Skip to main content
SpringerLink
Log in

Patellar component size effects patellar tilt in total knee arthroplasty with patellar resurfacing

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Patellar component positioning and patellofemoral kinematics are of great importance in total knee arthroplasty (TKA). The factors influencing patellar tilt are femoral rotation and lateral patellar release. However, the effect of patellar component size remains unknown. The aim of this study was to evaluate the intra-operative risk factors for patellar tilt, particularly the effect of the patellar component size. The hypothesis was that increasing the patellar component size would reduce the risk of patellar tilt.

Methods

878 primary TKAs with patellar resurfacing were included between January 2015 and October 2018. Analysis was performed at 1-year postoperatively on patients categorized into two groups: patellar tilt (PT) and no patellar tilt (NPT). A multivariate analysis was performed for the effect of patellar component size, femoral rotation, femoral overbuilding, patellar thickness and lateral release on patellar tilt risk. Secondary analysis was performed for any difference in clinical outcomes and revision rates between groups.

Results

Multivariate analysis showed that increasing the patellar component size decreased the risk of patellar tilt by 37% (p < 0.001). Placing the femoral component at 3° of external rotation decreased the risk of patellar tilt by 67% (p < 0.001). Secondary analysis showed better clinical outcomes in the NPT group, especially regarding global satisfaction, and KSS objective and subjective scores. The revision for any cause was less in the NPT group (p = 0.019). The cause for TKA revision was related to the patellar in 11% of cases in the NPT group and 65% in the PT group (p < 0.001).

Conclusion

Increased patellar component size and positioning the femoral component in external rotation decreases the risk of patellar tilt, improves clinical outcomes and decreases the rate of surgical revision.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

BMI:

Body mass index

HKA:

Hip knee ankle

KSS:

Knee society score

MPFL:

Medial patello-femoral ligament

NPT:

No patellar tilt group

OA:

Osteoarthritis

PE:

Poly-ethylene

PT:

Patellar tilt group

TKA:

Total knee arthroplasty

UKA:

Unicompartimental knee arthroplasty

References

  1. Adravanti P, Tecame A, de Girolamo L, Ampollini A, Papalia R (2018) Patella resurfacing in total knee arthroplasty: a series of 1280 patients at midterm follow-up. J Arthroplasty 33:696–699

    Article  Google Scholar 

  2. Agarwala S, Shetty V, Karumuri LK, Vijayvargiya M (2018) Patellar resurfacing versus nonresurfacing with patellaplasty in total knee arthroplasty. Indian J Orthop 52:393–398

    Article  Google Scholar 

  3. Allen W, Eichinger J, Friedman R (2019) Resurfaced versus non-resurfaced patella in total knee arthroplasty. J Knee Surg 32:611–615

    Article  Google Scholar 

  4. Atzori F, Sabatini L, Deledda D, Schiro M, Lo Baido R, Masse A (2015) Evaluation of anterior knee pain in a PS total knee arthroplasty: the role of patella-friendly femoral component and patellar size. Musculoskelet Surg 99:75–83

    Article  CAS  Google Scholar 

  5. Baldini A, Anderson JA, Cerulli-Mariani P, Kalyvas J, Pavlov H, Sculco TP (2007) Patellofemoral evaluation after total knee arthroplasty. Validation of a new weight-bearing axial radiographic view. J Bone Jt Surg Am 89:1810–1817

    Article  Google Scholar 

  6. Benjamin J, Chilvers M (2006) Correcting lateral patellar tilt at the time of total knee arthroplasty can result in overuse of lateral release. J Arthroplasty 21:121–126

    Article  Google Scholar 

  7. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS (1993) Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 286:40–47

    Google Scholar 

  8. Blackburne JS, Peel TE (1977) A new method of measuring patellar height. J Bone Jt Surg Br 59:241–242

    Article  CAS  Google Scholar 

  9. Chia SL, Merican AM, Devadasan B, Strachan RK, Amis AA (2009) Radiographic features predictive of patellar maltracking during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 17:1217–1224

    Article  Google Scholar 

  10. Cho WJ, Bin SI, Kim JM, Lee BS, Sohn DW, Kwon YH (2018) Total knee arthroplasty with patellar retention: the severity of patellofemoral osteoarthritis did not affect the clinical and radiographic outcomes. J Arthroplasty 33:2136–2140

    Article  Google Scholar 

  11. Classen T, Wegner A, Muller RD, Von Knoch M (2010) Femoral component rotation and Laurin angle after total knee arthroplasty. Acta Orthop Belg 76:69–73

    PubMed  Google Scholar 

  12. Dejour D, Ntagiopoulos PG, Saffarini M (2014) Evidence of trochlear dysplasia in femoral component designs. Knee Surg Sports Traumatol Arthrosc 22:2599–2607

    Article  Google Scholar 

  13. Dhollander AA, Bassens D, Victor J, Verdonk P (2013) Patellar tilt and thickness do not influence postoperative flexion in a high-flex design total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2817–2822

    Article  Google Scholar 

  14. Dong Y, Li T, Zheng Z, Xiang S, Weng X (2018) Adding patella resurfacing after circumpatellar electrocautery did not improve the clinical outcome in bilateral total knee arthroplasty in Chinese population: a prospective randomized study. J Arthroplasty 33:1057–1061

    Article  Google Scholar 

  15. Eshnazarov KE, Seon JK, Song EK (2016) Comparison of radiological assessments patellar resurfacing with retention for grade IV osteoarthritis in patellofemoral joint accomplished total knee arthroplasty. Vestn Rentgenol Radiol 97:28–32

    Article  CAS  Google Scholar 

  16. Gharaibeh MA, Monk E, Chen DB, MacDessi SJ (2018) Evaluation of the patellofemoral joint in total knee arthroplasty: validation of the weight bearing merchant radiographic view. Knee 25:1262–1271

    Article  Google Scholar 

  17. Gomes LS, Bechtold JE, Gustilo RB (1988) Patellar prosthesis positioning in total knee arthroplasty. A roentgenographic study. Clin Orthop Relat Res 236:72–81

    Google Scholar 

  18. Iwano T, Kurosawa H, Tokuyama H, Hoshikawa Y (1990) Roentgenographic and clinical findings of patellofemoral osteoarthrosis. With special reference to its relationship to femorotibial osteoarthrosis and etiologic factors. Clin Orthop Relat Res 252:190–197

    Google Scholar 

  19. Kaper BP, Woolfrey M, Bourne RB (2000) The effect of built-in external femoral rotation on patellofemoral tracking in the genesis II total knee arthroplasty. J Arthroplasty 15:964–969

    Article  CAS  Google Scholar 

  20. Kawano T, Miura H, Nagamine R, Urabe K, Matsuda S, Mawatari T et al (2002) Factors affecting patellar tracking after total knee arthroplasty. J Arthroplasty 17:942–947

    Article  Google Scholar 

  21. Keshmiri A, Maderbacher G, Baier C, Benditz A, Grifka J, Greimel F (2019) Kinematic alignment in total knee arthroplasty leads to a better restoration of patellar kinematics compared to mechanic alignment. Knee Surg Sports Traumatol Arthrosc 27:1529–1534

    Article  Google Scholar 

  22. Kim JH, Yoo BW, Kim CW (2015) Influence of the rotational alignment of the femoral and patellar components on patellar tilt in total knee arthroplasty. Knee Surg Relat Res 27:163–167

    Article  Google Scholar 

  23. Koh IJ, Kim MS, Sohn S, Song KY, Choi NY, In Y (2019) Patients undergoing total knee arthroplasty using a contemporary patella-friendly implant are unaware of any differences due to patellar resurfacing. Knee Surg Sports Traumatol Arthrosc 27:1156–1164

    Article  Google Scholar 

  24. Lee RH, Jeong HW, Lee JK, Choi CH (2017) Should the position of the patellar component replicate the vertical median ridge of the native patella? Knee 24:82–90

    Article  Google Scholar 

  25. Leichtle UG, Lange B, Herzog Y, Schnauffer P, Leichtle CI, Wulker N et al (2017) Influence of different patellofemoral design variations based on Genesis II total knee endoprosthesis on patellofemoral pressure and kinematics. Appl Bionics Biomech 2017:5492383

    Article  Google Scholar 

  26. Longo UG, Ciuffreda M, Mannering N, D'Andrea V, Cimmino M, Denaro V (2018) Patellar resurfacing in total knee arthroplasty: systematic review and meta-analysis. J Arthroplasty 33:620–632

    Article  Google Scholar 

  27. Matz J, Howard JL, Morden DJ, MacDonald SJ, Teeter MG, Lanting BA (2017) Do changes in patellofemoral joint offset lead to adverse outcomes in total knee arthroplasty with patellar resurfacing? A radiographic review. J Arthroplasty 32:783–787 (e781)

    Article  Google Scholar 

  28. Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone Jt Surg Am 56:1391–1396

    Article  CAS  Google Scholar 

  29. Merican AM, Ghosh KM, Baena FR, Deehan DJ, Amis AA (2014) Patellar thickness and lateral retinacular release affects patellofemoral kinematics in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:526–533

    Article  Google Scholar 

  30. Pietrzak J, Common H, Migaud H, Pasquier G, Girard J, Putman S (2019) Have the frequency of and reasons for revision total knee arthroplasty changed since 2000? Comparison of two cohorts from the same hospital: 255 cases (2013–2016) and 68 cases (1991–1998). Orthop Traumatol Surg Res 105:639–645

    Article  Google Scholar 

  31. Rajkumar N, Soundarrajan D, Dhanasekararaja P, Rajasekaran S (2019) Preoperative radiological parameters predicting the need for lateral retinacular release in total knee arthroplasty. J Arthroplasty 34:2925–2930

    Article  Google Scholar 

  32. Rassir R, van de Bunt F, Sierevelt IN, Nolte PA (2019) The value of postoperative prosthesis alignment and patellar height measurements on standard X-rays after total knee arthroplasty: does it relate to knee function after 5years? Knee 26:213–221

    Article  Google Scholar 

  33. Scuderi G, Scharf SC, Meltzer LP, Scott WN (1987) The relationship of lateral releases to patella viability in total knee arthroplasty. J Arthroplasty 2:209–214

    Article  CAS  Google Scholar 

  34. Shield WP 3rd, Greenwell PH, Chapman DM, Dalury DF (2019) Ignore the patella in revision total knee surgery: a minimum 5-year follow-up with patella component retention. J Arthroplasty 34:S262–S265

    Article  Google Scholar 

  35. 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

    Article  Google Scholar 

  36. Webb JE, Yang HY, Collins JE, Losina E, Thornhill TS, Katz JN (2017) The evolution of implant design decreases the incidence of lateral release in primary total knee arthroplasty. J Arthroplasty 32:1505–1509

    Article  Google Scholar 

  37. Weeks CA, Marsh JD, MacDonald SJ, Graves S, Vasarhelyi EM (2018) Patellar resurfacing in total knee arthroplasty: a cost-effectiveness analysis. J Arthroplasty 33:3412–3415

    Article  Google Scholar 

  38. Werth L, Saffarini M, Amsler F, Abdelkafy A, Hirschmann MT (2017) The need for secondary resurfacing is affected by trochlear height in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25:3818–3823

    Article  Google Scholar 

  39. Youm YS, Cho WS, Woo JH, Kim BK (2010) The effect of patellar thickness changes on patellar tilt in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 18:923–927

    Article  Google Scholar 

Download references

Acknowledgement

We thank Mr Philippe Wagner, for his assistance with statistical analysis of our data.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon North University Hospital, Hospices Civils de Lyon, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France

    Léopold Joseph, Cécile Batailler, Julien Roger, John Swan, Elvire Servien & Sébastien Lustig

Authors
  1. Léopold Joseph
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cécile Batailler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Julien Roger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. John Swan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Elvire Servien
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sébastien Lustig
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LJ: study design, data collection, statistical analysis, literature review and manuscript writing. CB, JR, JS: study design, literature review and manuscript editing. ES: study design and manuscript editing. SL: study design, supervision, literature review and manuscript editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cécile Batailler.

Ethics declarations

Conflict of interest

LJ, CB, JR and JS declare that they have no conflict of interest. ES: consultant for Corin. SL: consultant for Smith & Nephew, institutional research support to Corin and Amplitude.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patients were managed, operated and reviewed routinely as all TKA in our institution. Approval to collect the data both retrospectively and prospectively for the study was granted by The Advisory Committee on Research Information Processing in the Field of Health (CCTIRS) approved this study on June 4, 2015 under number 135-5265.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Joseph, L., Batailler, C., Roger, J. et al. Patellar component size effects patellar tilt in total knee arthroplasty with patellar resurfacing. Knee Surg Sports Traumatol Arthrosc 29, 553–562 (2021). https://doi.org/10.1007/s00167-020-05984-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-05984-9

Keywords

Search

Navigation