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1 1 Do Patients Do Better With A Nonresurfaced Patella In Total Knee Arthroplasty Using Selective Resurfacing? Sirmon KC MD, Percle J MS, Melancon C MS,

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Presentation on theme: "1 1 Do Patients Do Better With A Nonresurfaced Patella In Total Knee Arthroplasty Using Selective Resurfacing? Sirmon KC MD, Percle J MS, Melancon C MS,"— Presentation transcript:

1 1 1 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

2 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.

3 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

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

5 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

6 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

7 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

8 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

9 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

10 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

11 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:

12 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

13 Results Average F/U for resurfaced was 15.7 months and for nonresurfaced was 16.4 months Table 1Patient Demographics Resurfaced:LateralityGenderPre-Op Ant Knee Pain Yes56Left54Male34Yes46 No45Right47Female67No55 AgeBMIInsurance: Average64.86Average33.672Medicaid37 Range22-84Range Medicare3 Private61

14 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 2KOOS ADLKOOS PainKOOS QOLKOOS SportKOOS SymptomsOxfordAKS Resurfaced Non-resurfaced P Value

15 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 3KOOS ADLKOOS PainKOOS QOLKOOS SportKOOS SymptomsOxfordAKS (1) NR (2) <=55 (3) NR >70 (4) P Value 4 vs vs vs vs vs vs

16 Median = 32.4

17 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 BMIKOOS ADLKOOS PainKOOS QOLKOOS SportKOOS SymptomsOxfordAKS <= > p-value

18 Results Medicaid patients had lower outcomes scores than privately insured patients Private Insurance vs. Medicaid Table 5InsuranceKOOS ADLKOOS PainKOOS QOLKOOS SportKOOS SymptomsOxfordAKS Private (1) Medicare (2) Medicaid (3) P - Value Comp 1vs vs vs

19 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

20 References Bargren JH, Freeman MA, Swanson SA, Todd RC. ICLH (Freeman/Swanson) arthroplasty in the treatment of arthritic knee: a 2 to 4-year review. Clin Orthop. 1976;120:65-75.) Ackroyd CE, Polyzoides AJ. Patellectomy for osteoarthritis. A study of eighty-one patients followed from two to twenty-two years. J Bone Joint Surg Br. 1978;60: Compere CL, Hill JA, Lewinnek GE, Thompson RG. A new method of patellectomy for patellofemoral arthritis. J Bone Joint Surg Am. 1979;61: Clayton ML, Thirupathi R. Patellar complications after total condylar arthroplasty. Clin Orthop. 1982;170: Mochizuki RM, Schurman DJ. Patellar complications following total knee arthroplasty. J Bone Joint Surg Am. 1979;61: Aglietti P, Buzzi R, Gaudenzi A. Patellofemoral functional results and complications with the posterior stabilized total condylar knee prosthesis. J Arthroplasty. 1988;3: Goldberg VM, Figgie HE 3rd, Inglis AE, Figgie MP, Sobel M, Kelly M, Kraay M. Patellar fracture type and prognosis in condylar total knee arthroplasty. Clin Orthop. 1988;236: Grace JN, Rand JA. Patellar instability after total knee arthroplasty. Clin Orthop. 1988; 237: Lombardi AV Jr, Engh GA, Volz RG, Albrigo JL, Brainard BJ. Fracture/dissociation of the polyethylene in metal-backed patellar components in total knee arthroplasty. J Bone Joint Surg Am. 1988;70: Rosenberg AG, Andriacchi TP, Barden R, Gal- ante JO. Patellar component failure in cementless total knee arthroplasty. Clin Orthop. 1988;236: Stulberg SD, Stulberg BN, Hamati Y, Tsao A. Failure mechanisms of metal-backed patellar components. Clin Orthop. 1988;236: Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty. 1987;2: Cameron HU, Fedorkow DM. The patella in total knee arthroplasty. Clin Orthop. 1982; 165: Rand JA. Patellar resurfacing in total knee arthroplasty. Clin Orthop. 1990;260: Levitsky KA, Harris WJ, McManus J, Scott RD. Total knee arthroplasty without patellar resurfacing. Clinical outcomes and long-term follow-up evaluation. Clin Orthop. 1993;286: Stern SH, Insall JN. Total knee arthroplasty in obese patients. J Bone Joint Surg Am. 1990; 72:

21 Windsor RE, Scuderi GR, Insall JN. Patellar fractures in total knee arthroplasty. J Arthroplasty. 1989;4 Suppl:S63-7. Wasilewski SA, Frankl U. Fracture of polyethylene of patellar component in total knee arthroplasty, diagnosed by arthroscopy. J Arthroplasty. 1989;4 Suppl:S Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty. 1997;12: Scott WN, Kim H. Resurfacing the patella offers lower complication and revision rates. Orthopedics. 2001;24:24 Bellamy, N, et al.Osteoarthritis Index delivered by mobile phone (m-WOMAC) is valid, reliable, and responsive.Journal of Clinical Epidemiology 64 (2011) 182e190 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: Barrack, R, et al. Patellar Resurfacing in Total Knee Arthroplasty. J Bone Joint Surg Am. 2001;83: Rosenthal, B, et al. The Effect of Payer Type on Clinical Outcomes in Total Knee Arthroplasty. The Journal of Arthroplasty 29 (2014) 295–298 Han, I, et al. Correlation of the condition of the patellar articular cartilage and patellofemoral symptoms and function in osteoarthritic patients undergoing total knee arthroplasty. J Bone Joint Surg [Br] 2005;87-B: Pavlou, G, et al. Patellar Resurfacing in Total Knee Arthroplasty: Does Design Matter? A Meta-Analysis of 7075 Cases. J Bone Joint Surg Am. 2011;93: Smith, A.J. et al.Total knee replacement with and without patellar resurfacing: A Prospective, Randomised Trial Using The Profix Total Knee System. J Bone Joint Surg [Br] 2008;90-B:43-9. Pakos, E, et al. Patellar Resurfacing in Total Knee Arthroplasty: A Meta-Analysis. J Bone Joint Surg Am. 2005;87: Baker, P, et al. Early PROMs Following Total Knee Arthroplasty—Functional Outcome Dependent on Patella Resurfacing.The Journal of Arthroplasty 29 (2014) 314–319 Wood, D, et al. Patellar Resurfacing in Total Knee Arthroplasty: A Prospective, Randomized Trial. J Bone Joint Surg Am. 2002;84: Waters, T.S. et al. Patellar Resurfacing in Total Knee Arthroplasty: A Prospective, Randomized Study. J Bone Joint Surg Am. 2003;85: Burnett, R.S. et al. Patellar Resurfacing Compared with Nonresurfacing in Total Knee Arthroplasty A Concise Follow-up of a Randomized Trial.J Bone Joint Surg Am. 2009;91: Barrack, R, et al. Resurfacing of the Patella in Total Knee Arthroplasty. J Bone Joint Surg Am. 1997;79:

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