International Orthopaedics

, Volume 43, Issue 10, pp 2293–2301 | Cite as

Clinical and radiologic outcomes of two patellar resection techniques during total knee arthroplasty: a prospective randomized controlled study

  • Fuzhen Yuan
  • Zewen Sun
  • Haijun Wang
  • Yourong Chen
  • Jiakuo YuEmail author
Original Paper



A cutting guide technique for patella resurfacing in total knee arthroplasty was expected to result in less patellofemoral syndromes. The aim of this study was to identify differences in the patellofemoral function, clinical outcomes, and radiographic parameters between the freehand and cutting guide patellar resection techniques in patients undergoing total knee arthroplasty.


A prospective randomized controlled trial was conducted. The study was registered in a public trials registry (International Standard Randomized Trial No. NCT02268097). One-hundred total knee arthroplasties in 100 patients were randomly allocated into one of the two groups, and their results were followed for a mean of 28 months (range, 18 to 38 months) in a double-blind (both patient and evaluator), prospective study. Evaluation was performed by an independent observer using patellofemoral functional capacity, the Knee Society clinical rating system, the Western Ontario and McMaster Universities Osteoarthritis Indices, and radiographic examination.


In total, 14% of the patients were lost to follow-up. There was no difference in the incidence of anterior knee pain between the two groups. No patients received or required revisions. There was a significant difference in the outliers of lateral patellar tilt between the freehand and cutting guide groups (> 10°) (p = 0.036); however, the mean value of lateral patellar tilt did not differ significantly. There were no differences between groups with respect to the 30 seconds stair climbing test, complications, the Knee Society clinical rating system, the Western Ontario and McMaster Universities Osteoarthritis Indices, patient satisfaction, physical examination, hip-knee-ankle angle, lateral patellar displacement, or the Insall-Salvati ratio. Meanwhile, gender, age, weight, height, body mass index, pre-operative Knee Society scores, and pre-operative range of motion were not found to be related to the development of anterior knee pain.


Cutting guide technique group did not yield lower incidence of anterior knee pain. More outliers of lateral patellar tilt were observed in the freehand technique group. Overall, all patients in both groups had identical results in terms of patellofemoral functional capacity, clinical outcomes, and other radiographic results.


Knee Arthroplasty Patella Freehand Cutting guide 



This study was funded by the National Key R&D Program of China (No. 2017YFB1303000).

Compliance with ethical standards

The trial was registered in a public trial registry (International Standard Randomized Trial No. NCT02268097) and was approved by the institutional review board (IRB00006761-2011072). Informed consent was obtained from all enrolled patients.

Conflict of interest

The authors declare that they have no conflicts of interest.

Supplementary material

264_2018_4264_MOESM1_ESM.doc (219 kb)
ESM 1 (DOC 219 kb)
264_2018_4264_MOESM2_ESM.doc (54 kb)
ESM 2 (DOC 53 kb)


  1. 1.
    Ranawat CS, Flynn WJ, Saddler S, Hansraj KK, Maynard MJ (1993) Long-term results of the total condylar knee arthroplasty. A 15-year survivorship study. Clin Orthop Relat Res 94–102Google Scholar
  2. 2.
    Breeman S, Campbell M, Dakin H, Fiddian N, Fitzpatrick R, Grant A, Gray A, Johnston L, Maclennan G, Morris R, Murray D (2011) Patellar resurfacing in total knee replacement: five-year clinical and economic results of a large randomized controlled trial. J Bone Joint Surg Am 93:1473–1481. CrossRefPubMedGoogle Scholar
  3. 3.
    Longo UG, Ciuffreda M, Mannering N, D’Andrea V, Cimmino M, Denaro V (2017) Patellar resurfacing in total knee arthroplasty: systematic review and meta-analysis. J Arthroplast. CrossRefGoogle Scholar
  4. 4.
    Grassi A, Compagnoni R, Ferrua P, Zaffagnini S, Berruto M, Samuelsson K, Svantesson E, Randelli P (2018) Patellar resurfacing versus patellar retention in primary total knee arthroplasty: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc. CrossRefGoogle Scholar
  5. 5.
    Rand JA (1990) Patellar resurfacing in total knee arthroplasty. Clin Orthop Relat Res 110–117CrossRefGoogle Scholar
  6. 6.
    Pagnano MW, Trousdale RT (2000) Asymmetric patella resurfacing in total knee arthroplasty. Am J Knee Surg 13:228–233PubMedGoogle Scholar
  7. 7.
    Fu C, Wai J, Lee E, Myden C, Batuyong E, Hutchison CR, Anglin C (2012) Computer-assisted patellar resection for total knee arthroplasty. Comput Aided Surg 17:21–28. CrossRefPubMedGoogle Scholar
  8. 8.
    Assiotis A, Ng MSS, Mordecai S, Hollingdale J (2015) A novel freehand method for patellar resurfacing in total knee replacement. Acta Orthop Belg 81:340–343PubMedGoogle Scholar
  9. 9.
    Lombardi AJ, Mallory TH, Maitino PD, Herrington SM, Kefauver CA (1998) Freehand resection of the patella in total knee arthroplasty referencing the attachments of the quadriceps tendon and patellar tendon. J Arthroplast 13:788–792CrossRefGoogle Scholar
  10. 10.
    Camp CL, Martin JR, Krych AJ, Taunton MJ, Spencer-Gardner L, Trousdale RT (2015) Resection technique does affect resection symmetry and thickness of the patella during total knee arthroplasty: a prospective randomized trial. J Arthroplast 30:2110–2115. CrossRefGoogle Scholar
  11. 11.
    Anglin C, Fu C, Hodgson AJ, Helmy N, Greidanus NV, Masri BA (2009) Finding and defining the ideal patellar resection plane in total knee arthroplasty. J Biomech 42:2307–2312. CrossRefPubMedGoogle Scholar
  12. 12.
    Camp CL, Bryan AJ, Walker JA, Trousdale RT (2013) Surgical technique for symmetric patellar resurfacing during total knee arthroplasty. J Knee Surg 26:281–284. CrossRefPubMedGoogle Scholar
  13. 13.
    Stryker LS, Odum SM, Springer BD, Fehring TK (2017) Role of patellofemoral offset in total knee arthroplasty: a randomized trial. Orthop Clin North Am 48:1–7. CrossRefPubMedGoogle Scholar
  14. 14.
    Meftah M, Jhurani A, Bhat JA, Ranawat AS, Ranawat CS (2012) The effect of patellar replacement technique on patellofemoral complications and anterior knee pain. J Arthroplast 27:1075–1080. CrossRefGoogle Scholar
  15. 15.
    Barrack RL, Wolfe MW, Waldman DA, Milicic M, Bertot AJ, Myers L (1997) Resurfacing of the patella in total knee arthroplasty. A prospective, randomized, double-blind study. J Bone Joint Surg Am 79:1121–1131CrossRefGoogle Scholar
  16. 16.
    Benjamin J, Chilvers M (2006) Correcting lateral patellar tilt at the time of total knee arthroplasty can result in overuse of lateral release. J Arthroplast 21:121–126. CrossRefGoogle Scholar
  17. 17.
    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 13–14Google Scholar
  18. 18.
    Brosseau L, Balmer S, Tousignant M, O’Sullivan JP, Goudreault C, Goudreault M, Gringras S (2001) Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions. Arch Phys Med Rehabil 82:396–402. CrossRefPubMedGoogle Scholar
  19. 19.
    Barrack RL, Bertot AJ, Wolfe MW, Waldman DA, Milicic M, Myers L (2001) Patellar resurfacing in total knee arthroplasty - a prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am 83A:1376–1381CrossRefGoogle Scholar
  20. 20.
    Burnett RS, Haydon CM, Rorabeck CH, Bourne RB (2004) Patella resurfacing versus nonresurfacing in total knee arthroplasty - results of a randomized controlled clinical trial at a minimum of 10 years’ followup. Clin Orthop Relat Res 12–25. CrossRefGoogle Scholar
  21. 21.
    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  22. 22.
    Heesterbeek PJ, Beumers MP, Jacobs WC, Havinga ME, Wymenga AB (2007) A comparison of reproducibility of measurement techniques for patella position on axial radiographs after total knee arthroplasty. Knee 14:411–416. CrossRefPubMedGoogle Scholar
  23. 23.
    Chonko DJ, Lombardi AJ, Berend KR (2004) Patella baja and total knee arthroplasty (TKA): etiology, diagnosis, and management. Surg Technol Int 12:231–238PubMedGoogle Scholar
  24. 24.
    Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101:101–104. CrossRefPubMedGoogle Scholar
  25. 25.
    Biau D, Mullins MM, Judet T, Piriou P (2006) Mobile versus fixed-bearing total knee arthroplasty: mid-term comparative clinical results of 216 prostheses. Knee Surg Sports Traumatol Arthrosc 14:927–933. CrossRefPubMedGoogle Scholar
  26. 26.
    Saffarini M, Ntagiopoulos PG, Demey G, Le Negaret B, Dejour DH (2014) Evidence of trochlear dysplasia in patellofemoral arthroplasty designs. Knee Surg Sports Traumatol Arthrosc 22:2574–2581. CrossRefPubMedGoogle Scholar
  27. 27.
    Petersen W, Rembitzki IV, Bruggemann GP, Ellermann A, Best R, Koppenburg AG, Liebau C (2014) Anterior knee pain after total knee arthroplasty: a narrative review. Int Orthop 38:319–328. CrossRefPubMedGoogle Scholar
  28. 28.
    van Jonbergen HP, Reuver JM, Mutsaerts EL, Poolman RW (2014) Determinants of anterior knee pain following total knee replacement: a systematic review. Knee Surg Sports Traumatol Arthrosc 22:478–499. CrossRefPubMedGoogle Scholar
  29. 29.
    van Houten AH, Heesterbeek PJ, Wymenga AB (2016) Patella position is not a determinant for anterior knee pain 10 years after balanced gap total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:2656–2662. CrossRefPubMedGoogle Scholar
  30. 30.
    He JY, Jiang LS, Dai LY (2011) Is patellar resurfacing superior than nonresurfacing in total knee arthroplasty? A meta-analysis of randomized trials. Knee 18:137–144. CrossRefPubMedGoogle Scholar
  31. 31.
    Smith AJ, Wood DJ, Li MG (2008) Total knee replacement with and without patellar resurfacing - a prospective, randomised trial using the profix total knee system. J Bone Joint Surg Br 90B:43–49. CrossRefGoogle Scholar
  32. 32.
    Shin YS, Kim HJ, Ko YR, Yoon JR (2016) Minimally invasive navigation-assisted versus conventional total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. CrossRefGoogle Scholar
  33. 33.
    Unwin O, Hassaballa M, Murray J, Harries W, Porteous A (2017) Minimally invasive surgery (MIS) for total knee replacement; medium term results with minimum five year follow-up. Knee 24:454–459. CrossRefPubMedGoogle Scholar
  34. 34.
    Stolarczyk A, Nagraba L, Mitek T, Stolarczyk M, Deszczynski JM, Jakucinski M (2018) Does patient-specific instrumentation improve femoral and tibial component alignment in total knee arthroplasty? A prospective randomized study. Adv Exp Med Biol. Google Scholar
  35. 35.
    Park DY, Ji HM, Kwak KS, Nair SG, Won YY (2012) Three dimensional CT-based virtual patellar resection in female patients undergoing total knee replacement: a comparison between tendon and subchondral method. Clin Orthop Surg 4:193–199. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Fu CK, Wai J, Lee E, Hutchison C, Myden C, Batuyong E, Anglin C (2012) Computer-assisted patellar resection system: development and insights. J Orthop Res 30:535–540. CrossRefPubMedGoogle Scholar
  37. 37.
    Ledger M, Shakespeare D, Scaddan M (2005) Accuracy of patellar resection in total knee replacement. A study using the medial pivot knee. Knee 12:13–19. CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Fuzhen Yuan
    • 1
  • Zewen Sun
    • 1
  • Haijun Wang
    • 1
  • Yourong Chen
    • 1
  • Jiakuo Yu
    • 1
    Email author
  1. 1.Institution of Sports Medicine, Beijing Key Laboratory of Sports InjuriesPeking University Third HospitalBeijingChina

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