Patellofemoral Pain After Total Knee Arthroplasty

Giles R. Scuderi, MD, John N. Insall, MD, and W. Norman Scott, MD

Abstract

The incidence of patellofemoral complications after total knee arthroplasty has gruent femoral component or to
been reported to range from 2% to 7%. Such complications include pain, sub- errors in surgical technique.3
luxation, dislocation, loosening, and wear. Usually these complications are attrib- The minimal patellofemoral prob-
utable to prosthetic design or surgical technique. Today, it is understood that lems associated with the Total
patellofemoral prostheses must have a degree of congruence; must allow smooth, Condylar Knee replacement may
not abrupt, motion; and must restore a relatively normal size relationship between have been due in part to the limited
the patella and the femur. Surgical technique requires strict attention to (1) possible flexion of 90 degrees. This
restoration of the patellofemoral spacing while avoiding “overstuffing” of the reduced flexion may have obscured
patellofemoral compartment; (2) accurate superior and medial positioning of the the stresses that became appa-
patellar component; (3) restoration of the rotational alignment of the femoral and rent with newer implants, which
tibial components; and (4) appropriate balancing of the patellofemoral soft tissues. allowed a greater flexion arc. The
J Am Acad Orthop Surg 1994;2:239-246 Insall/Burstein Total Condylar Knee
prosthesis and the Insall/Burstein
Posterior Stabilized prosthesis (Zim-
mer), which was introduced in 1977,
Patellofemoral pain after total knee high rate of clinical success and is still did indeed improve motion (105
replacement can plague even patients in use today. Patients with a resur- degrees and 115 degrees, respec-
with an otherwise well-aligned pros- faced patella have a reduced inci- tively), but “patellar” problems
thesis. While the cause may some- dence of anterior knee pain and necessitated design changes. 2,4 In
times be obscure, it can often be perform better in stair activities when 1983, the design of the posterior sta-
traced to improper surgical tech- compared with patients who have bilized prosthesis was revised to
nique or questionable prosthetic not undergone knee replacement.2 incorporate a deeper, smoother patel-
design. lar groove to enhance both stability
Early operative techniques did and tracking.5 Current designs have
not include resurfacing the patella. Total Knee Prostheses been characterized by further deep-
Anterior knee pain occurred in as
many as 30% of patients, and patel- Design
lar malalignment necessitated reop- Early total knee prostheses, such Dr. Scuderi is Director, Insall Scott Kelly Insti-
tute for Orthopaedics and Sports Medicine, New
eration to replace the patella in 5% to as polycentric and geometric de-
York. Dr. Insall is Director, Insall Scott Kelly
10% of patients.1 The strategy to signs, did not include a patellar com- Institute. Dr. Scott is Director, Insall Scott Kelly
deal with these complications was ponent or an anterior femoral flange. Institute.
the development of femoral compo- The original Total Condylar Knee
nents that included an anterior and Freeman-Swanson implants Reprint requests: Dr. Scuderi, Insall Scott Kelly
Institute for Orthopaedics and Sports Medicine,
flange. However, this design fea- were the first to include a flat ante-
170 East End Avenue at 87th Street, New York,
ture, which replaced only half of the rior flange and a central dome. The NY 10128.
patellofemoral joint, did not dimin- reported 6% incidence of patellar
ish the postoperative occurrence of subluxation was considered to be One or more of the authors or the entity with
anterior knee pain. due to a lack of joint congruity. Sub- which they are affiliated have received something
of value from a commercial or other party related
In 1974 the polyethylene dome sequently, many other investigators
directly or indirectly to the subject of this article.
was introduced in the Insall/Burstein advocated a congruent articulation.
Total Condylar Knee prosthesis In retrospect, it is difficult to ascer- Copyright 1994 by the American Academy of
(Zimmer, Warsaw, Ind). This first tain whether the complication rate Orthopaedic Surgeons.
patellar replacement achieved a very was in fact secondary to the incon-

Vol 2, No 5, Sept/Oct 1994 239

Patellofemoral Pain After Arthroplasty

ening of the femoral sulcus. Yoshii et The more congruent anatomic cially when associated with patellar
al6 have shown, on the basis of in patellar component lowers the con- subluxation or dislocation. Obese
vitro analyses, that the combination tact stresses, but may increase shear patients are more likely to have
of a 4-mm-deep femoral sulcus and stress at the bone-prosthesis inter- patellar symptoms after total knee
medial placement of the patellar face. This concern was the impetus arthroplasty, especially during
component best reproduces normal for the design of the congruent- activities involving knee flexion.18
patellar tracking. Also, greater atten- contact, metal-backed patellar com- This increased incidence is attribut-
tion is now given to the rotational ponent with rotating bearings, able to greater patellofemoral-joint
alignment of the femoral component, which permits dynamic tracking of reaction forces, which may reach
since external rotation and lateral the patella by motion between the three to four times the patient’s
placement more closely restore nor- metal base plate and the polyethyl- body weight during knee-flexion
mal patellar tracking.7,8 ene surface.12 The rotating-bearing activities. A review of the literature
Current patellar prostheses are of patellar component maintains suggests that the archetypal patient
three basic designs: the component spherical area contact on the medial who does not need patellar resurfac-
with a central dome with or without and lateral facets when the compo- ing is short and relatively thin and
metal backing, the anatomic compo- nent is congruent with the femoral has a congruous patellofemoral
nent, and the component containing groove. Buechel et al12 reported an joint and less than grade III arthritic
rotating bearings. The central-dome overall complication rate of only changes.11
component is the most adaptive but 0.6% with this implant design.
has the least congruity. The advan- Long-term retrieval studies have Surgical Considerations
tage of this design is that it elimi- demonstrated continued mobility Restoration of patellofemoral
nates concerns about rotational and minimal wear. mechanics in total knee arthroplasty
alignment while maintaining con- The initial dome design with a is greatly influenced by the position
tact throughout the flexion arc. Kim patellar button with a central lug has of the femoral and tibial compo-
et al9 have shown that the total con- had a complication rate of less than nents. Since the objective is a knee
tact area in the patellofemoral joint 7% in 15-year clinical surveillance that has equal medial and lateral
replacement is only 21% of that in studies. However, the central lug soft-tissue tension in flexion and
the intact knee and that there is a ten- has always been suspected of en- extension, appropriate soft-tissue
dency for the patellar component to hancing patellar fractures. Subse- releases are often unquestionably
shift medially during knee flexion. quently, smaller central lugs were necessary to correct fixed deformi-
These alterations in knee kinemat- used, but the design provided insuf- ties. The rotational position of the
ics may be a reason for polyethylene ficient fixation. Currently, three- tibial and femoral components is
wear. In addition, the contact stresses pegged fixation is preferred with the also essential to the outcome of
on nonconforming central-dome central-dome polyethylene button. patellofemoral joint replacement.
components have been shown to Mason et al13 reported on the use of The landmarks for assessing
exceed the yield strength of ultra- the three-lug patellar component in femoral rotation are the femoral epi-
high-molecular-weight polyethylene, 577 knees and found no loosening an condyles, the posterior femoral
leading to creep and wear.10 Interest- average of 3 years after surgery. condyles, and the trochlea. Reestab-
ingly, although a “conforming” de- lishing external rotation of the
formation type of wear has been Indications femoral component improves the
noticed almost universally on these The routine use of patellar resur- patellar tracking by lateralizing the
prosthetic domes, it has not yet been facing devices remains a topic of anterior flange. Internal rotation of
associated with clinical problems. debate because of the potential com- the femoral component is to be
This type of conforming polyeth- plications, including patellar frac- avoided, since this positions the
ylene wear was influential in stimu- ture, patellar instability, implant patellofemoral groove medially,
lating the development of the loosening, component breakage, which makes it more difficult for the
“Mexican hat” patellar design, and rupture of the extensor mecha- laterally placed patella to track in the
which is characterized by a concave nism.14-16 Many surgeons favor uni- trochlear groove, leading to sublux-
peripheral lip that articulates with versal resurfacing of the patella. ation or dislocation. From a practi-
the convex femoral condyles. This The suggested indications include cal perspective, the transverse axis
configuration distributes the patel- inflammatory arthritis17 and signifi- of the medial and lateral femoral epi-
lofemoral compressive forces more cant Outerbridge grade III or grade condyles provides a safe landmark
evenly in flexion.11 IV patellofemoral arthritis, espe- when preparing the femur for com-

240 Journal of the American Academy of Orthopaedic Surgeons

 Giles R. Scuderi, MD, et al

ponent placement. Varying bone everted, and the redundant sy- surface should be level and in line
loss from the posterior condyles can novium is resected from both the with the undersurface of the quadri-
result in an unpredictable landmark; undersurface of the quadriceps ten- ceps tendon, so that there is a smooth
the result most often is that the don and the adjacent medial capsule transition from bone to tendon.
femoral component is misplaced in (Fig. 1, A). Since reproduction of the Use of a bone-prosthesis compos-
an internal rotational position. patellar thickness is influential in the ite that is thicker than the original
The position of the tibial compo- final outcome, the patella should be patella increases the tension of the
nent is also critical to restoration of measured with a caliper prior to lateral retinaculum, resulting in
the extensor mechanism. While pos- resection (Fig. 1, B). Until recently, patellar tilt—a situation that un-
terior placement on the plateau is this measurement was neglected, doubtedly has contributed to many
still recommended,16 contemporary which unquestionably resulted in of the problems associated with
tibial designs usually cover the “overstuffing” of the patellofemoral “design failure.” It is rather amazing
entire plateau, which makes rota- compartment. In general, the line of that more failures have not been
tional positioning of the tibial com- patellar resection should be from the reported, since the importance of
ponent more difficult. Internal margin of the medial articular sur- patellofemoral spacing has only
rotation of the tibial component rel- face to the margin of the lateral artic- recently been recognized.
ative to the tibia will cause external ular surface. A common error is to Once the surface has been pre-
rotation of the tibia when the knee is resect only the lateral or medial pared, the three lug holes are drilled
in extension, resulting in lateral dis- facet, which results in oblique place- such that the patella sits in a more
placement of the tibial tubercle. This ment of the patellar component. The medial and superior position on the
displacement increases the valgus use of patellar reamers seems to residual bone. This position recre-
forces and the tendency of the allow more precise resection of the ates the height of the central ridge of
patella to lateral subluxation or dis- patella. the patella and improves patellar
location. It is recommended that the In preparing the patella, marginal tracking. With the component in
posteromedial corner of the tibial osteophytes are excised so that the place, patellar tracking should be
tray be placed as far back on the tibia patellar reamer can be accurately tested observing the “rule of no
as possible, so that if the tibial com- positioned. The surface guide of the thumb.” According to this rule, the
ponent is symmetrical and correct patellar reamer is used as a template patella should remain in place
rotation is achieved, the posterolat- and should fit snugly around the through the full range of motion
eral corner will overhang on the patella. The patella is reamed so that without being held. To reduce lax-
tibia. the bone-prosthesis composite will ity along the extensor mechanism, a
Patellar preparation is another have a thickness equal to or 1 to 2 mm clamp can be used to place longitu-
critical factor for success. During less than the original thickness of the dinal traction on the quadriceps ten-
exposure of the knee, the patella is patella (Fig. 1, C). The cut patellar don (Fig. 2). The knee is then flexed,

A B C

Fig. 1 Patellar preparation. A, The synovium is resected from the undersurface of the quadriceps tendon, preventing later impingement.
B, The patellar thickness is measured before cutting the bone. C, The thickness of the bone-prosthesis composite should be equal to or slightly
less than the original thickness of the patella.

Vol 2, No 5, Sept/Oct 1994 241

Patellofemoral Pain After Arthroplasty

deformity accompanied by elonga-

tion of the medial collateral liga-
ment requires release of the
iliotibial band and lateral collateral
ligament. In order to maintain sta-
bility in flexion, it is desirable, if
possible, to preserve the popliteus.
The resultant extension gap usually
requires a thicker tibial component,
which elevates the joint line. With
A B the posterior stabilized prosthesis,
Fig. 2 A clamp on the quadriceps tendon provides longitudinal traction on the extensor mech- the joint line may be elevated as
anism and more closely reproduces patellar tracking during extension (A) and flexion (B). much as 10 mm without problems.
When the joint-line elevation is
excessive, the patellar component
and patellar tracking is observed. If Restoration of the natural or nor- will impinge on the anterior margin
the patella tracks laterally or tilts mal joint line has always been an of the tibial articular surface, a situ-
during flexion, a lateral release important consideration in total ation readily apparent during trial
should be performed. Sometimes knee arthroplasty. This is more reduction.
reducing the patellar thickness critical in posterior cruciate liga-
slightly can diminish the need for a ment–retaining designs, because
Etiology of Postoperative
lateral release. the ligament must be balanced
Patellofemoral Pain
When performing a lateral properly to achieve a good range of
release, an “inside-out” or “outside- motion. It is possible to have an Several factors are responsible for
in” technique may be utilized. ideally aligned knee in which the postoperative patellofemoral pain
Whichever technique is used, it is position of the joint line after after total knee arthroplasty (Table
desirable to minimize disruption of arthroscopy is different from that 1). These are patellar instability,
the vascular insult to the patella. of the natural knee. However, this patellar fractures, soft-tissue im-
For this reason, the lateral retinacu- change in the joint line affects the
lum is cut proximally into the ten- patellar height, which can be fur-
don of the vastus lateralis and ther influenced by several factors.
distally to the joint line.19 The lat- A patient may have preoperative
eral superior geniculate vessels are patella infera. If the femoral com-
isolated and preserved. If the ves- ponent is too far anterior or is
sels continue to act as a tether, they undersized in the anteroposterior
should be cauterized and cut. 19 dimension, a large flexion gap is
While this theoretically threatens created, and the collateral liga-
the patellar blood supply, it fortu- ments are unbalanced in extension.
nately has not resulted in clinical When this situation is created,
problems. Patellar tracking is then more bone must be resected from
reassessed. If there is still lateral the distal femur; this results in the
tracking, the position of all compo- need for a thicker tibial component,
nents should be reevaluated, espe- which elevates the joint line and
cially with respect to rotational decreases the patellar height.
position. A proximal patellar re- When a large flexion gap is present,
alignment may occasionally be nec- an alternative is to utilize a femoral
essary to restore central tracking of component with a larger antero-
the patella. In performing the posterior dimension and to aug-
proximal realignment, the medial ment the posterior condyles.
Fig. 3 Proximal patellar realignment and
capsule and vastus medialis are Valgus deformities also influ- lateral retinacular release. At the time of
pulled laterally and imbricated ence the flexion gap and potentially arthrotomy closure, the medial flap is imbri-
over the patella and quadriceps cause secondary patellar problems. cated over the quadriceps tendon.
tendon (Fig. 3). Correction of an excessive valgus

242 Journal of the American Academy of Orthopaedic Surgeons

 Giles R. Scuderi, MD, et al

Table 1
slightly smaller than, the original can contribute to devascularization
Etiology of Patellofemoral Pain patella. In general, a composite of the patella, the relationship to
Following Total Knee thickness of 19 to 22 mm is appro- fracture has been thought by some to
Arthroplasty priate. This reduces the tension on be minimal.26 In a recent study, Tria
the lateral retinaculum and, in com- et al19 suggest that routine lateral
Patellar instability bination with a lateral retinacular release sacrificing the superior and
Patellar fractures release, improves patellar track- inferior lateral geniculate arteries
Soft-tissue impingement ing.22 carries an increased risk of fracture.
Breakage of the patellar component Proximal patellar realignment Therefore, if one performs a routine
Loosening of the patellar and lateral retinacular release have lateral release, an attempt to pre-
component
been helpful in restoring patellar serve the superior lateral geniculate
Rupture of the extensor mechanism
tracking in situations in which there artery must be made. Of course,
is laxity of the medial supporting tracking is paramount, and if lateral
pingement, breakage of the patellar structures or there are recurrent release is necessary for successful
component, loosening of the patellar patellar dislocations with normally patellofemoral tracking, it must be
component, and rupture of the aligned components. Merkow et al20 performed. The contribution of the
extensor mechanism. reported no recurrence after use of fat pad to patellar vascularity also
this technique. Distal realignment has been reviewed as a possible etio-
Patellar Instability with an osteotomy of the tibial tuber- logic factor. One study reported a
Today patellar instability after cle has also been recommended, but potential compromise with radical
total knee arthroplasty is usually this is associated with an increased excision27; another found no differ-
due to an error in surgical tech- risk of rupture of the patellar ten- ence.28
nique or results from secondary don.23 Goldberg et al29 have classified
trauma.20,21 The most common pre- the patterns of patellar fracture and
ventable causes include failure to Patellar Fractures their influence on clinical outcome.
perform a lateral release, excessive The incidence of patellar frac- The type I pattern is a transverse
genu valgum, excessive thickness tures after total knee arthroplasty fracture through the middle or
of the resurfaced patella, and rota- ranges from less than 1% to 21%.24 superior pole of the patella without
tional malalignment of the tibial Fractures can occur in both resur- disruption of the implant or the
and femoral components. Patellar faced and nonresurfaced patellae. quadriceps tendon. Type II frac-
instability is manifested more fre- Many factors have been implicated tures disrupt the quadriceps tendon
quently as recurrent subluxation in the causation of these fractures, or loosen the patellar component.
than as dislocation, but neither including obesity, high activity Type III-A fractures occur at the
responds well to nonoperative level, poor component design, and inferior pole of the patella with dis-
treatment. Although the reopera- less than optimal bone quality. ruption of the patellar tendon.
tion rate for patellar instability is Excessive bone resection during Type III-B fractures also occur at the
reported to be less than 1%, the preparation of the patella also is inferior pole of the patella, but the
cause of instability must be under- associated with this complication, patellar tendon remains intact. The
stood in each case, and the treat- especially if the patella is cut too type IV pattern is a lateral fracture-
ment must be directed to that thin or is cut asymmetrically.25 On dislocation. Fracture patterns with-
specific cause. Furthermore, the the basis of in vitro experiments, it out disruption of the extensor
precise cause of the instability must has been recommended that at least mechanism or loosening of the
be identified at the time of surgery, 15 mm of residual patellar bone be patellar component can be treated
since lateral release alone may not maintained to minimize strain on nonoperatively with 3 to 6 weeks of
correct the problem. It may be nec- the patella. However, our clinical immobilization. In general, these
essary to revise all components, experience in more than 500 cases fractures have a satisfactory clinical
especially if there is internal rota- has shown that leaving as little as outcome.
tion of the femoral or tibial compo- 12 mm of residual patellar bone Most fractures should initially be
nents. 7,8 When an overly thick does not increase the risk of frac- immobilized in extension, until the
patella is causative, more patellar ture. patient can do a straight-leg raise.
bone should be resected such that While lateral release with sacri- Surgical intervention is confined to
the bone-prosthesis composite is no fice of the superior and inferior lat- those situations in which there is a
bigger than, and preferably is eral geniculate vessels theoretically severely displaced transverse frac-

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Patellofemoral Pain After Arthroplasty

ture or a comminuted fracture in and extension, such as one that calls implantation with a cemented poly-
which the extensor mechanism is for use of an exercise bicycle. Cases ethylene component is preferred.
disrupted. When surgical repair is that do not respond and continue to Many times the metal debris,
contemplated, elaborate means of be painful have benefited from whether titanium or cobalt chro-
internal fixation should be avoided. arthroscopic debridement of the mium, is associated with prolifera-
A partial patellectomy with repair fibrous nodule. tive darkly stained synovium, which
of the extensor mechanism can be a should be completely excised. If the
successful alternative. A loose Disruption of Metal-Backed metal backing of the patellar compo-
patellar component requires exci- Patellar Components nent has caused abrasion and fret-
sion. If the bone stock is adequate, The use of metal-backed patellar ting of the femoral component, the
a new component can be reim- components has been plagued by fail- femoral component should also be
planted. Otherwise, the patella ure and breakage. Since a porous revised, as it could disrupt the new
may be left without resurfacing coating can be applied only to a metal- patellar component.
after removal of all the methyl- backed component, uncemented
methacrylate. patellar components are prone to fail- Loosening of Cemented and
ure because of lack of material bond- Noncemented Components
Soft-Tissue Impingement ing and because the component The incidence of loosening of
After total knee arthroplasty, a thickness is less than 1 to 2 mm.31 non-metal-backed patellar implants
prominent fibrous nodule may It is not unusual for heavy, active has been reported to range from 1%
develop on the undersurface of the patients with good flexion to present to 3%. 32 If loosening occurs, the
quadriceps tendon at its junction 1 to 2 years after surgery with the treatment options, depending on
with the patella. Despite restoration sudden onset of pain and gradual symptoms, are (1) observation, (2)
of central patellar tracking, such a swelling. The presence of a broken arthroscopic excision, (3) reimplan-
nodule may catch or “clunk” as the or dissociated metal-backed patellar tation, and (4) patellectomy.
knee flexes and extends. 30 The component can be diagnosed on the Surprisingly, not all loose poly-
patient often will complain that the basis of the audible metallic grating ethylene patellar components cause
knee gets painfully stuck as it is that occurs as the knee flexes and symptoms; if there are no symptoms,
extended from a flexed position. extends. There is usually a sterile observation is acceptable. If a loose
This usually occurs at 30 to 45 effusion with a murky appearance. component is causing symptoms,
degrees of flexion. This soft-tissue The thin peripheral polyethylene simple removal is often an option
impingement problem originally may delaminate and shed polyethyl- and can be done arthroscopically.
appeared to be unique to the poste- ene particles, which in turn creates a The skin and capsule must be
rior stabilized prosthesis, especially foreign-body reaction that results in enlarged for removal of the compo-
the original design, but more osteolysis and loosening of the patel- nent; this is usually less traumatic
recently it has been reported with lar component. Further polyethyl- when done through a superior and
other implant designs. Factors that ene wear leads to exposure of the lateral incision. The presence of a
have been implicated include metal backing, which abrades the fibrous layer enveloping the remain-
abrupt changes in the radius of cur- femoral component, releasing metal ing patella often results in painless
vature of the femoral component, debris. An axial radiograph will motion; therefore, removal of the
use of a patellar component that is often show the metal backing articu- component is preferable to patellec-
too large, and irritation of the lating with the femoral component. tomy, especially in an older arthritic
quadriceps tendon. Patellar catch- Sometimes radiopaque particles are patient. The decision to perform
ing problems are attributed to the shown on the radiograph, or the reimplantation is strictly dependent
configuration of the femoral compo- polyethylene component is seen to on whether there is sufficient bone
nent at the anterior margin of the be free in the joint. The metal-backed stock. Reimplantation probably
intercondylar notch and impinge- patellar component should be used should be reserved for the more
ment of a fibrotic nodule that is usu- cautiously, if at all, until a better active patient. When performing
ally located on the undersurface of means of bonding the polyethylene reimplantation, the surgeon should
the quadriceps tendon proximal to to the metal base plate is designed. follow the routine principles of patel-
the patella. When a patellar clunk is Treatment of a broken patellar lar bone preparation previously pre-
diagnosed early, the patient may component involves removal of the sented. Patellectomy is rarely
respond to an exercise program that metal backing and replacement. If required; however, if it is necessary,
concentrates on repetitive flexion satisfactory bone stock remains, we recommend a Compere-type pro-

244 Journal of the American Academy of Orthopaedic Surgeons

 Giles R. Scuderi, MD, et al

cedure, which enhances quadriceps plication of total knee arthroplasty, mechanism allografting might be
function and anterior knee cosmesis. and the treatment outcome is gener- an acceptable alternative, but at this
Cementless total knee arthro- ally poor.33 The best way to avoid time there is no confirmatory data.
plasty presents somewhat different this problem is to use meticulous Midsubstance tears of the patellar
problems. With the implant designs surgical technique. The extensor tendon or quadriceps tendon are rare
used, metal backing of the patellar mechanism is placed at risk during but have been associated with loose
component has been necessary to medial parapatellar arthrotomy if patellar components that lie against
provide a porous surface for bone the patellar tendon is split and the and erode the tendon. Such ruptures
ingrowth. Because of the high shear medial border of the tendon is ele- should be addressed by methods
forces at the patella, especially at vated with the medial capsule. If similar to those normally used in the
extremes of flexion, disruption of there is difficulty in everting the repair or reconstruction of quadri-
bone ingrowth of the patellar compo- patella, a proximal quadriceps ceps and patellar tendon rupture.
nent is a risk. When ingrowth occurs, release or distal tubercle osteotomy
it is usually at the fixation pegs, not at should be performed for exposure.
the base plate. Incomplete fixation, Struggling for adequate expo- Summary
combined with the high and repeti- sure may lead to avulsion of the
tive shear forces, can cause a stress patellar tendon. Reconstruction for Patellar resurfacing in total knee
fracture at the peg-plate junction, an avulsed patellar tendon is, at arthroplasty is still undergoing
resulting in loosening of the patellar best, troublesome. In our experi- scrutiny. In general, it is recom-
component. Rosenberg et al31 have ence, simple reattachment is thor- mended that patellar replacement be
reported that this usually occurs oughly ineffective. Elevating routinely performed in patients with
about 2 years after implantation. periosteal flaps and burrowing the inflammatory arthritis. It is less cer-
In a continued effort to improve tendon has an anecdotal record of tain which patients with osteoarthri-
fixation of implants designed for resulting in very limited flexion tis can be effectively treated without
cementless arthroplasty, several (less than 70 degrees). Extensor- patellar resurfacing. The ideal pa-
manufacturers have introduced tient is a thin osteoarthritic person
recessed metal-backed patellar com- with a relatively normal-appearing
ponents. Theoretically, this design patella. The ideal prosthetic design
should protect the thin polyethylene has not been established, although
margin from the high peripheral the all-polyethylene dome, with its
forces. However, there is a trade-off, nonconforming design, has the
because the smaller contact area longest successful follow-up. De-
between the bone and the implant sign considerations on the horizon
increases the risk of fracture at the are inset components and recession
patellar margins. This would result of the anterior or trochlear aspects of
if unresurfaced bone articulated the femur. Clinical results that
with the femoral condyles at should be forthcoming within the
extremes of flexion. Also, in patients next few years will allow assessment
with inflammatory arthritis, articu- of the efficacy of these design char-
lar cartilage may serve as a nidus for acteristics. Recreation of patello-
continued inflammation. Therefore, femoral mechanics is greatly
the long-term effectiveness of this influenced by the rotational position
design has yet to be determined. of the femoral and tibial compo-
nents, as well as by restoration of
Rupture of the Extensor patellar thickness and alignment.
Mechanism Many complications are preventable
Disruption of the extensor mech- Fig. 4 Rupture of the quadriceps tendon. with the use of meticulous surgical
anism (Fig. 4) is a devastating com- technique.

Vol 2, No 5, Sept/Oct 1994 245

Patellofemoral Pain After Arthroplasty

References
1. Rand JA: Patellar resurfacing in total 12. Buechel FF, Rosa RA, Pappas MJ: A arthroplasty. J Arthroplasty 1991;63:251-
knee arthroplasty. Clin Orthop 1990;260: metal-backed, rotating- bearing patellar 258.
110-117. prosthesis to lower contact stress: An 23. Kirk P, Rorabeck CH, Bourne RB, et al:
2. Insall JN, Lachiewicz PF, Burstein AH: 11-year clinical study. Clin Orthop Management of recurrent dislocation of
The posterior stabilized condylar pros- 1989;248:34-49. the patella following total knee arthro-
thesis: A modification of the total 13. Mason MD, Brick GW, Scott RD, et al: plasty. J Arthroplasty 1992;7:229-233.
condylar design—Two to four-year clin- Three pegged all polyethylene patellae: 24. Windsor RE, Scuderi GR, Insall JN:
ical experience. J Bone Joint Surg Am 2 to 6 year results. Orthop Trans Patellar fractures in total knee arthro-
1982;64:1317-1323. 1994;17:991-992. plasty. J Arthroplasty 1989;4(suppl):
3. Freeman MAR, Samuelson KM, Elias SG, 14. Rand JA: The patellofemoral joint in S63-S67.
et al: The patellofemoral joint in total total knee arthroplasty. J Bone Joint Surg 25. Josechak RG, Finlay JB, Bourne RB, et al:
knee prostheses: Design considerations. Am 1994;76:612-620. Cancellous bone support for patellar
J Arthroplasty 1989;4(suppl):S69-S74. 15. Levitsky KA, Harris WJ, McManus J, et resurfacing. Clin Orthop 1987;220:
4. Insall J, Scott WN, Ranawat CS: The al: Total knee arthroplasty without 192-199.
total condylar knee prosthesis: A report patellar resurfacing: Clinical outcomes 26. Scuderi G, Scharf SC, Meltzer LP, et al:
of two hundred and twenty cases. J Bone and long-term follow-up evaluation. The relationship of lateral releases to
Joint Surg Am 1979;61:173-180. Clin Orthop 1993;286:116-121. patella viability in total knee arthro-
5. Scuderi GR, Insall JN: Total knee 16. Stern SH, Insall JN: Total knee arthro- plasty. J Arthroplasty 1987;2:209-214.
arthroplasty: Current clinical perspec- plasty in obese patients. J Bone Joint Surg 27. Kayler DE, Lyttle D: Surgical interrup-
tives. Clin Orthop 1992;276:26-32. Am 1990;72:1400-1404. tion of patellar blood supply by total
6. Yoshii I, Whiteside LA, Anouchi YS: 17. Fern ED, Winson IG, Getty CJ: Ante- knee arthroplasty. Clin Orthop 1988;229:
The effect of patellar button placement rior knee pain in rheumatoid patients 221-227.
and femoral component design on after total knee replacement: Possible 28. McMahon MS, Scuderi GR, Glashow JL,
patellar tracking in total knee arthro- selection criteria for patellar resurfac- et al: Scintigraphic determination of
plasty. Clin Orthop 1992;275:211-219. ing. J Bone Joint Surg Br 1992;74: patellar viability after excision of
7. Rhoads DD, Noble PC, Reuben JD, et al: 745-748. intrapatellar fat pad and/or lateral reti-
The effect of femoral component position 18. Figgie HE III, Goldberg VM, Figgie nacular release in total knee arthro-
on the kinematics of total knee arthro- MP, et al: The effect of alignment of plasty. Clin Orthop 1990;260:10-16.
plasty. Clin Orthop 1993;286:122-129. the implant on fractures of the patella 29. Goldberg VM, Figgie HE III, Inglis AE,
8. Anouchi YS, Whiteside LA, Kaiser AD, after condylar total knee arthro- et al: Patellar fracture type and progno-
et al: The effects of axial rotational plasty. J Bone Joint Surg Am 1989;71: sis in condylar total knee arthroplasty.
alignment of the femoral component on 1031-1039. Clin Orthop 1988;236:115-122.
knee stability and patellar tracking in 19. Tria AJ Jr, Harwood DA, Alicea JA, et al: 30. Beight JL, Yao B, Hozack WJ, et al: The
total knee arthroplasty demonstrated on Patellar fractures in posterior stabilized patellar “clunk” syndrome after poste-
autopsy specimens. Clin Orthop knee arthroplasties. Clin Orthop rior stabilized total knee arthroplasty.
1993;287:170-177. 1994;299:131-138. Clin Orthop 1994;299:139-142.
9. Kim W, Rand JA, Chao EYS: Biome- 20. Merkow RL, Soudry M, Insall JN: Patel- 31. Rosenberg AG, Andriacchi TP, Barden
chanics of the knee, in Rand JA (ed): lar dislocation following total knee R, et al: Patellar component failure in
Total Knee Arthroplasty. New York: replacement. J Bone Joint Surg Am cementless total knee arthroplasty. Clin
Raven Press, 1993, pp 9-57. 1985;67:1321-1327. Orthop 1988;236:106-114.
10. McNamara JL, Collier JP, Mayor MB, et 21. Bindelglass DF, Cohen JL, Dorr LD: 32. Booth RE Jr: Patellar complications in
al: A comparison of contact pressures in Patellar tilt and subluxation in total total knee arthroplasty, in Scott WN
tibial and patellar total knee compo- knee arthroplasty: Relationship to pain, (ed): The Knee. New York: Mosby-Year
nents before and after service in vivo. fixation, and design. Clin Orthop Book, 1994, vol 2, pp 1325-1352.
Clin Orthop 1994;299:104-113. 1993;286:103-109. 33. Lynch AF, Rorabeck CH, Bourne RB:
11. Vince KG, McPherson EJ: The patella in 22. Reuben JD, McDonald CL, Woodard PL, Extensor mechanism complications fol-
total knee arthroplasty. Orthop Clin et al: Effect of patella thickness on lowing total knee arthroplasty. J Arthro-
North Am 1992;23(4):675-686. patella strain following total knee plasty 1987;2:135-140.

246 Journal of the American Academy of Orthopaedic Surgeons