PATELLA RESURFACING: RARELY, IF EVER NECESSARY – AFFIRMS

Resurfacing the patella is performed the majority of the time in the US and in many regions it is considered standard practice. In many countries, however, the patella is left unresurfaced an equal amount of the time or even rarely ever resurfaced. Patella resurfacing is not a simple or benign procedure. There are numerous negative sequelae of resurfacing including loosening, fragmentation, avascular necrosis, lateral facet pain, stress fracture, acute fracture, late fracture, and restricted motion. In a study by Berend, Ritter, et al, failures of the patella component were reported 4.2% of the time at an average of only 2.6 years. A study was undertaken at Washington University in recent years to determine whether more clinical problems were observed following total knee replacement with or without patella resurfacing. Records were maintained on all problem total knees cases with well localised anterior knee pain. The referral area for this clinic is St. Louis which is among the largest American cities, with the highest percentage of total knees that are performed without patella resurfacing. During 4 years of referrals of total knee patients with anterior knee pain, 47 cases were identified of which 36 had a resurfaced patella and 11 had a non-resurfaced patella. Eight of 36 resurfaced patellae underwent surgery while only 2 of 11 non-resurfaced patellae underwent subsequent surgery. More than 3 times as many painful total knees that were referred for evaluation had already had their patella resurfaced. In spite of the fact that approximately equal number of total knees were performed in this area without patella resurfacing, far more patients presented to clinic with painful total knee in which the patella had been resurfaced. The numerous pathologies requiring a treatment following patella resurfacing included patella loosening, fragmentation of the patella, avascular necrosis patella, late stress fracture, lateral facet pain, oblique resurfacing, and too thick of a patellar composite. In a large multi-center randomised clinical trial at 5 years from the United Kingdom in over 1700 knees from 34 centers and 116 surgeons, there was no difference in the Oxford Score, SF-12, EQ-5D, or need for further surgery or complications. The authors concluded, “We see no difference in any score, if there is a difference, it is too small to be of any clinical significance”. In a prospective randomised clinical trial performed at Tulane University over 20 years ago, no differences were observed in knee score, a functional patella questionnaire, or the incidence of anterior knee pain between resurfaced and unresurfaced patellae at time intervals of 2–4 years, 5–7 years, or greater than 10 years. Beyond 10 years the knee scores of total knee patients with a resurfaced patella had declined significantly greater than those with a non-resurfaced patella. There are numerous advantages of not resurfacing the patella including less surgical time, less expense, a lower risk of “major” complications (especially late complications), and if symptoms develop in an unresurfaced patella, it is an easier salvage situation with more options available. A small percentage of total knee patients will be symptomatic whether or not their patella is resurfaced. Not resurfacing the patella retains more options and has fewer complications. The major determinant of clinical result and the presence of anterior knee pain after knee replacement is surgical technique and component design not whether or not the patella is resurfaced. Patella resurfacing is occasionally necessary for patients with inflammatory arthritis, a deformed or maltracking patella, or symptoms and pathology that are virtually restricted to the patellofemoral joint. For the vast majority of patients, however, patella resurfacing is not necessary.