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PEARLS & PITFALLS – SURGICAL TECHNIQUE

In 2012, Pilling et al. in a meta-analysis published in JBJS For surgeons who do not perform patellar resurfacing, some

Am, while analyzing randomized and controlled trials, found authors present the possibility of decreasing the incidence
similar results in anterior knee pain and satisfaction, however, of anterior knee pain with the patellar denervation procedure,

resurfacing patients underwent fewer additional procedures. which has been performed by many surgeons all over the
The possibility of being subjected to new surgical procedure world, including surgeons in Brazil. The thermo-coagulation
due to previous knee pain was 1% if the patella was around the patella margin with electro-cautery was first

resurfaced compared with 6% if it had not been subjected written by Keblish in 1991. In the Netherlands, 56% of the
to the procedure. This difference probably occurred due to surgeons defend the procedure (Van Jorbergen et al. 2010).

the likely temptation to attribute anterior knee pain to not The term used is itself considered controversial, due to
resurfacing the patella.
the anatomy of the innervation of the patella. It is innerved
by multiple superficial sensory nerves, and the presence
In general, Total Knee Arthropathy, when it comes to function
and longevity, has been investigated for years, demonstrating of Substance-P fibers, Ruffini and Pacini Corpuscles were
documented. However, there is no evidence of their exact
a rate of 15-20% of dissatisfaction with the function and relief
of pain. This unsatisfactory outcome for a group of patients role in the patella (Maralcan et al. 2005).

may not be related to known complications such as infection, We usually perform circumferential thermocoagulation of
instability, loosening, misalignment and implant failure. the patella rim with electrocautery (ECP) for patellar non-

Therefore, the function and the preoperative pain must be resurfacing. Pulavarti et all (2013), in a randomized controlled
defined, along with psychological and emotional factors that trial with 126 patients separated in two groups (63=EPC and
can consistently interfere with long-term results (Noiseux 58 = no EPC) with a 2-year follow-up, demonstrated that the

et al. 2014). Other etiological factors might be related to circumpatellar electrocautery seems to be a safe procedure
anterior knee pain and decrease of outcome scores, such that produces an increase in the satisfaction rate and flexion

as discomfort on incision, decreased sensitivity, neuromas, gain in patients after 2 years from the surgery. On the other
bursitis, tendonitis, patellar instability and fractures (Burnett & hand, no clinical or statistical differences were found in the
Bourne Inst Course Lect 2004). Dennis et al. (2010), showed validated standardized assessment rating scores. This

the incidence of painful patellar creptos after TKA, with outcome contrasts with the one reached by Yim at al (2012),
implants that replace the posterior cruciate ligament, in the who evaluated the clinical effects in reducing anterior knee

range of 0% to 14%. The causes found are related to several pain performing ECP in bilateral Arthroplasty with patellar
factors including the decrease of patellar tendon length, the non-resurfacing during TKA, not finding any statistical

use of a smaller patellar component, the increase of anterior differences in the improvement of function, range of motion
femoral condyle offset, which can increase the intensity of and assessment clinical scores.
quadriceps tendon contact against the superior aspect of
However, it is not surprising that Arthroplasty national
the inter-condylar box, hence increasing the risk of fibro- records data show a very wide gap in the proportion of
sinovial proliferation with the entrapment in the inter-condylar
patellar resurfacing in different countries. This is a fact that
region of the femoral component. It is recommended to pay cannot be attributed simply to cultural differences, making it
attention to these factors in order to avoid the increase in
necessary to analyse the multifactorial aspect.
prior post-Arthroplasty incidence. These can be added to the
set of factors that can contribute to the decision between the Many studies are yet to be carried out so that we can define
patellar resurfacing or not.
the best procedure to be performed, with the development

of appropriate tools aim to assess the outcome more
precisely, as well as the development of more specific
implants. Taking the evidence found in the present literature

into consideration, the performance of patellar resurfacing
should still be considered as a choice of the surgeon and it

should be reached in agreement with the patient, who must
be aware of the possible complications associated with each
person’s individual factors.

The appropriate surgical technique with the correction

of alignment and positioning of the implant remains the
best method in order to avoid anterior knee pain and its

associated complications, achieving more satisfactory results
The most recently developed implant types and the in the long term. As pointed out by Schindler in his review,

assessment tools specifically validated to assess post-
with the phrase of the Roman poet Ovid (43BC-18AD) “in
TKA patellofemoral pain and function must be included medio tutissimus ibis”, considering the compromise of the
selective resurfacing, that is, the decision between the
in future studies to reach a consensus regarding this
subject, including regarding a group of selective patellar extremes should be defined by more precise criteria.

resurfacing patients. More precise assessment criteria must
be developed in order to define this procedure. Therefore,
we remain uncertain concerning which procedure would

be the most appropriate one between performing patellar
resurfacing or not (Bourne 2011).
ISAKOS NEWSLETTER 2014: Volume II 19