Severe Patellofemoral Osteoarthritis Research Articles

Resurfacing Versus Non-resurfacing Patella in Total Knee Replacement: When and What to Choose.

The opinion on the necessity of patella resurfacing has been deeply divided in the scientific community. There are three approaches to the management of the patella in total knee arthroplasty (TKA). The first method involves always resurfacing the patella, the second method involves never resurfacing it, and the third method involves resurfacing the patella only under specific circumstances. Different data support each of these strategies, but no consensus on the best management has been reached. This is a retrospective study of 106 cases of TKA (including 29 resurfaced patellas and 77 non-resurfaced patellas), over 5 years, at the Trauma-Orthopedics Department of theCheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences, Casablanca, Morocco. Our objective is to conduct a comparative study between TKA with patella resurfacing and those without resurfacing, by analyzing the functional and radiological results obtained after the operation, to show each technique's advantages and disadvantages. The average age of our patients was 65 years with extremes ranging from 46 to 80 years. There was a clear female predominance with a sex ratio of 0.2. The left side was predominantly affected. Primary gonarthrosis was the main diagnosis. Our results showed no significant difference between the two groups in terms of patient satisfaction and Knee Society Score (KSS). Nevertheless, complications generated by resurfacing, such as infection, anterior pain, stiffness, and loosening of the patellar component, as well as additional costs and increased operative time, were observed. In the majority of meta-analyses, there was no discernible difference in clinical and functional results between the resurfaced and non-resurfaced groups, suggesting that patellar resurfacing is not beneficial and, therefore, unnecessary. It appears that regular resurfacing is not necessary. However, there is agreement that resurfacing the patella is the best course of action for patients with inflammatory arthropathy, considerable patella malalignment, and severe patellofemoral osteoarthritis. There are arguments in favor of each of the patella resurfacing techniques, but none of them are particularly compelling, each of these strategies has itsadvantages and should not be considered bad. The final decision, therefore, rests on each surgeon's practice, training, and experience.

Poster 312: Graft harvest for ACL reconstruction from the contralateral knee does not increase patellofemoral arthritis rates versus a normal knee

Objectives: Previous outcome studies after anterior cruciate ligament (ACL) reconstruction have suggested a link between patella tendon (PT) graft harvest and increased incidence of patellofemoral (PF) degenerative changes. However, with the graft harvest on the same knee as the ACL reconstruction, it is difficult to specifically elucidate whether this association is directly from the graft harvest itself as opposed to other factors. Knowledge of the incidence of PF osteoarthritis (OA) after graft harvest from the contralateral knee may provide insight into this relationship. The purpose of this study was to compare PF OA rates between contralateral versus ipsilateral graft harvest for ACL reconstruction. Methods: A database of long-term follow up of ACL reconstruction patients done by a single surgeon was queried to find surgeries done between minimum 15 years and maximum 25 years ago. Patients were included if they had long term radiographs within this window for evaluation of PF OA. Exclusion criteria included revision ACL reconstruction, bilateral ACL involvement, subsequent graft retear, contralateral ACL tear, PF chondral wear seen at the time of surgery, preoperative or subsequent surgeries to either knee, or the presence of preoperative PF OA. Once patients met inclusion criteria, they were separated into groups based on ipsilateral or contralateral PT graft harvest. Standard Merchant’s radiographs were taken by the same technicians with the assistance of a Merchant’s board. Radiographs were graded by the physical therapist that saw the patient back for their long term research visit, each individually trained to grade the images based on the set criteria. Radiographs were graded as none, mild, moderate, or severe PF OA based on joint space narrowing of none, <50%, >50% but <100%, and complete, respectively. Patellofemoral OA rates were then statistically compared utilizing chi-squared analysis or Fisher’s exact test. These criteria produced an ipsilateral group with 95 patients and a contralateral group with 98 patients. Mean ages at time of surgery, height, weight, and sex distribution were not statistically different between groups. The ipsilateral group had a slightly, but statistically significantly, longer mean follow up interval (20.0 vs. 17.4 years, p<.001). Results: In the ipsilateral graft group, PF OA of any grade was present in 20.0% of the involved ACL reconstructed knees and 9.5% of the uninvolved normal knees, which was a statistically significant difference ( p=.041, OR 2.4). In the contralateral graft group, PF OA was present in 10.2% of the ACL reconstructed knees and 13.3% of the contralateral graft donor knees ( p=.506). Patellofemoral OA of any grade was present in 14.7% of all knees in the ipsilateral group and 11.7% of all knees in the contralateral group ( p=.348). When comparing the uninvolved normal knee from the ipsilateral group to the contralateral graft donor knee of the contralateral group, there was no statistical difference in PF OA rates of any grade (9.5% vs. 13.3% p=.407). The ACL reconstructed knee in the ipsilateral group exhibited PF OA in 20.0% and 10.2% in the contralateral group ( p=.057). With regard to moderate or severe PF OA in either knee, the rates were not statistically significant between the ipsilateral and contralateral groups. When comparing the ipsilateral group normal knee to the contralateral group donor knee, the rates of moderate or severe PF OA were 1.1% and 2.0% respectively, which was not statistically significantly different. Conclusions: Previous studies suggest that patella tendon grafts are associated with higher rates of PF OA after ACL reconstruction. Our study reveals that PF OA rates are not statistically increased when a patella tendon graft alone is taken from the knee, when compared to a normal control knee. However, when ACL reconstruction and PT graft are combined in the same knee, there is a statistically significant increase in PF OA versus the uninvolved normal knee, with the ACL reconstructed knee with ipsilateral graft being 2.4 times more likely to experience PF OA than the uninvolved knee. Furthermore, harvesting the ACL graft from the contralateral knee trends toward decreased PF OA rates in the ACL reconstructed knee, though this is not statistically significant. We conclude that the PT graft itself does not increase PF OA rates and that contralateral PT graft harvest may provide advantages to ipsilateral graft harvest with regard to PF OA.

Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellafemoral osteoarthritis Iwano Stages 3-4: a study based on arthroplasty registry data.

To determine whether the preoperative degree of degeneration of the patellofemoral joint really affects the outcome of total knee arthroplasty (TKA) surgery without patella resurfacing and thus to establish a parameter that might serve as a guiding factor to decide whether or not to perform retropatellar resurfacing. It was hypothesized that patients with preoperative mild patellofemoral osteoarthritis (Iwano Stages 0-2) would significantly differ from patients with preoperative severe patellofemoral osteoarthritis (Iwano Stages 3-4) in terms of patient-reported outcome (Hypothesis 1) and revision rates/survival (Hypothesis 2) after TKA without patella resurfacing. Application of a retrospective-comparative design on the basis of Arthroplasty Registry data that included patients with primary TKA without patella resurfacing. Patients were allocated to the following groups based on preoperative radiographic stage of patellofemoral joint degeneration: (a) mild patellofemoral osteoarthritis (Iwano Stage ≤ 2) and (b) severe patellofemoral osteoarthritis (Iwano Stages 3-4). The Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) score was assessed preoperative and 1 year postoperative (0: best, 100 worst). In addition, implant survival was calculated from the Arthroplasty Registry data. In 1209 primary TKA without patella resurfacing, postoperative WOMAC total and WOMAC subscores did not differ significantly between groups, but potentially suffered from type 2 error. Three-year survival was 97.4% and 92.5% in patients with preoperative mild and severe patellofemoral osteoarthritis, respectively (p = 0.002). Five-year survival was 95.8% vs. 91.4% (p = 0.033) and 10-year survival was 93.3% vs. 88.6% (p = 0.033), respectively. From the study findings, it is concluded that patients with preoperative severe patellofemoral osteoarthritis have significantly higher risks for reoperation than do those with preoperative mild patellofemoral osteoarthritis-when treated with TKA without patella resurfacing. Hence, it is recommended that patella resurfacing be applied in patients with severe Iwano Stage 3 or 4 patellofemoral osteoarthritis during TKA. III, Retrospective comparative.

Tibial tubercle-Roman arch (TT-RA) distance is superior to tibial tubercle-trochlear groove (TT-TG) distance when evaluating coronal malalignment in patients with knee osteoarthritis.

To verify tibial tubercle-Roman arch (TT-RA) distance is superior to tibial tubercle-trochlear groove (TT-TG) distance in preoperative assessment of patellofemoral joints in patients with knee osteoarthritis. Patients with knee osteoarthritis from 2016 to 2020 were considered eligible for inclusion in this study. We divided the patients into valgus group and varus group and did 1:1 matching for the two groups. We measured the TT-TG distance, TT-RA distance, patellar height, patella tilt, hip-knee-ankle (HKA) angle, and Iwano's classification of patellofemoral osteoarthritis (PFOA) by computed tomography images or radiographs. The intraclass correlation coefficient (ICC) of each measurement, the correlations and differences among the parameters, and binary logistic regression analysis were conducted. Each group in this study included 75 knees. The inter-observer and intra-observer reliability of the TT-TG distance decreased with the increasing degree of PFOA (ICC < 0.75). The reliability of the TT-RA distance showed excellent agreement in different stages of Iwano's classification. The HKA angle was poorly correlated with the TT-TG distance (r = 0.34, p = 0.003) and the TT-RA distance (r = 0.39, p = 0.001) in valgus knees. As the HKA angle increased by 1 degree, the TT-TG and TT-RA distance increased by nearly 0.45 mm and 0.61 mm, respectively. Valgus malalignment and severe PFOA revealed significant ORs of 3.26 (95% CI [1.06-10.03], p = 0.036) and 3.10 (95% CI [1.01-9.54], p = 0.048) with regard to pathological TT-RA distance, respectively. The TT-RA distance was more reliable than the TT-TG distance in patients with knee osteoarthritis. Valgus malalignment and severe PFOA were risk factors for pathological TT-RA distance. • The TT-RA distance is a reliable and repeatable alternative to the TT-TG distance in evaluating coronal malalignment, especially in patients with severe PFOA. • We validated the significant relationships between TT-TG distance or TT-RA distance and HKA angle in valgus knees, while the correlations among such parameters were not significant in varus knees. • Pathological lateralization of the tibial tubercle was prone to be traced in patients with valgus malalignment or severe PFOA, which could contribute to the patellofemoral malalignment.

Short-term improvement of patellofemoral pain in medial unicompartmental knee arthroplasty with patellar denervation: a prospective comparative study.

Medial osteoarthritis (OA) knees with symptomatic patellofemoral (PF) arthritis were not recommended for UKA in the past. However, UKA has shown good clinical results in patients with medial OA knee with symptomatic PF arthritis. On the contrary, this procedure is not recommended for patients with severe PF OA. Patella denervation (PD) by circumferential electrocautery can reduce the severity and incidence of anterior knee pain in TKA. However, to the best of our knowledge, there are no studies reporting anterior knee pain and complications of medial UKA with PD in severe PF OA. We have conducted a prospective comparative study to assess the short-term results of anterior knee pain and complications after medial UKA with PD or without PD in medial compartment arthritis and severe PF arthritis patients. This prospective comparative study was conducted from January 2018-September 2019 at Pranungkaew Hospital, Nonthaburi, Thailand. A total of 66 patients with medial compartment and severe patellofemoral arthritis were allocated to UKA with or without patella denervation. The primary outcomes were Kujala anterior knee pain scale and complications measured at 6months after the surgery. Sixty-six patients (37 patients undergoing UKA with PD and 27 patients undergoing UKA without PD) of medial compartment and severe lateral facet patellofemoral arthritis (62 female, 4 male; mean age 60.16 (5.03) years; 17 PF grade III, 49 PF grade IV) were included in this study. The mean preoperative Kujala scores were 54.96 (range 30-80) (SD 2.59) in the no-PD group (group I) and 47.77 (range 27-75) (1.62) in the PD group (group II), respectively (p value = 0.009). All baseline characteristics were also comparable between treatment groups except the preoperative Kujala score. The mean final value of Kujala score was 70.22 (range 50-96) (2.40) in the no-PD group (group I) and 80.10 (range 60-95) (SD 1.50) in the PD group (group II), respectively (p value < 0.001). The mean difference of Kujala score was statistically significantly higher by 9.88 (4.48, 15.28) points in the PD group when compared to the no-PD group. There were no complications in both groups after surgery. Patellar denervation seems to provide short-term benefits improving the Kujala score in patients with PF OA undergoing UKA. III. Trial Registration ClinicalTrials.gov: NCT03676179.

Compared outcomes 16 and 25 years after lateral wedge augmentation trochleoplasty: Rate of recurrent dislocation and progression to osteoarthritis

BackgroundLateral wedge augmentation trochleoplasty (LWAT) was the earliest described trochleoplasty technique but was gradually replaced by other methods for the treatment of patello-femoral instability with trochlear dysplasia. Data on the outcomes of this procedure in adults are limited. We therefore performed a retrospective study in patients managed by LWAT to assess (1) clinical (recurrent instability and functional scores), (2) and radiological (patello-femoral osteoarthritis) outcomes. HypothesisLWAT is associated with a low long-term rate of recurrent patello-femoral dislocation and with no risk of progression to severe patello-femoral osteoarthritis. Material and methodsBetween 1988 and 1995, LWAT was performed on 66 knees in 58 patients to treat patello-femoral instability with trochlear dysplasia. Among them, 17 knees in 13 patients were re-evaluated 16 then 25 years after surgery and were included in the study. At both time points, the following were recorded: stability, pain, the Lille patello-femoral function score, and changes in radiographic and computed tomography findings. In addition to LWAT, Insall's realignment vastus medialis advancement was performed in 4 cases, sartorius muscle transposition in 9 cases, and anterior tibial tubercle osteotomy in 10 cases. ResultsNo episodes of patello-femoral dislocation were recorded during the 25-year follow-up. The mean Lille patello-femoral function score (0 worst to 100 highest) was 90±15 (range, 48–99) after 16 years and 86±23 (range, 33–94) after 25 years. After 16 years, 8/17 knees had evidence of patello-femoral osteoarthritis, which was Iwano stage 1 in 7 cases and Iwano stage 2 in 1 case. Patello-femoral osteoarthritis was noted in 12 of 13 knees after 25 years but was mild (Iwano stage 1 or 2) in 8 cases. After 25 years, arthroplasty had been performed for 4 of the 17 knees, with 2 cases each of patello-femoral arthroplasty and total knee arthroplasty. ConclusionLWAT is a reliable procedure that provides sustained protection against patello-femoral dislocation and good functional scores when used to treat patello-femoral instability due to trochlear dysplasia. Our results do not support claims that LWAT may be associated with high rates of severe osteoarthritis even after more than 20 years. Level of evidenceIV, retrospective observational study with no control group.

Effects of arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation in treatment of moderate and severe patellofemoral osteoarthritis

Objective To investigate the clinical effects of arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation for treatment of moderate and severe patellofemoral osteoarthritis. Methods A retrospective case-control study was done on 80 patients with moderate to severe patellofemoral osteoarthritis who were treated in our hospital between March 2013 and March 2015. According to treatment methods, the patients were divided into two groups: Group A including 40 cases (22 cases of Outerbridge grade Ⅲ degree and 18 cases of Outerbridge grade Ⅳ) undergone arthroscopic debridement, and Group B including 40 cases (22 cases of Outerbridge grade Ⅲ degree and 18 cases of Outerbridge grade Ⅳ) undergone arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation. The Kujula scores and Lysholm scores of the patellofemoral joint were compared between the two groups before and after operation. The lateral patellofemoral angle was measured according to patellar axial X-ray performed 3 months after operation to evaluate patellofemoral joint function. Results All patients were followed up for 13-36 months (average 19.8 months). The patellofemoral joint scores of the two groups was increased at different degrees after operation. In moderate patellofemoral osteoarthritis patients, at 3 months after operation and the last follow-up of Group B, Kujula scores [(85.1±6.8)points, (86.8±4.6)points] and Lysholm scores [(88.1±1.8)points, (88.4±2.3)points] were higher than that of Group A [(78.1±5.7)points, (78.3±5.3)points, (82.4±2.9)points, and (82.5±2.5)points] (P 0.05). According to the Lysholm scores, the excellent rate after operation in Group B (86%) was higher than that of Group A (55%) (P 0.05). Within each group, although the Kujula scores and Lysholm scores at 3 months postoperatively and at the last follow-up were improved compared with before operation, but the difference was not statistically significant (P>0.05). According to the Lysholm scores, although the excellent rate after operation of Group B (33%) was higher than that of Group A (28%), with insignificant statistical difference (P>0.05). No matter Outerbridge Ⅲ or Ⅳ patellofemoral osteoarthritis a patient was, the lateral patellofemoral angle of Group A after operation had no significant improvement (P>0.05), while Group B showed significant improvement after operation (P<0.01). Group B had better improvements than that of Group A (P<0.01). Conclusions Compared with simple arthroscopic debridement, patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation can better relieve the symptoms of moderate patellofemoral osteoarthritis and improve knee function. But for patients with severe patellofemoral osteoarthritis, this method is not effective. Key words: Arthritis; Patellofemoral pain syndrome; Arthroscopies

Patellofemoral joint arthroplasty

Isolated patellofemoral osteoarthritis (PFOA) is symptomatic in around 10% of people aged over 55 years. This article presents a review of the treatment of PFOA with isolated patellofemoral arthroplasty (PFA). PFA has evolved in patient selection, surgical technique and implant design since its inception in the 1950s. Despite good clinical outcomes and survivorship being reported in the literature from a number of implants, PFA still remains a controversial subject due to high revision rates reported from large registries such as the National Joint Registry (NJR). Whilst patient selection and intra-operative techniques to optimize extensor mechanism function and avoid dynamic ‘overstuffing’ of the patellofemoral joint are key to the success of PFA, they are often overlooked. More recently, concomitant procedures to address patellar instability, tibiofemoral malalignment and patellofemoral malalignment have been performed to optimize PFA outcomes. With attention to detail in patient selection and surgical technique, using appropriate implants, PFA can lead to improved clinical outcomes and high survivorship for the treatment of isolated severe PFOA.

Patelloplasty without resurfacing of the patella in total knee replacement in patients without severe patellofemoral osteoarthritis

Purpose The aim of this prospective study was to assess the clinical results of nonresurfacing patelloplasty in total knee arthroplasty for osteoarthritis in middle-aged active patients with less erosion of the patellar articular cartilage, based on the hypothesis that patellar denervation provides pain relief and improvement in clinical results. Patients and methods The study was conducted during the period between June 2009 and December 2013 on 59 knees of 55 patients (four bilateral) who met the criteria. The procedure was performed in three hospitals using the same technique. We used the Knee Society Knee Scoring System for overall assessment of patients' knees. For patellofemoral status, we used the Outerbridge Grading System and we used the scale of Stern and Insall to assess anterior knee pain. Results The mean Knee Society Scores for the patients were improved from 15.2 preoperatively to 91.3 at postoperative follow-up. Fifty-one patients could use stairs without symptoms or with mild pain (grades 0 and I), and four patients were unable to use stairs due to severe symptoms (grade II); one of them was able to use stairs after 2 years of follow-up. Conclusion The results of patelloplasty without resurfacing of the patella in selected patients, clinically, radiologically, and intraoperatively are comparable to the results of patellar resurfacing, but with fewer hazards and complications.

Altered gait biomechanics and increased knee-specific impairments in patients with coexisting tibiofemoral and patellofemoral osteoarthritis

Coexisting patellofemoral osteoarthritis (PFOA) is a common finding in patients with tibiofemoral osteoarthritis (TFOA). The purpose of this study was to elucidate whether severity of coexisting PFOA in patients with TFOA is correlated with altered sagittal-plane gait biomechanics and greater knee-specific impairments. One hundred and six patients with radiographic TFOA were stratified into three groups of no PFOA, mild PFOA, and severe PFOA. All patients completed instrumented gait analysis, quantitative quadriceps strength testing and knee range of motion assessment. Compared to patients with no PFOA, those with severe PFOA exhibited reduced loading-response knee flexion excursions (p=0.002) and increased peak single-leg stance external knee flexion moments (p<0.05). The severe PFOA group also demonstrated lower quadriceps strength compared to the no PFOA and mild PFOA groups (p<0.001). Regression analysis further revealed that quadriceps strength and knee extension range of motion were independently associated with altered sagittal-plane knee biomechanics during gait (p<0.03). Reduced loading response knee flexion excursion during gait may be an attempt to decrease patellofemoral joint loading by patients with severe PFOA but it may increase impact loading of their arthritic tibiofemoral joint. Additionally, the greater external knee flexion moments observed during the single-leg stance phase of gait can lead to an overall increase in patellofemoral joint loading and symptoms in patients with more severe PFOA. Given the association between knee-specific impairments and altered gait biomechanics in our study, addressing quadriceps muscle weakness and limited knee extension range of motion may be indicated in patients with TFOA and severe coexisting PFOA.

The middle and long clinical results of patellofemoral arthroplasty for severe patellofemoral osteoarthritis

Objective To evaluate the clinical significance, and middle and long clinical outcomes of patellofemoral arthroplasty for the treatment of severe patellofemoral osteoarthritis. Methods Between January 1991 to July 1999, we studied retrospectively the outcomes of patellofemoral arthroplasty using the prosthesis (type Y-L-Q) designed by us in 39 patients (48 knee joints) with severe patellofemoral os-teoarthritis. There were 6 males (6 knee joints) and 33 females (42 knee joints) with a mean age of 54.4 years (range, 38 to 68 years). The patients were followed up at 3, 6, 12 months and subsequent years (per year) after operation. The evaluate standard was designed by us, which mainly included the symptoms of the patients and the functions of the knee joints. Results All the patients were followed up for average 12.7 years (range, 8 to 16 years). The last follow-up showed the clinical outcomes were: excellent in 29 knees, good in 12, acceptable in 2 and bad in 5. The excellent and good rate was 85.4%.There was no loosening or breakage of the prosthesis and no patellar fracture. 3 patients (5 knee joints) were performed total knee arthroplasty due to the degenerative progression of the knee joints, in which accounted for 10.4%. The mean time interval between the patellofemoral arthroplasty and total knee arthroplasty was 9.3 years (range, 7 to 12 years). Conclusion Patellofemoral arthroplasty with the prosthesis designed by us was a simple and effec-tive method for the severe isolated patellofemoral osteoarthritis. It could not only eliminate the pain of patel-la, but also delay the time of total knee arthroplasty. Key words: Osteoarthritis, knee; Arthroplasty, replacement, knee; Prosthesis design

Impact of patellofemoral osteoarthritis on long-term outcome of high tibial osteotomy and effects of ventralization of tibial tubercle

BackgroundMedial compartment osteoarthritis (OA) of the knee frequently accompanies patellofemoral osteoarthritis (PF-OA). No consensus has been reached whether it is better to include treatment for the PF joint at the time of high tibial osteotomy (HTO), or if treatment of the PF joint is unnecessary. The purpose of this comparative retrospective study on medial compartment OA of the knee accompanying PF-OA was to examine the effects of PF-OA on the long-term outcome of HTO and to evaluate the significance of ventralization of the tibial tubercle when combined with HTO. MethodsWe studied the impact of PF-OA on the long-term outcome of HTO and the effects of ventralization of the tibial tubercle, which was performed in conjunction with HTO for medial and PF compartment OA more than 10 years previously. The 42 subjects included 14 men (15 knees) and 26 women (27 knees). Their mean age at the time of surgery was 60.7 years, and the follow-up period was 10–15 years (average 12 years). Ventralization of the tibial tubercle was performed on 18 knees. ResultsA significant relation was observed between improvement of the clinical knee score and preoperative radiological PF-OA stage in the HTO patients (P < 0.05). Radiologically, no correlation was observed between the shift in radiological PF-OA stage and the presence or absence of ventralization of the tibial tubercle. Among the preoperative radiological moderate and severe PF-OA cases, no significant relation was found between the presence or absence of ventralization of the tibial tubercle performed with HTO and improvement of the knee joint function score. ConclusionIn cases of severe PF-OA in which HTO was performed, ventralization of the tibial tubercle as combined surgery did not prove effective at the long-term follow-up.