This week’s Orthopaedic Crossfire® debate was part of the 33rd Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “Patella Resurfacing: Rarely, if Ever, Necessary.” For is Robert L. Barrack, M.D., Washington University School of Medicine, St. Louis, Missouri. Opposing is Steven B. Haas, M.D., Hospital for Special Surgery, New York, New York. Moderating is Thomas P. Sculco, M.D., Hospital for Special Surgery, New York, New York.
Dr. Barrack: For my first 10 years I resurfaced the patella almost always. Now I hardly ever do, and that was after I did a series of randomized trials that told me that there was very little, if any, advantage to doing it.
So, the data is really confusing, varied and contradictory.
Most studies show that the results are equivalent. At least as many studies indicate that routine resurfacing may have some advantages.
But the individual studies are underpowered, and the sample sizes are too small. I’m sure what you’re going to hear from Dr. Haas is about meta-analyses and registries. But if you look at all these meta-analyses what they would tell you is the reoperation rate is higher when you don’t resurface the patella.
The problem with the pooled literature is that many of these reviews include 30-year-old data which is really outdated. If we look at the registry data, you find the same thing.
The other problem is that patella resurfacing complications are vastly underreported. Usually there is not a good operation for the problems that you create. Those problems can be pretty significant and are more common than you think.
Pooled data can be misleading because the type of components used in surgery can dramatically impact the results. The best performing knee in the Swedish Registry only worked when you didn’t resurface the patella.
One of the major manufacturers actually promoted this knee. Said it was the best performer, but only when the patella was not resurfaced. The same implant, when resurfaced, did worse than average.
The Swedes don’t pay attention to this. They rarely resurface the patella in spite of the fact that they report it is more common to have to be revised. If the incidence of reoperation is higher in registries and meta-analyses, then why not just resurface the patella routinely?
The problem is that it’s not a benign or simple procedure.
Over resection, under resection, oblique resection, are all problems and AVN [avascular necrosis] is an occasional problem. And these all lead to negative sequalae.
How often do these occur?
Berend et al.’s (CORR, 2001) report from years ago showed in only 2.6 years that a lot of patellas were starting to fragment. While relatively few were revised, that was at 5 years. What’s going to happen at 10 years and 15 years?
In conclusion, patella resurfacing remains a debated topic.
Excellent results can be obtained with either approach.
Patella resurfacing is common in the U.S. It’s standard practice in some communities, but in the St. Louis area where Leo Whiteside practices, it’s really not done to a great extent.
I have never seen one of Leo’s patients need to come to me for a subsequent resurfacing. I would tell patients, “You might need a second operation, but it’s more than offset by the risk of complications of routinely resurfacing.”
I think the results are similar and surgical technique is important, but ultimately, it’s not whether or not you resurface the patella…I agree with Adolph Lombardi. I think five years from now we’re going to be doing mostly uncemented components without patella resurfacing.
