A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing: A concise follow-up at a mean of 3.7 years

Department of Orthopaedic Surgery, Deventer Hospital, P. O. Box 5001, 7400 GC Deventer, The Netherlands.
The Bone & Joint Journal (Impact Factor: 3.31). 08/2011; 93(8):1054-9. DOI: 10.1302/0301-620X.93B8.26560
Source: PubMed
ABSTRACT
The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar electrocautery with no electrocautery in total knee replacement in the absence of patellar resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly assigned circumpatellar electrocautery (intervention group) or no electrocautery (control group). The primary outcome measure was the incidence of anterior knee pain. A secondary measure was the standardised clinical and patient-reported outcomes determined by the American Knee Society scores and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery and 131 had no electrocautery. The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to 31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to 77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee scores and function scores were similar in the intervention and control groups (knee score: 92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100) versus 84.5 (30 to 100), respectively (p = 0.49)). Our study suggests that in the absence of patellar resurfacing electrocautery around the margin of the patella improves the outcome of total knee replacement.

Full-text

Available from: Rudolf W. Poolman
1054 THE JOURNAL OF BONE AND JOINT SURGERY
KNEE
A randomised, controlled trial of
circumpatellar electrocautery in total knee
replacement without patellar resurfacing
H. P. W. van
Jonbergen,
V. A . B . Scholtes,
A. van Kampen,
R. W. Poolman
From Deventer
Hospital, Deventer,
The Netherlands
H. P. W. van Jonbergen, MD,
PhD, Orthopaedic Surgeon
Department of Orthopaedic
Surgery
Deventer Hospital, P. O. Box
5001, 7400 GC Deventer, The
Netherlands.
V. A. B. Scholtes, PhD, Senior
Researcher
R. W. Poolman, MD, PhD,
Orthopaedic Surgeon
Department of Orthopaedic
Surgery, Joint Research
Onze Lieve Vrouwe Gasthuis,
P. O. Box 95500, 1090 HM
Amsterdam, The Netherlands.
A. van Kampen, MD, PhD,
Professor
Department of Orthopaedic
Surgery and Orthopaedic
Research Laboratory
Radboud University Nijmegen
Medical Centre, P. O. Box 9101,
6500 HB Nijmegen, The
Netherlands.
Correspondence should be sent
to Dr H. P. W. van Jonbergen;
e-mail: vanjonbergen@dz.nl
©2011 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.93B8.
26560 $2.00
J Bone Joint Surg [Br]
2011;93-B:1054-9.
Received 20 December 2010;
Accepted after revision 12 April
2011
The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative
anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and
patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar
electrocautery with no electrocautery in total knee replacement in the absence of patellar
resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly
assigned circumpatellar electrocautery (intervention group) or no electrocautery (control
group). The primary outcome measure was the incidence of anterior knee pain. A secondary
measure was the standardised clinical and patient-reported outcomes determined by the
American Knee Society scores and the Western Ontario and McMaster Universities
(WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery
and 131 had no electrocautery.
The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to
31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control
group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and
the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean
total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to
77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee
scores and function scores were similar in the intervention and control groups (knee score:
92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100)
versus 84.5 (30 to 100), respectively (p = 0.49)).
Our study suggests that in the absence of patellar resurfacing electrocautery around the
margin of the patella improves the outcome of total knee replacement.
Anterior knee pain is reported in 4% to 49% of
patients after primary total knee replacement
(TKR).
1-3
The cause is unknown, but may be
related to the characteristics of the patient,
4,5
the
degree of wear of the patellar cartilage,
6
the
design of the prosthesis,
1,3,7
the operative
technique
8-11
and the use of patellar resurfac-
ing.
2,4,12
Both the peripatellar soft tissues and the
infrapatellar fat pad have been implicated as a
source of anterior knee pain.
10,13
Immunohis-
tochemical research on the innervation of this
area has shown the presence of substance-P noci-
ceptive afferent fibres in the peripatellar soft
tissues.
14
Therefore, the damage to these
pain receptors using electrocautery could theo-
retically desensitise or denervate them and reduce
post-operative anterior knee pain.
15-18
Several studies have described the use of cir-
cumpatellar electrocautery in TKR with
19-21
and
without
20,22,23
patellar resurfacing. However,
only two have specifically addressed the results of
circumpatellar electrocautery in primary
TKR,
24,25
with neither providing evidence as to
its value in clinical practice. A recent postal sur-
vey with a response rate of 92% showed that
56% of orthopaedic surgeons in The Nether-
lands use circumpatellar electrocautery when not
resurfacing the patella, and 32% use electrocau-
tery when resurfacing the patella.
26
Our hypothesis was that primary TKR with
circumpatellar electrocautery would lead to
partial denervation and improved pain relief
compared with no electrocautery. The primary
objective of this blinded, prospective, parallel,
randomised study was to determine the clinical
effect of circumpatellar electrocautery on ante-
rior knee pain in TKR without patellar resurfac-
ing. Secondary objectives were to assess
differences in standardised clinical and patient-
reported outcomes.
Patients and Methods
In 2008, we initiated a prospective, outcome-
assessor and patient-blinded, parallel-group,
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CIRCUMPATELLAR ELECTROCAUTERY IN TOTAL KNEE REPLACEMENT WITHOUT PATELLAR RESURFACING 1055
VOL. 93-B, No. 8, AUGUST 2011
randomised clinical trial according to the CONSORT state-
ment.
27
The study was approved by the Regional Ethics
Committee and Institutional Review Board.
Between May 2008 and May 2009, all patients who were
to have TKR for primary osteoarthritis were considered for
inclusion by the five orthopaedic surgeons involved. They
excluded those who had any of the following: isolated
patellofemoral osteoarthritis, contralateral patellar resur-
facing (primary or revision), inability to speak Dutch, total
hip replacement (THR) or contralateral TKR within the
study period or less than one year beforehand, inflamma-
tory arthritis, a history of patella fracture, patellectomy,
patellofemoral instability, unicondylar knee replacement,
high tibial or distal femoral osteotomy or any operation
involving the extensor mechanism, a medical disorder
which restricted walking and disabling disease involving
other joints of the lower limbs. Eventually, 352 consecutive
patients were recruited, of whom 300 provided written
informed consent (Fig. 1).
All the eligible patients were assessed pre-operatively by
one of the five participating surgeons who obtained the
American Knee Society knee and functional scores.
28
The
Dutch version of the 24-item Western Ontario and
McMaster Universities osteoarthritis index (WOMAC)
Likert version 3.0
29
was completed by all 300 patients
who also participated in a standardised pre-operative
work-up programme.
Operative technique. Each operation was performed by one
of the five surgeons in a standardised manner according
to the manufacturer’s instructions, using the NexGen LPS
(Zimmer, Warsaw, Indiana) posterior-stabilised fixed-bearing
TKR without patellar resurfacing. The patients were oper-
ated on under spinal anaesthesia combined with a femoral
nerve block and with tourniquet control. Blinding of the
Assessed for eligibility
(n = 352)
Randomised (n = 300)
Excluded (n = 52)
Not meeting inclusion criteria
(n = 40)
Declined to participate (n = 12)
Allocated to
TKR with circumpatellar electrocautery
(n = 150)
Received TKR with circumpatellar
electrocautery
(n = 150)
Number of patients treated by each
surgeon
I 58
II
*
27
III
*
22
IV 13
V 30
Lost to follow-up (n = 0)
Excluded after receiving
allocated treatment (n = 19)
Received THR or contralateral TKR
within study period (n = 14)
Developed incapacitating pulmonary
disease (n = 1)
Died within study period (n = 4)
Analysed (n = 131)
Analysis:
patients
Follow-up: patients
Allocation:
care providers
Allocation: patients
Enrolment: patients
Analysed (n = 131)
Lost to follow-up (n = 0)
Excluded after receiving
allocated treatment (n = 19)
Received THR or contralateral TKR
within study period (n = 14)
Developed incapacitating back pain
(n = 1)
Supracondylar fracture 7 months
post-operative (n = 1)
Died within study period (n = 3)
Number of patients treated by each
surgeon
I 56
II
*
30
III
*
27
IV 9
V 28
Allocated to
TKR without circumpatellar electrocautery
(n = 150)
Received TKR without circumpatellar
electrocautery
(n = 150)
Fig. 1
CONSORT flow diagram showing the enrolment of the patients, the allocation of treatment and the comple-
tion of the study (* denotes a surgeon’s preference to perform electrocautery; THR, total hip replacement; TKR
total knee replacement).
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1056 H. P. W. VAN JONBERGEN, V. A. B. SCHOLTES, A. VAN KAMPEN, R. W. POOLMAN
THE JOURNAL OF BONE AND JOINT SURGERY
patients was achieved by shielding their view with a vertical
drape.
After a midline skin incision and medial arthrotomy, the
patella was everted laterally, and remained there until stabil-
ity had been assessed using the trial components. In all cases,
the patellar fat pad was resected to improve the exposure of
the proximal tibia. When orientating the femoral compo-
nent we used 5° of distal femoral valgus and 3° of external
rotation relative to the posterior condyles. After cementing
the femoral and tibial components, the damage to the patel-
lar articular cartilage was assessed according to the
Outerbridge
30
grading system. Osteophytes were removed
only if considered necessary for correct patellar tracking.
Also, a lateral release at least 2 cm lateral to the border of
the patella was performed only if clinically indicated after
an assessment of patellofemoral instability on passive test-
ing of the range of movement.
The patients were randomly assigned to receive TKR
with (intervention group) or without (control group) cir-
cumpatellar electrocautery. The randomisation was per-
formed at operation using sequentially numbered, opaque
sealed envelopes, each bearing only a number on the out-
side. Within the 300 envelopes there was an equal number
of instructions for circumpatellar electrocautery or no addi-
tional treatment. These had been prepared before the study
using computer-generated random-number tables by an
assistant who did not participate in the study. In order to
conceal the allocation, the next available numbered enve-
lope was opened by a nurse in the operating theatre after
cementing of the femoral and tibial components, assess-
ment of the patellar cartilage, and any soft-tissue treatment
for patellofemoral instability. The instructions informed the
surgeon whether to undertake circumpatellar electrocau-
tery. This was not revealed to the patient. Any electrocau-
tery was performed using the Valleylab electrocautery unit
(Valleylab Inc., Boulder, Colorado) with monopolar coagu-
lation diathermy set to 50 W. The technique used only
superficial electrocautery to a depth of no more than 1 mm
in a circular fashion (360°) and within 5 mm of the edge of
the patella. In both groups, after lavage, the medial arthro-
tomy, subcutaneous tissue and skin were closed in layers
over a suction drain.
All 300 patients received the same post-operative treat-
ment according to an integrated pathway protocol, with
analgesia monitored by an anaesthetist. The physiotherapy
programme was identical for both groups, with immediate
post-operative protected weight-bearing with crutches. The
patients were discharged from hospital after four days if
they were able to actively flex the operated knee to 90°. All
received antithrombotic prophylaxis for six weeks with
low-molecular-weight heparin. After six weeks, full unre-
stricted weight-bearing was allowed without walking aids.
All the patients had a scheduled follow-up at two and eight
weeks and one year post-operatively. Anteroposterior
standing and lateral non-weight-bearing radiographs were
taken at eight weeks and one year. All the healthcare pro-
fessionals involved with the follow-up examinations were
blinded as to which group the patient had been assigned.
A trained nurse practitioner assessed the primary and
secondary outcomes at one year post-operatively. The pri-
mary outcome was the incidence of anterior knee pain
according to the rating system described by Waters and
Bentley
2
(Table I). Along with the question “Do you expe-
rience pain at the anterior aspect of the knee?”, patients
who responded ‘yes’ were further questioned as to whether
it interfered with activity and whether its severity war-
ranted further surgery. The secondary outcomes at one year
were assessed using the American Knee Society knee and
function scores, obtained by the nurse practitioner, and the
WOMAC questionnaire completed by all patients.
Statistical analysis. The baseline characteristics were analy-
sed by descriptive statistics using the mean and range for
continuous variables and frequencies for categorical vari-
ables. For the primary outcome measure, the clinical ante-
rior knee pain rating system
2
was dichotomised. A rating of
I, II or III was coded as presence of anterior knee pain,
while a rating of 0 was coded as its absence. The prevalence
of anterior knee pain in both groups including the 95%
confidence interval (CI) was calculated, and the chi-
squared test was used to compare the categorical data
between the groups. A two-sided p-value 0.05 was con-
sidered to indicate statistical significance. The relative risk
reduction and the number needed to treat were calculated
with 95% CIs. For the three secondary outcome measures
(American Knee Society knee and function scores and
WOMAC index), the data were first assessed for normality
using the Kolmogorov-Smirnov test with p < 0.05, after
which repeated measures analysis of variance was used to
analyse for differences over time between both groups. All
the analyses were performed according to the intention-to-
treat principle. Before the study began, a calculation of
sample size was performed using estimates of the preva-
lence of anterior knee pain of 25% after TKR without
patellar resurfacing.
2
With the use of a 15% effect size, a
Tab l e I. The clinical anterior knee pain rating system described by Waters and Bentley
2
Rating Description
0No pain
I Mild pain which does not intrude on daily activities
II Moderate pain which is a nuisance; patient not considering further surgery
III Severe pain; patient considering further surgery
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CIRCUMPATELLAR ELECTROCAUTERY IN TOTAL KNEE REPLACEMENT WITHOUT PATELLAR RESURFACING 1057
VOL. 93-B, No. 8, AUGUST 2011
significance level (alpha) of 0.05 using a two-sided test and
a power of 80%, a sample size of 113 knees in each group
was required to detect a significant difference.
Results
There were no statistically significant differences between
groups pre-operatively (Table II). The characteristics of the
19 patients who were excluded after receiving electro-
cautery did not differ from the 19 who were excluded in the
non-electrocautery group (Fig. 1). All patients received the
allocated treatment. Eight knees in the intervention group
and nine in the control group required lateral retinacular
release. Three knees, two in the intervention group and one
in the control group, showed signs of a deep infection
within six weeks of TKR and received successful operative
and antibiotic treatment. At their one-year follow-up, these
patients had no clinical signs of infection of their TKR. In
three knees in the intervention group and one in the control
group, manipulation under anaesthesia was performed to
improve flexion after the fourth post-operative week. These
patients had obtained more than 90° of flexion at the final
review. There were no radiological signs of patellar
osteonecrosis.
31
At one year of follow-up, 67 patients reported anterior
knee pain, representing an overall incidence of 25.6%
(95% CI 20 to 31). There were 25 patients in the interven-
tion group and 42 in the control group with a respective
incidence of 19.1% (95% CI 12 to 26) and 32.1% (95% CI
24 to 40) (p = 0.02).
The number of knees in each group and grading of ante-
rior knee pain rating is presented in Table III. The differ-
ences in gradings were statistically significant (p = 0.03).
The use of circumpatellar electrocautery resulted in a rela-
tive risk reduction of 40% (95 CI 9 to 61) for post-opera-
tive anterior knee pain, with a number needed to treat of
7.7 (95% CI 4.3 to 41.4).
The intervention group had a better mean total WOMAC
score at follow-up at one year (16.3 (0 to 77.7)) compared
with the control group (21.6 (0 to 76.7)) (p = 0.04). Addi-
tional analysis of the component items within the
mean WOMAC questionnaire showed a statistically signifi-
cant better mean WOMAC function subscale for the inter-
vention group (15.3 (0 to 77.9)) compared with the control
group (20.4 (0 to 80.9)) (p = 0.02). However, no statisti-
cally significant differences were noted between the inter-
vention and control groups for the mean WOMAC pain
Table II. Clinical details of both groups
Intervention group
(n = 131)
Control group
(n = 131) p-value
*
Side
Right:left 77:54 81:50 0.71
§
Mean (range) age at operation in years 71 (53 to 91) 72 (47 to 90) 0.87
Female:male 95:36 84:47 0.14
§
Mean (range) height in cm 167 (148 to 194) 169 (145 to 193) 0.21
Mean (range) weight in kg 84 (55 to 120) 84 (55 to 125) 0.88
Mean (range) BMI
in kg/m
2
30.1 (19.2 to 42.8) 29.4 (20.5 to 43.8) 0.22
ASA
classification 0.46
§
1 13 10
2105102
3 13 19
Predominant location of pre-operative knee pain 0.97
§
Anterior 16 14
Medial 67 69
Posterior 3 2
Lateral 10 12
Generalised 35 34
Intra-operative cartilage patella (Outerbridge grading)
30
0.96
§
0 10 13
1 11 12
2 40 36
3 39 39
4 31 31
Mean (range) duration of follow-up in years 1.1 (1.0 to 1.1) 1.0 (1.0 to 1.1) 0.45
* analysis of variance, unless otherwise stated
† BMI, body mass index
‡ ASA, American Society of Anesthesiologists
§ chi-squared test
Page 4
1058 H. P. W. VAN JONBERGEN, V. A. B. SCHOLTES, A. VAN KAMPEN, R. W. POOLMAN
THE JOURNAL OF BONE AND JOINT SURGERY
subscale (10.7 (0 to 70) versus 15.8 (0 to 85), respectively;
p = 0.14) or stiffness subscale (23.2 (0 to 100) versus 28.2
(0 to 100), respectively; p = 0.18). Similarly, no statistically
significant differences were observed in the mean American
Knee Society knee score (92.4 (55 to 100) versus 90.4 (51
to 100), respectively; p = 0.14) or function score (86.5 (15
to 100) versus 84.5 (30 to 100), respectively; p = 0.49)
(Table IV).
Discussion
In this study, circumpatellar electrocautery gave a signifi-
cantly lower incidence of anterior knee pain at one year
post-operatively compared with no circumpatellar electro-
cautery. Moreover, we found that the WOMAC score was
better in the intervention group, mostly attributed to its
function component. This suggests that anterior knee pain
might be related to the functional results.
Numerous studies have assessed various factors thought
to be related to anterior knee pain, including the character-
istics of the patients,
4,5
the degree of wear of the patellar
cartilage,
6
the design of prosthesis,
1,3,7
the operative tech-
nique,
8-11
and the use of patellar resurfacing.
2,4,12
Although
some of these factors could be related to denervation,
others are probably not. Therefore it seems likely that the
cause of anterior knee pain after TKR is multifactorial.
Some of these variables may have influenced our results. In
a randomised, controlled trial comparing patellar resurfac-
ing with non-resurfacing, weight but not the body mass
index (BMI) was found to be associated with the develop-
ment of anterior knee pain in those who did not have patel-
lar resurfacing.
4
In our study, the baseline characteristics
including weight, height and BMI, were similar in the
groups. However, we did not stratify our analysis for
weight or BMI. The degree of wear of the patellar articular
cartilage is another factor which potentially influences the
prevalence of anterior knee pain.
6
Selective resurfacing has
been recommended in patellae with Outerbridge grade-IV
changes, since patients with this degree of patellofemoral
wear are 21 times more likely to require revision and
undergo patellar resurfacing than those with lesser grades.
6
We did not find a correlation between the incidence of ante-
rior knee pain and the extent of cartilage damage, which
has been reported in other studies.
4,32-34
We used the poste-
rior-stabilised, fixed-bearing NexGen prosthesis in all
Table III. Number of patients with anterior knee pain at follow-up at one year
Anterior knee pain rating Intervention group (n = 131) Control group (n = 131)
010689
I 1824
II 6 9
III 1 9
Table IV. Clinical outcome after total knee replacement with pre- and post-operative clinical scores
(mean, range). The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) is nor-
malised and expressed on a scale of 0 to 100
Intervention group (n = 131) Control group (n = 131) p-value
*
AKSKS
Pre-operative 51.7 (18 to 77) 52.7 (17 to 89)
Post-operative 92.4 (55 to 100) 90.4 (51 to 100) 0.14
AKSFS
Pre-operative 54.4 (0 to 80) 54.4 (10 to 90)
Post-operative 86.5 (15 to 100) 84.5 (30 to 100) 0.49
WOMAC total score
Pre-operative 56.6 (16.0 to 98.3) 57.0 (22.8 to 94.6)
Post-operative 16.3 (0 to 77.7) 21.6 (0 to 76.7) 0.04
WOMAC pain score
Pre-operative 54.2 (0 to 95) 55.3 (15 to 100)
Post-operative 10.7 (0 to 70) 15.8 (0 to 85) 0.14
WOMAC stiffness score
Pre-operative 58.8 (0 to 100) 59.1 (0 to 100)
Post-operative 23.2 (0 to 100) 28.2 (0 to 100) 0.18
WOMAC function score
Pre-operative 57.0 (8.8 to 100) 56.3 (0 to 95.0)
Post-operative 15.3 (0 to 77.9) 20.4 (0 to 80.9) 0.02
* Analysis of variance
† AKSKS, American Knee Society knee score
‡ AKSFS, American Knee Society function score
Page 5
CIRCUMPATELLAR ELECTROCAUTERY IN TOTAL KNEE REPLACEMENT WITHOUT PATELLAR RESURFACING 1059
VOL. 93-B, No. 8, AUGUST 2011
patients. It has been suggested that a fixed design may be
associated with a higher incidence of anterior knee pain
than a mobile-bearing prosthesis.
3
We undertook TKR
without patellar resurfacing, since definite evidence for its
use is lacking.
12
The manner by which circumpatellar electrocautery
results in a reduced rate of anterior knee pain may be desen-
sitisation or denervation of the pain receptors in the anterior
knee.
17,18
This mechanism could be operating in the different
procedures collectively described as patelloplasty. Since
patellar resurfacing requires removal of osteophytes and
synovial tissue to allow accurate resection and restore patel-
lar thickness, this may at least in part result in denervation.
Gupta et al
25
reported a lack of improvement after patel-
lar rim electrocautery at a minimum of two years following
TKR without patellar resurfacing when using the rotating-
platform, mobile-bearing Low Contact Stress total knee
prosthesis (LCS; DePuy International, Leeds, United King-
dom). This alone may account for the lower incidence of
anterior knee pain compared with the posterior-stabilised,
fixed-bearing NexGen prosthesis used in our study.
3
Also,
their patients had not been randomised, but were matched
retrospectively.
25
Whether this difference arises from our
relatively short follow-up warrants further attention. Some
authors
4,35
have reported a gradual decrease in anterior
knee pain after TKR, whereas others have described an
increase over time.
36
In order to assess the long-term out-
come, we will re-evaluate our patients to determine
whether the clinical effect of circumpatellar electrocautery
diminishes with time.
In summary, the results of our randomised, controlled
trial at one year show that circumpatellar electrocautery in
TKR without patellar resurfacing results in a lower inci-
dence of anterior knee pain and better WOMAC scores
compared with no circumpatellar electrocautery.
Listen live
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We wish to thank members of the Anterior Knee Pain Study Group (A. F. W. Bar-
naart, R. H. G. P. van Erve, H. P. W. van Jonbergen, A. van Kampen, R. Koorevaar,
D. D. Langeloo, R. W. Poolman and D. M. Werkman) and Mrs I. Wippert for her
invaluable assistance in evaluating the patients and co-ordinating the knee
replacement integrated care pathway.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
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    • "Li et al. stated that there were several deficiencies in their review and that their results should be further confirmed by additional high-quality RCTs. However, two more recent RCTs, reported in 2014, came to the opposite conclusion: Van Jonbergen et al. [22] conducted an RCT involving 300 knees analysed at a mean of 3.7 years of follow-up, and they reported that there was no significant difference in anterior knee pain incidence between their patellar denervation group and their no-denervation group (n.s.). Pulavarti et al. [16] randomised 126 consecutive knees undergoing primary TKA into either a denervation group or a no-denervation group, performing assessments at 3, 12, and 24 months after surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: The effectiveness of patellar denervation in reducing anterior knee pain and improving patient satisfaction and quality of life after total knee arthroplasty (TKA) is still controversial. A meta-analysis was conducted to try to settle the controversy. The electronic databases PubMed, Web of Science, Embase, and Cochrane Library were systematically searched. Of 374 papers identified, seven randomised controlled trials involving 898 patients (983 knees) were eligible for data extraction and meta-analysis. Analysis showed that patellar denervation can significantly improve clinical outcomes for the first 12 months of follow-up after TKA, including anterior knee pain incidence (P = 0.008), visual analogue scale score (P < 0.001), patellar score (P < 0.001), Knee Society Score (P = 0.03), Knee Society Score function score (P = 0.03), and knee range of motion (P = 0.008). However, no statistical significance in outcomes was found between the patellar denervation group and no-denervation group for any of those parameters after 12 months of follow-up. The best currently available evidence suggests that patellar denervation can significantly reduce anterior knee pain incidence and improve early clinical outcomes after TKA. However, after a prolonged period of follow-up, this advantage seems to disappear. Even so, the use of patellar denervation in primary TKA is recommended because it is safe and produces good early clinical outcomes. Therapeutic study, Level II.
    Full-text · Article · Mar 2015 · Knee Surgery Sports Traumatology Arthroscopy
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    • "Third, the incidences of anterior knee pain in two groups were not stratified based on the degree of chondromalacia of the patellar cartilage. Many studies have suggested that the incidence of anterior knee pain did not associate with the chondromalacia [26, 35]. "
    [Show abstract] [Hide abstract] ABSTRACT: Anterior knee pain is a major cause of complaint in total knee arthroplasty (TKA) without patellar resurfacing. The concept of improved patellar tracking and decreased retropatellar contact pressure for lateral retinacular release theoretically suggests that patients with lateral retinacular release in TKA would achieve a lower incidence of anterior knee pain when compared without lateral retinacular release. We sought to determine (1) whether those patients who received a routine lateral retinacular release in TKA would attain lower incidence of anterior knee pain as compared to patients who received TKA without lateral retinacular release and (2) whether lateral retinacular release would increase the lateral retinacular release-related complications. A total of 148 patients who underwent TKA with the use of the Gemini MK II mobile bearing were randomized to receive either routine lateral retinacular release (intervention group) or not (control group). Patients were assessed by the visual analogue scale for anterior knee pain, the Knee Society clinical scoring system of knee score and function score, and patellar score for clinical function. Patients' satisfaction and lateral retinacular release-related complications were also evaluated. The overall incidence of anterior knee pain in the intervention group at 18 months follow-up was 5.6 %, while that of the control group was 20.6 % (p = 0.009). No statistical difference was detected between the two groups in terms of lateral retinacular release-related complications (n.s.), patients' satisfaction (n.s.), knee score (n.s.), function score (n.s.), and patellar score (n.s.) at 18 months follow-up. The present study suggests that routine lateral retinacular release can reduce anterior knee pain and does not increase lateral retinacular release-related complications, in TKA with the use of the Gemini MK II mobile bearing without patellar resurfacing. Therapeutic, Level I.
    Full-text · Article · Nov 2013 · Knee Surgery Sports Traumatology Arthroscopy
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    • "This study has several weaknesses. It is a retrospective review of Registry data and does not record the indication for secondary resurfacing of the patella, nor the surgeon’s practice of using electrocautery around the unresurfaced patella – there is evidence that such treatment may improve post-operative pain.13 We have assumed that modern patellar resurfacings and TKR designs are very similar in terms of their functional results. "
    [Show abstract] [Hide abstract] ABSTRACT: Our study aimed to examine if a mobile-bearing total knee replacement (TKR) offered an advantage over fixed-bearing designs with respect to rates of secondary resurfacing of the patella in knees in which it was initially left unresurfaced. We examined the 11-year report of the New Zealand Joint Registry and identified all primary TKR designs that had been implanted in > 500 knees without primary resurfacing of the patella. We examined how many of these were mobile-bearing, fixed-bearing cruciate-retaining and fixed-bearing posterior-stabilised designs. We assessed the rates of secondary resurfacing of the patella for each group and constructed Kaplan-Meier survival curves. Our study showed a significantly higher rate of revision for secondary resurfacing of the patella in the fixed-bearing posterior-stabilised TKR designs compared with either fixed-bearing cruciate-retaining or mobile-bearing designs (p = 0.001 and p = 0.036, respectively). This New Zealand Registry study shows that during the last 11 years, revision procedures to resurface an unresurfaced patella in primary TKR occurred at a higher rate in fixed-bearing posterior-stabilised designs.
    Full-text · Article · Jul 2013
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