1,594

Everting of Retracting Patella during Total Knee Replacement?

E Carlos Rodriguez-Merchan

E. Carlos Rodriguez-Merchan, Department of Orthopaedic Surgery, “La Paz” University Hospital, Madrid, Spain
E. Carlos Rodriguez-Merchan, Department of Orthopaedic Surgery, School of Medicine, “Autonoma” University, Madrid, Spain

Correspondence to: E. Carlos Rodriguez-Merchan, MD, PhD, Department of Orthopaedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046-Madrid, Spain.
Email: ecrmerchan@gmx.es
Telephone: +34-91-606712724
Received: May 21, 2014
Revised: July 4, 2014
Accepted: July 9, 2014
Published online: August 23, 2014

ABSTRACT

Background: Patellar retraction versus patellar eversion during total knee replacement (TKR) is a current controversial issue in the literature regarding postoperative pain, recovery of quadriceps function, component position, complications and differences in outcomes.

Question: Is there any difference between retracting and everting the patella during TKR regarding the aforementioned parameters?

Methods: A PubMed and Cochrane Library search was performed on 28 February 2014 using “eversion of patella” as keywords. Only nine prospective randomized studies focused on the question of this article were found.

Results: Six papers analyzed postoperative pain; three of them did not find differences while three found differences in favor of retracting patella. Two papers studied recovery of quadriceps function. One of them found no difference while the other encountered better return of quadriceps function after patella retraction. Five papers analyzed component positioning. Four found no differences, while one encountered a higher rate of malposition in patellar retraction. Five articles studied complications resulting from either technique. Three of them encountered no differences. One found 2/60 intraoperative complications in patellar eversion, while the other found 2/50 cases of delayed wound healing in patellar retraction. Seven papers analyzed the short-term and long-term results. Two of them found no differences, but the other five encountered better ROM in patellar retraction.

Conclusions: Retracting patella seems to be associated with better ROM, although no differences in component malposition between patellar eversion and patellar retraction have been found. Contradictory results have been encountered regarding postoperative knee pain, complications, and recovery of quadriceps power.

© 2014 The Authors. Published by ACT Publishing Group Ltd.

Key Words: TKR; Patella; Eversion; Retraction; Pain; Quadriceps function; Component position; Complications; Outcomes; Comparison

Rodriguez-Merchan EC. Everting of Retracting Patella during Total Knee Replacement? International Journal of Orthopaedics 2014; 1(2): 38-40 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/825

Introduction

Patellar retraction (lateral subluxation) versus patellar eversion during total knee replacement (TKR) is a current controversial issue in the literature regarding postoperative pain, recovery of quadriceps function, component position, complications resulting from either technique, and differences in short-term and long-term outcomes[1-9]. That is why the author considers that this is an important and relevant topic that could be of interest for the orthopaedic community.

The purpose of this article is to answer the following question: Is there any objective difference between everting and retracting patella during TKR regarding postoperative pain, recovery of quadriceps function, component position, complications resulting from either technique, and differences in short-term and long-term outcomes?

METHODS

A PubMed search was performed on 28 February 2014. Using “eversion of patella” as keywords fifty-one articles were found, but only twenty-eight of them were focused on the question of this article[1-28]. Nine of them were prospective randomized studies with high grade of evidence[1-9]. In fact, seven of them have been included in the Cochrane Library. The findings of nine randomized articles published so far on the topic have been considered for this report. Our aim has been to answer this question: Is there any difference between everting and retracting patella during TKR regarding postoperative pain, recovery of quadriceps function, component position, complications resulting from either technique, and differences in short-term and long-term outcomes?

RESULTS

Five parameters have been studied in this review: postoperative pain, recovery of quadriceps function, component position, complications resulting from either technique and differences in short-term and long-term outcomes (Table 1).

Six papers analyzed postoperative pain[2-7]. Three of them encountered no differences between patellar retraction and patellar eversion[4,5,7]. In one paper patellar retraction yielded better pain score on day one[2]. In another article less pain was found at 6 weeks postoperatively in patellar retraction[3]. Better pain scores were encountered in the first two postoperative weeks in another study after patellar retraction[6].

Recovery of quadriceps function was better in one report[8], but no differences were found in another one[7].

No differences were encountered in component positioning in four papers[2,3,6,9], but one article showed a higher rate of malposition in patellar retraction[5].

Three papers found no differences regarding complications resulting from either technique[5,7,9]. However, in one report there were 2 intraoperative complications in the eversion patella group[2] while in another one there were 2 cases of delayed wound healing in the retraction patella group[3].

Five articles showed better ROM in the 2 first postoperative weeks[6]; at 6 weeks postoperatively[3]; at 1 month, 2 months and 3 months[2]; at 3 months[9]; and at 1 year[1]. However, 2 articles found no differences at 6 weeks, 3 months, 6 months and 1 year[7]; and at 3 months and 1 year[5].

Conclusion

In this review we have tried to find potential differences between everting or retracting the patella during TKR regarding five parameters, on the basis of the results of prospective randomized reports[1-9].

The five parameters analyzed in this review have been the following: postoperative pain, recovery of quadriceps function, component position, complications resulting from either technique, and differences in short-term and long-term outcomes.

Although ROM has been better after patellar retraction in five articles[1-3,6,9] two papers found no differences between patellar retraction and patellar eversion[5,7]. Thus, we could assume that ROM appears to be better after patella retraction because the majority of authors favor patella retraction.

No differences have been found in component positioning in four papers[2,3,6,9], although one the articles encountered fewer ourliers after patella retraction[6]. Only one paper found a higher rate of malposition after patellar retraction[5].

The review of the literature found contradictory results regarding postoperative pain[2-7], recovery of quadriceps function[7,8], and complications[2,3,5,7,9]. These unsolved questions require further well-designed prospective randomized studies focused on the controversial topics.

In conclusion, most authors found that retracting patella is associated with better ROM. Most authors encountered no differences in component malposition. However, contradictory results have been found regarding postoperative knee pain, complications, and recovery of quadriceps power. These are controversial issues that require further research. Long-term results are still missing.

CONFLICT OF INTEREST

There are no conflicts of interest with regard to the present study.

REFERENCES

1 Arnout N, Victor J, Cleppe H, Soenen M, Van Damme G, Bellemans J. Avoidance of patellar eversion improves range of motion after total knee replacement: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2009; 17: 1206-10

2 Boerger TO, Aglietti P, Mondanelli N, Sensi L. Mini-subvastus versus medial parapatellar approach in total knee arthroplasty. Clin Orthop Relat Res 2005; 440: 82-7

3 Dalury DF, Mulliken BD, Adams MJ, Lewis C, Sauder RR, Bushey JA. Early recovery after total knee arthroplasty performed with and without patellar eversion and tibial translation. A prospective randomized study. J Bone Joint Surg Am 2009; 91: 1339-43

4 Pongcharoen B, Yakampor T, Charoencholvanish K. Patellar tracking and anterior knee pain are similar after medial parapatellar and midvastus approaches in minimally invasive TKA. Clin Orthop Relat Res 2013; 471: 1654-60

5 Reid MJ, Booth G, Khan RJ, Janes G. Patellar eversion during total knee replacement: a prospective, randomized trial. J Bone Joint Surg Am 2014; 96: 207-13

6 Seon JK, Song EK. Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial. J Arthroplasty. 2006; 21: 777-82

7 Umrani SP, Cho KY, Kim KI. Patellar eversion does not adversely affect quadriceps recovery following total knee arthroplasty. J Arthroplasty 2013; 28: 591-4

8 Walter F, Haynes MB, Markel DC. A randomized prospective study evaluating the effect of patellar eversion on the early functional outcomes in primary total knee arthroplasty. J Arthroplasty 2007; 22: 509-14

9 Wohlrab D, Zeh A, Mendel T, Hein W. Quadsparing approach in total knee arthroplasty (Article in German). Oper Orthop Traumatol. 2009;21:25-34.

10 Bonutti PM, Mont MA, Kester MA. Minimally invasive total knee arthroplasty: a 10-feature evolutionary approach. Orthop Clin North Am 2004; 35: 217-26

11 Bonutti PM, Mont MA, McMahon M, Ragland PS, Kester M. Minimally invasive total knee arthroplasty. J Bone Joint Surg Am 2004;86-A Suppl 2: 26-32

12 Bonutti PM, Seyler TM, Kester M, McMahon M, Mont MA. Minimally invasive revision total knee arthroplasty. Clin Orthop Relat Res 2006; 446: 69-75

13 Crottet D, Kowal J, Sarfert SA, Maeder T, Bleuler H, Nolte LP, Dürselen L. Ligament balancing in TKA: evaluation of a force-sensing device and the influence of patellar eversion and ligament release. J Biomech 2007; 40: 1709-15

14 Flören M, Davis J, Peterson MG, Laskin RS. A mini-midvastus capsular approach with patellar displacement decreases the prevalence of patella baja. J Arthroplasty 2007; 22(6 Suppl 2): 51-7

15 Flören M, Reichel H, Davis J, Laskin RS. The mini-incision mid-vastus approach for total knee arthroplasty. Oper Orthop Traumatol 2008; 20: 534-43

16 Haas SB, Cook S, Beksac B. Minimally invasive total knee replacement through a mini midvastus approach: a comparative study. Clin Orthop Relat Res 2004; 428: 68-73

17 Halder A, Beier A, Neumann W. Mini-subvastus approach for total knee replacement (Article in German). Oper Orthop Traumatol 2009; 21: 14-24

18 Hasegawa M, Kawamura G, Wakabayashi H, Sudo A, Uchida A. Changes to patellar blood flow after minimally invasive total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2009; 17: 1195-8

19 Kamei G, Murakami Y, Kazusa H, Hachisuka S, Inoue H, Nobutou H, Nishida K, Mochizuki Y, Ochi M. Is patella eversion during total knee arthroplasty crucial for gap adjustment and soft-tissue balancing? Orthop Traumatol Surg Res 2011; 97: 287-91

20 Laskin RS. Surgical exposure for total knee arthroplasty: for everything there is a season. J Arthroplasty 2007; 22(4 Suppl 1): 12-4

21 Luring C, Hüfner T, Kendoff D, Perlick L, Bäthis H, Grifka J, Krettek C. Eversion or subluxation of patella in soft tissue balancing of total knee arthroplasty? Results of a cadaver experiment. Knee 2006; 13: 15-8

22 Mont MA, Zywiel MG, McGrath MS, Bonutti PM. Scientific evidence for minimally invasive total knee arthroplasty. Instr Course Lect 2010; 59: 73-82

23 Pagnano MW, Meneghini RM. Minimally invasive total knee arthroplasty with an optimized subvastus approach. J Arthroplasty 2006; 21(4 Suppl 1): 22-6

24 Ryan JA, Meyers KN, Dibenedetto P, Wright TM, Haas SB. Failure of the patellar tendon with the patella everted versus noneverted in a matched-pair cadaver model. HSS J 2010; 6: 134-7

25 Schroer WC, Diesfeld PJ, Reedy ME, LeMarr AR. Mini-subvastus approach for total knee arthroplasty. J Arthroplasty 2008; 23: 19-25

26 Sharma V, Tsailas PG, Maheshwari AV, Ranawat AS, Ranawat CS. Does patellar eversion in total knee arthroplasty cause patella baja? Clin Orthop Relat Res 2008; 466: 2763-8

27 Sosna A, Pokorný D. On the “subvastus” approach in surgery of the knee joint (Article in Czech). Acta Chir Orthop Traumatol Cech 1997; 64: 15-20

28 Stoffel KK, Flivik G, Yates PJ, Nicholls RL. Intraosseous blood flow of the everted or laterally-retracted patella during total knee arthroplasty. Knee 2007; 14: 434-8

Peer reviewer: Peter Schandelmaier, Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, DONAUISAR Klinikum Deggendorf, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover, Perlasbergerstr. 41, 94469 Deggendorf, Germany.

Refbacks

  • There are currently no refbacks.


Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.