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Do Patients Do Better With A Nonresurfaced Patella In Total Knee Arthroplasty Using Selective Resurfacing?Sirmon KC MD, Percle J MS, Melancon C MS, Thompson H PhD, Dasa V MDLSU-New Orleans Orthopaedic Department

Disclosure

I do not have any relationship(s) with commercial interests.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Background• Controversy concerning resurfacing the patella when performing a TKA • Patellofemoral joint was an afterthought in early designs • Improvements in designs have made the choice to resurface much easier• Still heavily debated• Malrotation• Navigation • Patellectomy

Background• The introduction of patellar replacement in 1974 was monumental

but proved to be a challenge

• Fracture, osteonecrosis, aseptic loosening, dislocation, maltracking, overstuffing, catastrophic failure, polyethylene wear, patellar clunk, and disruption of the extensor mechanism

• Clayton ML, Thirupathi R. Patellar complications after total condylar arthroplasty. Clin Orthop. 1982;170:152-5.

• Grace JN, Rand JA. Patellar instability after total knee arthroplasty. Clin Orthop. 1988; 237:184-9.

Background• Anterior knee pain must be adequately assessed before

arthroplasty

• Some of the traditional indications for resurfacing the patella are advanced age, anterior knee pain, patellofemoral radiographic signs of arthritis, inflammatory arthritis, etc.

• The ongoing controversy of whether or not to resurface is one that troubles many orthopaedic surgeons

• Some follow strict guidelines or follow their past experiences in arthroplasty

• Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty 1997

Objective• Our objective was to research patients from a database

who had undergone a total knee arthroplasty with selective resurfacing by one surgeon

• We hypothesized that revision patella resurfacing would be lower than the historical average and patient outcome would be equivalent to those with a resurfaced patella

• Secondary hypothesis was that high BMI negatively correlated with patient outcomes and that insurance status would correlate with outcomes scores

Methods• Between 5/2008 and 12/2012 all patients with primary

osteoarthritis (OA) undergoing a primary total knee arthroplasty (TKA) at a single university-affiliated hospital were considered for inclusion in the study

• The study was approved by the university’s IRB

• Inclusion criteria

• Patients with primary OA

• Patients with prior TKA were excluded from the study

Methods• A total of 97 patients with 117 TKA’s were included in the

study to evaluate retrospective data

• 81 pts (101 TKA’s) elected to participate in a phone interview establishing our outcomes scores

• Patient satisfaction was based on outcomes scores consisting of the Knee and Osteoarthritis Outcome Score (KOOS), the Oxford knee score, and the Anterior Knee Pain Rating

Methods

• The anterior knee pain rating used was previously used by Waters 2003 and consisted of whether anterior knee pain was present, whether it interfered with activity, and whether its severity warranted further surgery

Methods• Of the patients that were called to participate one

elected to not participate and one ended the phone call halfway through the interview

• Several (fourteen) patients were unable to be reached or had a nonworking number

Methods• Hawker, et al.

• To ascertain constant vs intermittent pain using a set of questions administered to 100 pts by phone

• Measure of Intermittent and Constant OA Pain (ICOAP), suitable for use by clinicians to document progression or worsening of pain, response to therapy, and indication for need for referral to surgery for consideration of joint replacement

• WOMAC, HOOS, KOOS used to test reliability of new tool

• Breeman, et al.

• Used telephone questionnaires for some participants to determine outcomes scores

• Hawker, G.A. et al.Development and preliminary psychometric testing of a new OA pain measure e an OARSI/OMERACT initiative. Osteoarthritis and Cartilage (2008) 16, 409e414

• Breeman, S, et al. Patellar Resurfacing in Total Knee Replacement: Five-Year Clinical and Economic Results of a Large Randomized Controlled Trial. J Bone Joint Surg Am. 2011;93:1473-81

Methods• All surgeries were performed by a single surgeon

• The patients all had an arthroplasty performed with a posterior stabilized (PS) knee. The patella was resurfaced if the patient was age 65 years or older and was not resurfaced if age 64 or younger

• All patients underwent the same protocol postoperatively

• All pair-wise comparisons were conducted using alpha level adjusted t tests conducted after an overall analysis of variance

Results

• Average F/U for resurfaced was 15.7 months and for nonresurfaced was 16.4 months

Table 1 Patient

Demographics

Resurfaced: Laterality Gender

Pre-Op Ant Knee Pain

Yes 56 Left 54 Male 34 Yes 46No 45 Right 47 Female 67 No 55

Age BMI Insurance: Average 64.86 Average 33.672 Medicaid 37Range 22-84 Range 20.98-52 Medicare 3

Private 61

Results

• No significant difference was found between the two groups in terms of KOOS, Oxford, and Anterior Knee Pain Rating (AKPR)

• 4 out of 45 (8.88%) patients underwent subsequent patellar resurfacing

• At 11 months, 2 years, 3 months, and a planned resurfacing at the 6 month f/u visit

Table 2 KOOS ADL KOOS Pain KOOS QOL KOOS Sport KOOS Symptoms Oxford AKS

Resurfaced 79.0109 79.2014 63.767 28.75 74.8691 34.4889 0.8889

Non-resurfaced 78.2561 80.0098 66.4897 34.5536 80.1148 34.8571 0.8214

P Value 0.8573 0.8468 0.6425 0.367 0.1404 0.8717 0.7255

Results

• We found that a significant amount of >70 year old patients had better outcomes scores in some categories when compared to younger nonresurfaced and resurfaced patients

Table 3 KOOS ADL KOOS Pain KOOS QOL KOOS SportKOOS

Symptoms Oxford AKS

55-64 (1) NR 74.1434706 75.3516713 59.6145833 28.3333333 75.8321548 32.7500000 1.12500000

65-70 (2) 71.7324343 70.6783950 54.1666667 28.3333333 73.3325397 31.0526316 1.05263158

<=55 (3) NR 76.6902415 79.7225833 60.6250000 28.0000000 74.0711286 33.5000000 0.75000000

>70 (4) 85.6418251 86.7867117 76.6032895 38.1578947 83.1391805 38.3684211 0.63157895

P Value

4 vs 1 0.0312 0.0301 0.0213 0.2400 0.1098 0.0547 0.04744 vs 2 0.0179 0.0057 0.0059 0.2841 0.0513 0.0208 0.1151

4 vs 3 0.1115 0.2022 0.0404 0.2515 0.0617 0.1150 0.6503

3 vs 1 0.6776 0.4681 0.9048 0.9725 0.7384 0.8236 0.1919

3 vs 2 0.4512 0.1634 0.4770 0.9744 0.8961 0.4922 0.3187

2 vs 1 0.7023 0.4514 0.5318 1.0000 0.6454 0.6190 0.8031

Median = 32.4

Results

• Concerning our secondary outcomes, we found that patients with a higher BMI had lower outcomes scores

• In almost all categories the lower BMI’s had a trend towards better outcomes scores

Table 4

BMI KOOS ADL KOOS Pain KOOS QOL KOOS Sport KOOS Symptoms Oxford AKS

<=32.4 81.4586667 82.0572311 71.7730392 31.5686275 81.8766723 36.76470590.705882

35

>32.4 75.6005978 77.2112176 58.5459184 32.4489796 73.5705831 32.58000001.000000

0

p-value 0.1579 0.2410 0.0214 0.8906 0.0177 0.0627 0.1214

Results

• Medicaid patients had lower outcomes scores than privately insured patients

• Private Insurance vs. Medicaid

Table 5 Insurance KOOS ADL KOOS Pain KOOS QOL KOOS Sport KOOS Symptoms Oxford AKSPrivate (1) 82.2269 82.4879 68.2739 36.3571 79.0916 36.5493 0.7606

Medicare (2) 71.8478 74.4052 59.8214 20.7143 80.7149 32 0.9286Medicaid (3) 68.5664 72.0545 57.0313 22.8125 69.6403 28.8125 1.1875

P - Value Comp1vs2 0.2427 0.0809 0.957 0.2748 1 0.4831 11vs3 0.0479 0.0160 0.4873 0.367 0.1596 0.0382 0.32192vs3 1 0.6565 1 1 0.257 1 1

Conclusions• One of very few studies to use the Anterior Knee Pain Rating

• Largest series of medicaid patients concerning resurfacing of patellas in TKA

• Commercial insured patients had better outcomes scores than Medicaid patients

• No significant difference found between the nonresurfaced and resurfaced groups

• >70 year old patients had better outcomes scores compared to both resurfaced and nonresurfaced younger patients

• Patients with higher BMI had lower outcomes scores compared to patients with lower BMI

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