some controversy
regarding
whether
total
knee
arthroplasty is best performed with or
without insertion of a patellar
prosthesis. Pain may develop in the
patellofemoral joint postoperatively if
the arthroplasty is performed without a
patellar replacement. Postoperative
200
EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
rates of these complications, which
included postoperative anterior knee
pain, subluxation, dislocation, patellar
fracture, ranged from 4 percent to 50
percent.3,4 Because many of these
patellofemoral complications seemed
to be more common after the patella
had been resurfaced, so-called selective
resurfacing was suggested as a means
of lowering the prevalence of complications after total knee arthroplasty.5,6
Abdullatif
retension was done for 36 knees (Table
II).
The surgical technique was
similar in all cases using a medial
parapatellar approach and the PFC
Modular prosthesis. The femoral and
tibial components were inserted with
cement. In the resurfacing group an allpolyethylene offest-dome patellar component was cemented into position.
When resurfacing was not performed, a
so-called patelloplasty was carried out,
included removal of osteophytes,
smoothing of fibrillated cartilage, and
drilling of eburnated bone.
This study aimed at comparing
the results of total knee arthroplasty
with and without patellar replacement.
All patients were managed with
the
same
inoperative
regimen,
including administration of antibiotics
and prophylaxis against venous thrombosis.
Physical
therapy
was
conducted in a uniform fashion for all
patients, according to a protocol
provided to the therapists. This consisted of weight-bearing as tolerated
and active flexion conducted twice
daily under the supervision of the
therapist and commencing on the first
postoperative day.
MATERIAL AND METHODS:
This series included 43 patients
submitted to total knee arthroplasty.
Surgery was done at Boraha Hospital,
UAE during the period of 2000 to
2004. The patients included 18 male (3
bilateral and 15 unilateral cases, i.e. 21
knees) and 25 females (10 bilateral and
15 unilateral cases, i.e. 35 knees).
Patients data is presented in (Table I).
All the operations were
performed by the same surgical team.
The indication for the operation was
degenerative osteoarthrosis that was
severe enough to warrant total knee
arthroplasty after an adequate trail of
non-operative therapy. The criteria for
exclusion included a previous tibial
osteotomy or operation involving
extensor mechanism, arthroscopic
debridement, inflammatory arthropathy, and severe deformity (varus
angulation, valgus angulation, or
flexion deformity more than 15
degrees). The 43 patients with 56 knees
were randomized to resurfacing or
retention of the patella after all femoral
and tibial cuts had been made and
immediately before preparation of the
patella. Resurfacing of the patella was
done for 20 knees, and the patellar
Preoperatively,
an
anteroposterior radiograph with the patient
standing and lateral radiographs were
made (Figure 1, 2 and 3) and were
evaluated at 6 months intervals
postoperatively (Figure 4). The radiographs were analyzed; on the anteroposterior radiograph, the anatomical
axis was measured with use of the
longitudinal axes of the femur and the
tibia as references. On the lateral
radiograph, the Insall-Salvati index(7)
was used to calculate the patellar height
by dividing the length of the patellar
tendon. Patellar tilt and subluxation
were measured as described by Gomes
et al.,8.
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EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
Abdullatif
patellae that had grade-IV chondromalacia were left non-surfaced, and 11
patellae had grade-IV chondromalacia
were resurfaced. This differences was
non-significant (P=0.41) (Table IV).
RESULTS:
Demographic results
The study group consisted of 56
knees in 43 patients. Twenty knees had
resurfacing of the patella had 36 did
not. The mean age of the patients who
had resurfacing was 56.3 years (range,
58-72 years) compared with 68.5 years
(range, 59-78 years) for those who had
not; this difference was significant
(P<0.05). The mean body weight of the
patients who had resurfacing of the
patella was 71.5 kg (range, 69-80 kg)
compared with 75.2 kg for those who
had not (range, 68-81 kg); this
difference was not significant (P=
0.05). The higher percentage of female
patients (58%) than male patients
(41.8%) was significant.
The mean score for pain in
preoperative knees was 42.9 points
(range, 42-48 points), compared with
the mean score for pain at postoperative knees of 86.8 points (range,
91-70 points); this difference shown to
be significant (P<0.05). The mean
postoperative pain score for the knees
without resurfacing was 70.4 points
(range, 56.6-65 points) com-pared with
91.5 points (range, 89-94 points), for
the knees that had resurfacing of the
patella, this diffe-rence showed
significant (P<0.05) (Table IV).
The mean duration of follow-up
was 38 months (range; 36-41 months).
Of 20 knees that had resurfacing of the
patella, 10 knees were for females and
10 knees for males; of 26 knees that
had bilateral procedure, 3 patients were
males, and 10 patients were females.
The female patients were with a non
resurfaced patella was 25 knees
(44.6%), compared to 11 knees (19%)
in the male patients; the difference was
significant (P 0.05) (Table III).
We could detect no significant
differences, in the prevalence of the
postoperative knee pain score, that
were attributable to whether or not the
patella had been resurfaced or to the
body weight (P=0.25).
There were no acute infection
within the follow-up time. Three knees
without resurfacing subsequently were
resurfaced (16 months, and 18
months), all because of the anterior
knee pain. The degree of chondromalacia was advanced as detected at
the time of resurfacing.
Operative results
The mean duration of the
operation was 120 minutes (range,
110-140 minutes) for the knees that
had resurfacing of the patella compared
with 110 minutes (range 95-135
minutes) for those without resurfacing;
this difference was not significant
(P=0.061).
After resurfacing, the pain was
less, however, as the mean duration of
follow-up for these patients was less
than 12 months; these results must be
considered preliminary (Figure 5, 6, 7).
The patellae were examined
intraoperatively to determine the
degree of chondromalacia.1-9 Fifteen
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EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
Abdullatif
Table I: The patients data.
Patients
43
Male
18 (41.8%)
Female
25 (58.1%)
P value
P<0.05*
64.9 ys
(63-68 y)
65.8
(58-72 ys)
P>0.05 NS
71.8 kg
(68-78 kg)
21 (37.5%)
73.0 kg
(63-81 kg)
35 (62.5%)
P>0.05 NS
15 (26.7%)
15 (26.7%)
P>0.05 NS
6 (10.7%)
20 (35.7%)
P<0.05*
Age
Mean
Range
Weight
Mean
Range
Knees (56)
Unilateral
30 (54.5%)
Bilateral
26 (45.4%)
P<0.05*
* : Significant
NS : Non significant
Table II: Weight and age distribution in the two groups.
Knees
number = 56
Weight (kg)
Mean
Range
Age (years)
Mean
Range
* : Significant
NS : Non significant
Resurfacing patellae
20 (35.7%)
Non-resurfacing patellae
36 (64.2%)
P value
P<0.05*
71.5 kg
(69-80 kg)
75.2 kg
(68-81 kg)
P>0.05 NS
65.3 ys
(58-72 ys)
68.5 ys
(59-78 ys)
P<0.05*
Table III: Sex distribution in the two groups.
Patients
No. = 43
Male
18 (41.8%)
Female
25 (58.2%)
21 (37.5%)
15 (83.33%)
6 (3 pts) (10.7%)
10 (47.6%)
11 (52.3%)
35 (62.5%)
15 (60.0%)
20 (10 pts) (35.7%)
10 (28.5%)
25 (71.4%)
Knees
Number=
56
Unilateral= 30
Bilateral=
26
With resurfacing of the Patella
Without surfacing of the Patella
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EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
Abdullatif
Table IV: Pain score (points) related to chondromalacia and patellar resurfacing
Grade of Chondromalacia
Pain Score
(points)
No. of knees
Preop
Number
Mean
Resurfacing (n=20)
GI
GII
GIII
GIV
Non-resurfacing (n=36)
GI
GII
GIII
GIV
0 (0%)
2 (3.7%)
7 (12.5%)
11 (19.6%)
0
45.7
44.5
41.4
0 (0%)
3 (5.3%)
18 (33.7%)
5 (26.7%)
0
49.7
47.8
45.0
43.8
47.5
Post-op
Number
Mean
90
93.9
91.5
89.5
0
56.6
89.1
65.7
Figure 1. Preoperative standing view
Figure 2. AP view
Figure 3. Preoperative knee
Figure 4. Postoperative total knee
replacement
204
91.6
70.7
EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
Figure 5. Preoperative knee patella
Abdullatif
Figure 6. After total knee replacement
without resurfaced patella
Figure 7. Same knee (figure 5) after secondary patellar resurfacing
percent (twenty-six of fifty-two knees)
in other literatures.13-16 In the study of
Picetti et al.,16 postoperative anterior
knee pain was reported as being more
common in obese patients when the
patella had not been resurfaced; In
another study published in the same
year; however, such pain was reported
as being more common in obese
patients when the patella had been
resurfaced.17 The proposed indications
for resurfacing the patella had varied
widely, included obesity, preoperative
anterior knee pain, moderate to severe
chondromalacia, patellar tilt or
deformity, and patellar height.18 Picetti
et al.,16 recommended resurfacing of
the patella for all patients who had
height of more 160 centimeters, a
DISCUSSION:
Resurfacing of the patella was
not a feature of many early designs of
total knee protheses. The occurrence of
postoperative patellofemoral pain,
resulted in the incorporation of
patellofemoral resurfacing into most
subsequent designs. With the advent of
modern
condylar
components,
resurfacing of the patella become a
standard
part
of
total
knee
10-12
arthroplasty.
Our reported cases of
anterior knee pain after total knee
arthroplasty with surfaced patellae
were not significant, comparing to the
non surfaced patellae cases, there were
no subluxation, dislocation, patellar
fractures. These complications were 4
percent (sixteen of 396 knees) to 50
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EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
weight of more than sixty kilograms,
anterior knee pain preoperatively, and
grade-IV chondromalacia. It should be
noted that these guidelines would leave
very few patients with a non-resurfaced
patella.
Abdullatif
will have anterior knee pain after either
resurfacing or retnesion of the patella.
Preoperative anterior knee pain
seems to be a logical reason to
resurface the patella. Resurfacing of
the patella relieved anterior pain in the
knee in forty-five (92%) of forty-nine
knees that had had that symptoms in
the study by Barrak et al.,25 In our
study; we found that the presence of
such pain preoperatively did not
predict its occurrence postoperatively,
the pain does seem to be improved by
resurfacing the patella.
Boyd et al.,3 recommended
resurfacing of the patella both for
patients who have degenerative
osteoarthrosis and for those who have
inflammatory arthritis, despite the fact,
in their study, the rate of patellar
complications in osteoarthritic knees
was 4 percent after resurfacing
compared with 6 percent after arthroplasty without resurfacing. The same 6
percent prevalence of patellofemoral
pain was found by Sneppen et al.,19
The present study confirms that only a
small percentage of patients will have
anterior knee pain after resurfacing of
the patella, that is consistent with the
rates reported by Bourne et al.,20
With a mean duration of
follow-up of 38 months, the results of
the present study must be considered
preliminary. It is possible that
additional patellofemoral complications will develop in the study group
with the passage of time. A number of
studies have shown that virtually all
currently available designs of total
knee implants alter patellar tracking to
some degree,(21,22) therefore altering the
stresses on the extensor mechanism.
Recently developed total knee designs
represent an attempt to improve the
patellofemoral articulation with a
deeper, more anatomical groove that
should yield more anatomical kinematics, the prevalence of postoperative
patellofemoral symptoms theoretically
should decrease.23
Chondromalacia of the patella,
as assessed at the time of total knee
arthroplasty, has been used as a reason
to resurface the patella. Boyd et al.
compared the results, at a mean of 6.5
years postoperatively, for 396 knees
that had had resurfacing.13 Their
patients had had selective resurfacing
on the basis of the appearance of the
patella at the time of the operation.
Those authors recommended resurfacing of the patella for osteoarthrosis
knees. The prevalence of anterior knee
pain in our study for the GIV
chondromalacia of the patella after
retension of the patella was significantly different (mean= 65.7 points),
compared with the mean; 89.5 points
for the resurfaced patellae (Table IV)
(P<0.05). The prevalence of anterior
knee pain in this study was
contradicted with other reported
studies, by Cameron,24 who confirms
that only a small percentage of patients
Acknowledgment:
Special thanks to Mr. Dr. J.
Sefton, Consultant Orthop. Surg. U.K.
and Dr. Mahmoud Zien El-Din,
Consultant Orthop. Surg. U.A.E.
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Clin. Orthop. 1989; 248: 13-14.
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EL-MINIA MED., BULL., VOL. 16, NO. 2, JUNE, 2005
2. Grace, J.N.; and Sim, F.H.;
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3. Boyd, A.D., Jr; Ewald, F.C.;
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6.Keblish, P.A.; Varma, A.K.; and
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7.Insall, J.: and Salvati, E.: Patella
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8.Gomes, L.S.M.; Bechtold, J.E.;
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9.Outerbridge, R.E.: The etiology
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10.Dennis, D.A.: Patellofemoral
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11.Gunston, F.H.; and MacKenzie,
R.I.: Complications of polycentric knee
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11-17.
12. Ranawar, C.S.: The patellofemoral joint in total condylar knee
Abdullatif
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93-99.
13.Boyd, A.D., Jr; Ewald, F.C.;
Thomas, W.H.; Boss, R.; and Sledge,
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resurfacing of the patella. J Bone and
Joint Surg. May 1993; 75-A: 674-681.
14.Enis, J.E.; Gardner, R.;
Robledo, M.A.; and Smith, R.:
Comparison of patellar resurfacing
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260: 38-42.
15.Healy, W.L.; Wasilewoki, S.A.;
Takei, R.; and Oberlander, M.:
Patellofemoral complications following
total
knee
arthroplasty.
Correlation with implant design and
patient risk factors. J. Arthroplasty
1995; 10: 197-201.
16.Picetto, G.D., III; McGann,
W.A.; and Welch, R.B.: The
patellofemoral joint after total knee
arthroplasty
without
patellar
resurfacing. J. Bone and Join Surg.
Oct. 1990; 72-A: 1379-1382.
17.Stern, S.H.; and Insall, J.N.:
Total knee arthroplasty in obese
patients. J. Bone and Joint Surg. Oct.
1990; 72-A: 1400-04.
18.Frymore, J.W.: Knee and leg:
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v. 613. Rosemont, Illinois, The
American Academy of Orthopaedic
Surgeon, 1993.
19.Sneppen, O.; Gudmundsson,
G.H.; and Bunger, C.: Patellofemoral
function in total condylar knee
arthroplasty. Internet. Orthop. 1985; 9:
656-68.
20.Bourne, R.B.; Rorabeck, C.H.;
Vas, M.: Resurfacing versus not
resurfacing the patella during total
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21.Mclean, C.A.; Tanzer, M.;
Laxer. E.: The effect of femoral
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‫‪Abdullatif‬‬
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‫‪component designs on the contact and‬‬
‫‪tracking characteristics of the unre‬‬‫‪surfaced patella in TKA. Orthop.‬‬
‫‪Trans. 1994; 18: 616-617.‬‬
‫;‪22.Mastuda, S.; Ishinishi, T.‬‬
‫‪White, S.E.; and Whiteside, L.A.: The‬‬
‫‪patellofemoral joint after total knee‬‬
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‫‪and contact stress. Trans. Orthop. Res.‬‬
‫‪Soc. 1996; 21: 728.‬‬
‫;‪23.Braakman, M.; Verberg, A.D.‬‬
‫;‪Bronsema, G.; Van Leeuwen, W.M.‬‬
‫‪and Eeftinck, M.P.: The outcome of‬‬
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‫‪Orhtop. 1995; 19: 7-11.‬‬
‫‪24.Cameron, H.U.: Comparison‬‬
‫‪between patellar resurfacing with an‬‬
‫‪inset plastic button and patelloplasty.‬‬
‫‪Canadian J. Surg. 1991; 34: 49-52.‬‬
‫;‪25.Barrack, R.L.; Wolfe, M.W.‬‬
‫‪Alexander, M.M.; Waldman, D.A.:‬‬
‫‪Resurfacing of the patella in total knee‬‬
‫‪arthroplasty. A prospective, Rando‬‬‫‪mized, Double-Blind study. J Bone and‬‬
‫‪Joint Surg. 1997; 79-A,8: 1121-1123.‬‬
‫الم الركبة األمامي بعد استبدال مفصل الركبة‪ -‬مقارنة النتائج لالستبدال الكامل‬
‫شامالً عظم الرضفة مع عدم استبدال عظم الرضفة‬
‫محمد فؤاد عبد اللطيف‬
‫قسم جراحة العظام – كلية طب المنيا‬
‫أجريت الدراسة على ثالثة وأربعين مريضا ً لستةة وممستين ر بتة لتت ة تن عاتت الرضت ة‬
‫مشتوةة بشتدح ثيتج أجريتت للمرضتى استةبدا امت لم بت الر بتة بم بت بتااع باستتةمدات‬
‫المسماح (ب‪ -‬ف‪ -‬ج)‪.‬‬
‫أجريتتت الدراستتة متتال ا عتتوات ‪ 2004-2000‬ف ت مسةش ت ى البراثتتة با متتارات العربيتتة‬
‫المةثدح ةت امةيار المرضى المقرر لهت إجراء استةبدا م بت الر بتة عشتوائيا ً ثيتج ةتت استةبدا‬
‫عات الرض ة لعشرين ر بة ولت يةت اسةبدا ‪ 36‬ر بة مع عدت الةدم سوى بالثف الجراثت‬
‫للرض ة‪.‬‬
‫تتان الهتتدف الدراس ت ةتتو مقاراتتة الاةتتائس الستتريرية ستتةبدا م ب ت الر بتتة شتتامال عاتتت‬
‫الرض ة مع اسةمدات الةقويت السريري المة ق علية ف جمعية جراثتة الر بتة بالاقتا المعةتادح متع‬
‫ةقويت ش وى المرضى ومعد ثر ة الر بة و ذلك الاةائس اإلشعاعية‪.‬‬
‫أاهرت الاةائس اآلة ‪-:‬‬
‫ةثستتن فت اقتتا واتتائف الر بتتة للم اب ت المستتةبدلة بال امت إلتتى ‪ 81.6‬درجتتة مقاراتتة بت ‪70.7‬‬
‫درجة يش و ثمااية مرضى من آلت أمتام بالر بتة المستةبدلة بتدون عاتت الرضت ة مقاراتة بواثتدح‬
‫فق ةت اسةبدا عات الرض ة‪.‬‬
‫ً‬
‫استتةملم متتن الدراستتة أن ا ستتةبدا ال ام ت لم ب ت الر بتتة شتتامال لعاتتت الرض ت ة يع ت اةتتائس‬
‫أفض من ثالة عدت اسةبدا العات الرضت ة ويم تن ة بيتق ةتذن الاةتائس ببت ة عامتة استةاادا ً إلتى‬
‫المقاراة اإلثبائية‪.‬‬
‫‪208‬‬