In this issue of the journal, the 2 leading papers are related to the patello-femoral joint, not in the sense of patello-femoral pain syndrome in young persons, but patello-femoral replacement [1, 2]. Patello-femoral replacement is undoubtly a very controversial topic and there are still numerous outstanding questions. Both papers state that patello-femoral replacement is controversial and moreover that early designs often were far from successful. The question whether the patella should be resurfaced or not still remains unanswered. Current literature is also often biased and methodologically flawed. There are some strong proponents that claim that patients in whom the patella has been resurfaced have less pain and that there is no need for secondary resurfacing. There are similarly strong opponents that argue implant-related complications and patellar (mal)tracking in resurfaced knees often lead to clinical problems, even in the short-term.

There are not an overwhelming number of comparative studies with proper design, and the clinical results are more or less equivalent. One of the reasons is the “all-or-nothing” approach to patello-femoral resurfacing. To resurface or not might even be claimed to be a lottery. There are strong advocated who “always” resurface and on the other hand those who “never” resurface. As on so many occasions, the truth is probably somewhere in-between. We need to understand the individual requirements of each patient and each knee much better. The major problem is the lack of large studies with good study design and long-term follow-up. Also, what are the most reasonable end points in such studies? And how do we discriminate the patello-femoral pain from the general knee pain in the osteoarthritic knee? Not even the large nation-wide arthroplasty registers have given us the complete answers.

So, is there a light in the tunnel? We know now that first-generation patello-femoral replacements did not work well, mainly due to high failure rates, even in the short- and medium term. Second-generation implants with femoral cuts based on the total knee designs have produced much more promising results. Those results are still only medium-term and long-term results with the second-generation implants are still pending. Many of the current problems are related to progress of the general arthritis in the entire knee and less due to complications such as implant wear and loosening. This might be compared to the general problems of TKAs in terms of polyethylene implant wear and consequently loosening of the implant. Custom-made implants and computer navigated surgery also appear to be promising when patello-femoral implants are planned.

As stated in the above-mentioned papers, the future for patello-femoral replacement surgery seems to be bright with new implants, custom guides and surgical navigation. However, larger studies with longer follow-up are needed before all questions can be properly answered. “Selective resurfacing” is most probably the best answer we have today. Time will show.