Recovery after Total Knee Arthroplasty: Does one or two knees matter?

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Abstract

Conflict of interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 3. Orthop Traumatol Surg Res. 2019 Feb;105(1S):S43-S51. doi: 10.1016/j.otsr.2018.04.028. Epub 2018 Jul 7. Patellar complications after total knee arthroplasty. Putman S(1), Boureau F(2), Girard J(2), Migaud H(2), Pasquier G(2). Author information: (1)Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France. Electronic address: sophie.putman@chru-lille.fr. (2)Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France. Patellar complications are a source of poor total knee arthroplasty (TKA) outcomes that can require re-operation or prosthetic revision. Complications can occur with or without patellar resurfacing. The objective of this work is to answer six questions. (1) Have risk factors been identified, and can they help to prevent patellar complications? Patellar complications are associated with valgus, obesity, lateral retinacular release, and a thin patella. Selecting a prosthetic trochlea that will ensure proper patellar tracking is important. Resurfacing is an option if patellar thickness is greater than 12mm. (2) What is the best management of patellar fracture? The answer depends on two factors: (a) is the extensor apparatus disrupted? and (b) is the patellar implant loose? When either factor is present, revision surgery is needed (extensor apparatus reconstruction, prosthetic implant removal). When neither factor is present, non-operative treatment is the rule. (3) What is the best management of patellar instability? Rotational malalignment should be sought. In the event of femoral and/or tibial rotational malalignment, revision surgery should be considered. If not performed, options consist of medial patello-femoral ligament reconstruction and/or medialization tibial tuberosity osteotomy. (4) What is the best management of patellar clunk syndrome? When physiotherapy fails, arthroscopic resection can be considered. Recurrence can be treated by open resection, despite the higher risk of complications with this method. (5) What is the best management of anterior knee pain? The patient should be evaluated for causes amenable to treatment (fracture, instability, clunk, osteonecrosis, bony impingement on the prosthetic trochlea). If patellar resurfacing was performed, loosening should be considered. Otherwise, secondary resurfacing is appropriate only after convincingly ruling out other causes of pain. A painstaking evaluation is mandatory before repeat surgery for anterior knee pain: surgery is not in order in the 10% to 15% of cases that have no identifiable explanation. (6) What can be done to treat patellar defects? Available options include re-implantation (with bone grafting, cement, a biconvex implant, or a metallic frame), bone grafting without re-implantation, patellar reconstruction, patellectomy (best avoided due to the resulting loss of strength), osteotomy, and extensor apparatus allograft reconstruction. LEVEL OF EVIDENCE: V, expert opinion. Copyright © 2018 Elsevier Masson SAS. All rights reserved. DOI: 10.1016/j.otsr.2018.04.028