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All issues Volume 11 (2025) SICOT-J, 11 (2025) 10 Full HTML
Open Access
Issue
SICOT-J
Volume 11, 2025
Article Number 10
Number of page(s) 4
Section Knee
DOI https://doi.org/10.1051/sicotj/2025004
Published online 20 February 2025

Paraphrasing the message “Save the meniscus”, the message “Save the patella” comes to tell us to be more critical on the decision regarding the patella management during total knee arthroplasty (TKA). Patella is not just a bone in the center of the knee joint but it is the largest sesamoid bone in the human skeleton, acting as a fulcrum that increases the lever arm of the extended knee and thereby facilitates the function of the quadriceps muscle [1]. Interestingly, the patella can be characterized as the brain of the knee joint, based on the increased brain activity involved during movement of the knee [2]. Thus, preserving the patella during TKA it is critically important.

Typically, there are three surgical approaches regarding the patella management during TKA: always resurface, never resurface and selectively resurface the patella. However, it seems that the decision to resurface the patella, as part of TKA procedure, is mainly based on the surgeon’s preference and training, geographic location and personal experience [3], rather than evidence-based clinical guidelines. According to different studies and registries, surgeons in the United States routinely resurface the patella (> 90%), while Scandinavian countries, including Norway and Sweden, are on the lower end of the spectrum with only 2% to 3% of the surgeons selecting to resurface the patella [4, 5]. Advocates of routine patellar resurfacing state that it decreases post-operative anterior knee pain, the need for a second operation, thus improving patient-reported outcomes. On the contrary, surgeons who leave the patella unresurfaced, support that this approach minimizes the risk of patellar fracture, avascular necrosis, patellar tendon injury and component loosening [4, 5].

Therefore, the surgeons usually perform either osteophytes removal or/and cartilage smoothing “patelloplasty” in moderate cases [5]. The loss of the cushioning effect of the articular cartilage, in cases of degeneration of the patellar cartilage, leads the subchondral bone experiences increased pressure, while the underlying nerves were exposed, resulting in pain and functional impairment of the affected joint [6]. In these cases, patellar denervation may help to decrease post-operative anterior knee pain, improve patient’s satisfaction and minimize the complications [6]. Furthermore, in severe cases with extensor mechanism tightness, partial lateral patella facetectomy or lateral retinaculum release were proposed to restore central patellar tracking and improve knee kinematics (Figure 1) [7]. However, the choice to resurface the patella during TKA is a combination of the above-mentioned factors (Figure 2) with the addition to this “equation” of the thickness, the shape and the osteometabolic state of the patella [8]. Among the contraindications to patellar resurfacing is a thin and eroded patella, where the thickness after resection would be less than 12 mm [4]. In addition, poor bone quality of the patella can ultimately lead to poor bone-prosthesis or bone-cement-prosthesis integration and to an increased risk for periprosthetic fracture, making the patella unsuitable for a resurfacing procedure (Figure 2) [8].

thumbnail Figure 1

Illustration shows the patella management during total knee arthroplasty (the option of not-resurfacing the patella).

thumbnail Figure 2

Illustration shows the patella management during total knee arthroplasty (the option of resurfacing the patella and the factors to take into consideration).

In 2024, we may continue to debate over the patellar management during primary TKA, but we can all agree that up to 20% of patients undergoing TKA remain unsatisfied, regardless of resurfacing of the patella [4, 9]. Despite the substantial advances in primary TKA regarding the surgical technique, instrumentation, alignment strategy and implant design, patient satisfaction is a relative concept that is strongly linked to patient expectations. Several studies have been conducted to investigate the satisfaction rate of secondary patellar resurfacing, demonstrating that the overall dissatisfaction rate ranged from 41% to 65% [10–14]. Toro-Ibarguen et al., in a retrospective study, showed that in 59% of the patients who underwent secondary patellar resurfacing for persistent anterior knee pain, there was no pain improvement, while 65% of the patients were dissatisfied [10]. The authors concluded to be less likely to recommend this procedure as a treatment option for this subgroup of patients. More recently, Thomas et al. demonstrated that 66% of patients did not benefit from secondary patella resurfacing and emphasized the importance of clarifying the cause of anterior knee pain after the primary TKA [11]. These findings are also supported by a systematic review and meta-analysis including six studies of 604 knees, with a mean follow-up period of 42 months [12]. The authors demonstrated that 41% of the patients were dissatisfied after secondary patella resurfacing with half of the patients not achieving improvements in anterior knee pain and functional ability. A complication rate ranging between 3.4% and 30% among the included studies was noted [12]. In conclusion, despite the trend towards higher re-operation rates with unresurfaced patella, resurfacing the patella during primary TKA may not be necessary, due to the fact that it is not clear that the need of re-operation is a direct consequence the patella being unresurfaced [13]. Finally, the increase of costs and health-care resources during TKA, with patella resurfacing, needs to be considered during the decision-making process [14].

Of course, the moto “Save the Patella” does not mean “Do not Resurface the Patella”, but proceed with caution following the indications for patellar resurfacing. Therefore, it is crucial to develop accurate criteria to identify patients would benefit from primary patella resurfacing. Also, within patients with persistent anterior knee pain, who had not undergone patella resurface, it is critical to identify the best candidates for secondary patella resurfacing. In this aspect, malrotation and aseptic or septic loosening of TKA components represent exclusion criteria. Maybe something less personal like. Any senior or junior surgeon needs to remember this moto:

Save the Patella.

Funding

This study did not receive any specific funding.

Conflicts of interest

The authors declare that they have no relevant financial or non-financial interests to report.

Data availability statement

Data are available on request from the authors.

Author contribution statement

Author 1: Investigation, conceptualization, writing, preparing figures and final editing; Author 2: writing and reviewing; Author 3: reviewing and editing; Author 4: reviewing and supervision.

Ethics approval

Ethics approval was not required.

Informed consent

The authors declare that this study does not contain any personal information that could lead to the identification of the patients.

References

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Cite this article as: Vasiliadis AV, Giovanoulis V, Chytas D & Noussios G. (2025) Save the Patella. SICOT-J 11, 10. https://doi.org/10.1051/sicotj/2025004.


© The Authors, published by EDP Sciences, 2025

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

All Figures

thumbnail Figure 1

Illustration shows the patella management during total knee arthroplasty (the option of not-resurfacing the patella).
In the text
thumbnail Figure 2

Illustration shows the patella management during total knee arthroplasty (the option of resurfacing the patella and the factors to take into consideration).
In the text

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