(opvrigh I 994 by The Joiirial of Bo,u ,,nI Joi,t S,,rgerv.

Ituorporuted

Current Concepts Review

The Patellofemoral Joint in Total Knee Arthroplasty*

BY JAMES A. RAND. M.D.t. SCOTFSDALE. ARIZONA

Iii V(’Sti,g(ltiO?i pc’rfornied at the Mayo Clinic Scottsdale, Scottsdale

The patella improves the moment arm of the quad- the anterior superior iliac spine to the center of the
riceps, provides an articulation with low friction, pro- patella, and the patellar ligament, defined clinically
tects the distal aspect of the femur from trauma and the with a line drawn from the center of the patella to the
quadriceps from attritional wear, and improves the cos- center of the tibial tubercle37. This angle is known as
metic appearance of the knee”. the Q angle. This vector of force, which is oriented in a
Complications related to the extensor mechanism valgus direction, must be resisted by the soft-tissue re-
are the most frequent reasons for a reoperation in an straints and by the prominence of the lateral facet of the
aseptic knee after arthroplasty with a current design of trochlea.
total condylar prosthesis. The prevalence of complica- The distal articular surface of the femur may be
tions involving the extensor mechanism in large series considered to be represented by three circular sur-
has ranged from 1.5 to 12 per cent9”5’. Patient selec- faces’7. The floor of the patellar groove articulating with
tion, operative technique, and the design of the implant the patella between 10 and 100 degrees of flexion of the
all influence the frequency of these complications. The joint represents one circle. The posterior aspects of the
combination of high loads, small contact areas, chang- femoral condyles articulating with the tibia between 10
ing contact points. and multiple soft-tissue attachments and 150 degrees of flexion form the second circle. The
make the patella particularly vulnerable to problems axis of flexion and extension of the knee passes through
after total knee arthroplasty. the center of the second circle’79’. The distal aspects of
the condyles articulating with the tibia from 0 to 10
Anatomy and Biomechanics
degrees of flexion form the third circle’7. The radius
Knee motion is a combination of rolling, gliding. and of the patellar groove averages twenty-four millimeters
rotation of the femoral condyles with respect to the and subtends an arc of 90 degrees. The average height
tibial plateaus. The axis of rotation of the knee for of the trochlea of the femur is between thirty-one and
flexion and extension lies along a line that connects the thirty-four millimeters, and the average width of the
origins of the collateral ligaments on the medial and trochlear groove is between thirty-five and thirty-eight
lateral femoral epicondyles555. There is a variable rela- millimeters’. However, there is considerable variability
tionship between the transepicondylar line and a line in trochlear height and width. The patellar retinacular
tangential to the posterior aspects of the femoral con- reflections lie within the central area of the patellar
dyles that averages 3 degrees9’9t. Although the major circle’7. It has been suggested that the patellar retinacula
motion about the axis of flexion and extension is flexion, act as collateral ligaments for the patellofemoral joint’7.
varus and internal rotation occur during flexion because The contact area on the patella between the patella
the axis is not perpendicular to the sagittal plane. A and the femur varies with the angle of flexion of the
longitudinal rotational axis lies anterior to the axis of knee, and the location of contact on the patella between
flexion and extension and passes near the insertion of the patella and the femur is distal in extension and pro-
the anterior cruciate ligament on the tibia and the origin gresses proximally with flexion of the knee252’3435. The
of the posterior cruciate ligament on the femur. The area of patellofemoral contact increases with flexion29.
orientation of these axes results in the screw-home Contact between the quadriceps tendon and the femur
mechanism of knee motion’. The screw-home mecha- begins at more than 70 degrees of flexion29. The maxi-
nism creates an angle between the line of pull of the mum area of contact between the patella and the femur
quadriceps, measured clinically with a line drawn from occurs at 120 degrees of flexion34. The patellofemoral
contact area increases as much as four times with quad-
*No benefits in any form have been received or will be received riceps load because of deformation of cartilage29.
from a commercial party related directly or indirectly to the subject
Contact pressures within the patellofemoral joint
of this article. No funds were received in support of this study.
tOrthopaedic Department. Mayo Clinic Scottsdale. 134(X) East are high, with maximum values occurring at 90 degrees
Shea Boulevard. Scottsdale. Arizona 85259. of flexion when the 0 angle is normal34. Changes in the

612 THE JOURNAL OF BONE AND JOINT SURGERY

 THE PATELLOFEMORAL JOINT IN TOTAL KNEE ARTHROPLASTY 613

0 angle of 10 degrees can increase patellofemoral con- arthroplasties was 2.4 per cent for knees that had not
tact pressures by 45 per cent at 20 degrees of flexion’. had resurfacing of the patella compared with 2.5 per
The reaction force of the patellofemoral joint may be cent for those that had”. In a series of 891 duopatellar
0.5 times body weight during walking on a level surface total knee arthroplasties that were followed for 6.5
and as much as 6.5 to 7.6 times body weight during years, the rate of complications was 4 per cent (sixteen)
stair-climbing. of 396 knees that had had resurfacing of the patella
Maximum force in the quadriceps muscle and pate!- compared with 12 per cent (fifty-eight) of 495 knees that
lar ligament is generated at 60 degrees of flexion with had not (p < 0.0O01). In the group of 495 knees that had
values approaching 3000 newtons35. Forces in the patel- not had resurfacing, 10 per cent (fifty-one knees) had
lar ligament are 30 per cent greater than those in the chronic pain, and 13 per cent (forty) of the 300 knees
quadriceps muscle at 30 degrees of flexion, while the that had inflammatory arthritis and 6 per cent (eleven)
converse is true at 90 and 120 degrees of flexion35. If of the 195 knees that had osteoarthrosis had pain.
a patellectomy is performed, the moment arm for the In a study of knees in which a total condylar pros-
quadriceps is decreased and a 30 to 40 per cent decrease thesis had been inserted without resurfacing of the pa-
in quadriceps torque occurs58’. tella, Picetti et al.59 reported that 24 per cent (twenty) of
Total knee arthroplasty has several biomechanical eighty-four knees that had osteoarthrosis had patello-
effects on the patellofemoral joint. Designs of pate!lar femoral pain at four and a half years after the arthro-
implants may be considered as axisymmetrical (dome p!asty. The authors recommended resurfacing of the
shaped), one-plane symmetrical (anatomically shaped), patella for all patients who have rheumatoid arthritis
or two-plane symmetrical (modified dome shaped)42. and for patients who have osteoarthrosis and are more
When seven different designs of total knee arthro- than 160 centimeters tall and weigh more than sixty-five
plasties were compared, the total contact area in the kilograms59. In yet another study of the total condylar
patellofemoral joint was only 21 per cent of that in the prosthesis, patients who had had total knee arthroplasty
intact knee joint42. Contact areas of the axisymmetrical with resurfacing of the patella had an improved ability
design decreased less with malalignment than did con- to climb stairs compared with patients who had not had
tact areas of the one-plane symmetrical design. There resurfacing of the patella78.
was a tendency for the prosthetic patella to shift medi- In a study of twenty-five patients who had had a
ally on knee flexion compared with the control pate!la, bilateral total knee arthroplasty with use of the Syn-
which shifted laterally42. These alterations of knee kine- atomic prosthesis (DePuy, Warsaw, Indiana) with resur-
matics and the decrease in patellofemoral contact area facing of the patella on only one side, the side that had
after total knee arthroplasty may be responsible for been resurfaced demonstrated improved strength and
complications such as polyethylene wear, loosening, and less pain referable to the patella than the contralateral,
subluxation. non-resurfaced side’9.
Abraham et al., in a study of 100 variable-axis total
Resurfacing of the Patella knee arthroplasties that had been followed for a mini-
Resurfacing of the patella at the time of a total knee mum of five years, found no differences in pain or func-
arthroplasty remains controversial. Resurfacing may tion between the fifty-three knees that had not been
improve relief of pain and the ability to climb stairs, resurfaced and the forty-seven knees that had. In a pro-
compared with total knee arthroplasty done without spective study of thirty-five patients who had rheuma-
resurfacing, but it does so at the risk of complications toid arthritis and who had had a bilateral total knee
such as loosening or wear of the implant. The frequency arthroplasty with resurfacing of the patella on only one
of resurfacing of the patella in centers where a large side, there were no differences in relief of pain or in
number of arthroplasties are performed increased from function between the knees that had been resurfaced
30 per cent in the 1970s72 to 68 per cent in 19850. Rec- and those that had not at an average of 2.7 years after
ommendations have ranged from routine resurfacing of the arthroplasty75. In a study of 138 total condylar knee
the patella8’9’’78 to no resurfacing’27576 to the selection prostheses in patients who had rheumatoid arthritis and
of only some knees for resurfacing”72 at the time of total who had not had resurfacing of the patella, sixteen (13
knee arthroplasty. Indications for resurfacing of the pa- per cent) of the 119 knees that were followed for an
tella include rheumatoid or another type of inflam- average of five years had moderate or severe pain2’. The
matory arthritis, eburnated bone in the patellofemoral authors concluded that a patellar height (the distance
joint, cystic changes in the patella, a lack of congruence between the inferior pole of the patella and the articular
between the patella and the trochlear design of the pros- surface of the tibial plateau) of less than fifteen milli-
thesis, and maltracking of the patella84872. The only con- meters was associated with pain in the knee. In another
traindication to resurfacing of the patella is insufficient study, fourteen patients who had osteoarthrosis were
bone stock, because adequate fixation of the implant followed for an average of 7.5 years after a bilateral
cannot be achieved. total knee arthroplasty with resurfacing of the patella
The rate of reoperation in a series of 238 total knee on only one side. At the time of follow-up, six patients

VOL. 76-A, NO. 4. APRIL i994

614 J. A. RAND

rated both sides as equal, six preferred the resurfaced not critical3. Medial placement of the patellar implant
side, and one preferred the side that had not had resur- to recreate the height of the median ridge of the patella
facing’. Of the total group of seventy-nine knees that provides more normal tracking of the patella than does
had not had resurfacing of the patella in that study, 19 central placement of the implant on the patella85. In
per cent were mildly painful in the anterior aspect at the vitro, the combination of a four-millimeter-deep troch-
follow-up examination4. lear groove and placement of the patellar implant in a
Therefore. resurfacing of the patella probably should medial position reproduced normal tracking of the pa-
be performed selectively in patients who have osteo- tella85. External rotation of the femoral component re-
arthrosis. The patella may be left unresurfaced if there is ferable to the posterior aspects of the femoral condyles
an absence of eburnated bone, crystalline disease, or in another in vitro model more normally reproduced
synovial inflammation and if there is congruent tracking tracking of the patella than did a neutral or internally
and normal shape of the patella9”7. The patella should rotated femoral component2. However, even external
be resurfaced in most patients who have rheumatoid rotation of the femoral component resulted in a medial
arthritis or if the surgeon has doubt regarding the fulfill- tracking pattern of the patella compared with that of the
ment of all of the criteria for not resurfacing the patella. untreated, control knee. Lateral placement of the fem-
oral component in yet another in vitro model allowed
Prevalence of Ma/position tutiti tvlalaligiunent more normal tracking of the patella than did central
of tile Pate//ar Component placement of the prosthesis when the prosthesis had a
Experienced surgeons have noted asymmetrical re- high lateral ridge of the trochlea8. Reproduction of the
surfacing (placement of the articular surface of the pa- height of the femoral trochlea (with avoidance of an-
tellar implant not parallel to the anterior surface of the tenor displacement of the femoral component) assists
patella). tilt, and subluxation of the patella on radio- in the maintenance of proper tension in the extensor
graphs of knees that had a satisfactory clinical result mechanism. Neutral or external rotation of the tibial
after a total knee arthroplasty7’’’77. In a series reported component referable to the tibia decreases the 0 angle
on by Sneppen et al., subluxation of the patella was and assists in the tracking of the patella.
identified after fourteen and patellar tilt was identi- Insertion of a patellar prosthesis into a cavity cre-
fied after eight of 100 total condylar knee arthroplas- ated in the patella has been recommended to provide
ties. In another series of 100 total knee arthroplasties, improved alignment and greater patella-patellar im-
Ranawat’ reported patellar tilt in fourteen knees and plant composite strength compared with those of a re-
asymmetrical resurfacing in seven. In my previous series surfacing patellar prosthesis, which is onlayed222541’. In a
of fifty total knee arthroplasties5. asymmetrical resur- comparison of twenty patellar resurfacing prostheses
facing was present in nine knees and patellar tilt, in with twenty inset prostheses, the inset implants pro-
five knees. Bindelglass et al.7 reported patellar tilt in vided less patellar tilt and improved alignment referable
seventy-two knees and patellar subluxation in thirty- to the osseous patella than did the resurfacing im-
four knees in a study of 234 total knee arthroplasties. plants25. Five years after 140 total knee arthroplasties
with an inset metal-backed patellar prosthesis, there
Technique
were four fractures, two lateral subluxations, but no
The technique of total knee arthroplasty affects loosening of the patellar component2.
the frequency of complications involving the extensor Of 451 inset metal-backed patellar components that
mechanism. Reproduction of the original thickness of were followed for four years, seven subluxated laterally
the patella after resurfacing of the patella, assurance and two loosened. No component was revised because
of an even resection of the patellar bone parallel to of wear.
the non-articular surface of the patella, maintenance of
Previous Patellectomy
the joint line (the same relationship between the in-
ferior pole of the patella and the articular surface of Total knee arthroplasty after a previous patellec-
the tibia). and soft-tissue balancing to allow correct tomy presents some technical problems. Since the pa-
tracking of the patella are important technical consider- tella, the extensor mechanism, and the cruciate ligaments
ations8453. Removal of the strong subchondral cancellous provide anterior-posterior stability of the knee, the
bone of the patella during resurfacing weakens the pa- posterior cruciate ligament must be functional or a
tella3. After removal of the articular surface and adja- posterior-stabilized total knee design should be used in
cent subchondral bone, a resulting minimum thickness a patient who has had a patellectomy5. If both cruciate
of fifteen millimeters of patellar bone has been recom- ligaments are removed from a knee that has had a patel-
mended to minimize strain on the patella7.The mechan- lectomy. posterior subluxation of the tibia (referable to
ical strength of the remaining cancellous bone after the femur) may occur after a total knee arthroplasty. A
removal of the articular surface and adjacent subchon- study of seven unconstrained total knee arthroplasties
dral bone of the patella is variable; consequently, the revealed six satisfactory results after four years’. Two of
location of the fixation pegs of the patellar implant is these knees, however, had anterior-posterior laxity at 90

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 TIlE PATELLOFEMORAL JOINT IN TOTAL KNEE ARTHROPLASTY 615

degrees of fiexion. Bayne and Cameron reported the of the tibia! tubercle, with or without proximal re-
results of fourteen total knee arthroplasties after a pat- alignment, has been recommended’, but it is associated
ellectomy. Ten knees had been initially treated with a with the potential for rupture of the patellar ligament27.
resurfacing condylar prosthesis: two, with an unlinked The results of treatment of instability of the patella are
hinged prosthesis: and four, with a hinged prosthesis. Six variable. Merkow et al.55 reported no recurrences after
of the ten initial resurfacing condylar prostheses were operative treatment of twelve knees that had had dislo-
revised. A good result was achieved with two ofsix (four cation of the patella after a total arthroplasty. However,
primary and two revision) resurfacing condylar prosthe- necrosis of the skin and a patellar fracture developed in
ses. one of two primary unlinked hinged prostheses, and one knee each. Brick and Scott” reported two repeat
five of six (two revision and four primary) hinged pros- dislocations and two subluxations after operative treat-
theses9. In a study of total knee arthroplasties in eleven ment of nineteen knees. Additional complications in-
patients who had had a previous patellectomy, a good or cluded two avulsions of the tibial tubercle and one
excellent result was achieved in only five knees com- deep infection. Grace and Rand27 reported the oper-
pared with all eleven knees in control patients who had ative treatment of twenty-five knees that had had sub-
had a total knee arthroplasty without a previous patel- luxation of the patella after a total arthroplasty. The
lectomy47. Factors that were related to a satisfactory re- subluxation recurred in four of fourteen knees that had
sult were less than four previous operations on the knee, been treated with proximal realignment. There were
severe arthritis evident on the radiographs, and a strong no recurrent dislocations in nine knees that had been
quadriceps muscle47. In another study, a good or excellent treated with combined proximal and distal realignment,
result was achieved after seven of fourteen primary total but a rupture of the patellar ligament developed in two
knee arthroplasties done after a patellectomy and after of these knees. The two remaining knees had been
eleven of fourteen primary total knee arthroplasties treated with revision of the component, and the sublux-
done without a previous patellectomy4. A good or excel- ation of the patella recurred in one of them. Kirk et al.43
lent result was also achieved in seven of twelve knees reported no recurrent dislocations or ruptures of the
treated with a revision total arthroplasty. The combina- patellar ligament in fifteen knees in which dislocation
tion of a diagnosis of traumatic osteoarthrosis and a following a total arthroplasty had been treated with
previous patellectomy was associated with a poor prog- distal transfer of the patellar ligament with use of a
nosis after total knee arthroplasty: seven of the twelve modified Trillat procedure.
patients who had a revision total knee arthrop!asty had
Patellar Fractures
this combination of factors45. Buechel suggested use of a
bone graft to the extensor mechanism to replace patellar The prevalence of patellar fractures after a total
function and reported a satisfactory result, after an aver- knee arthrop!asty has ranged from 0.1 per cent (twelve
age of six years of follow-up. after six of seven total knee of 8249) to 8.5 per cent (ten of 1 Fractures
arthroplasties done with this method’3. occur in both resurfaced and unresurfaced patellae. In
a study by Grace and Sim, the rate of fracture after total
Instability of the PateUa knee arthroplasty was 0.05 per cent (three of 5530) for
Instability of the patella after total knee arthroplasty the unresurfaced patellae compared with 0.33 per cent
may occur with or without resurfacing of the patella. (nine of 2719) for the resurfaced patellaeM. The rate of
Subluxation is more frequent than dislocation”. The fracture was higher after a revision (0.61 per cent: three
prevalence of symptomatic instability of the patella lead- of 495 knees) than after a primary total knee arthro-
ing to a reoperation is low: 0.5 per cent (twenty-five of plasty (0.12 per cent; nine of 7754 knees).
5463) to 0.8 per cent (twenty-four of 2887) in centers A patellar fracture may be due to trauma, fatigue,
where a large number of arthroplasties are performed’27. or stressn. Fatigue fractures are more common than
The etiology of instability includes malposition of the traumatic fractures. The etiology of a fatigue fracture
component, soft-tissue imbalance. trauma, and exces- may be avascularity4’53737482, malalignment of the compo-
sive valgus alignment of the knee9276. Internal rotation nent2’, excessive resection of bone’528, or use of a large
of the femoral or tibia! component, or both; a femoral central fixation peg on the patellar implant’573.
component of excessive size: and an excessive thickness The vascular supply to the patella is potentially at
of the patella-patellar implant composite compared with risk when an anteromedial arthrotomy is performed in
the patellar thickness before resurfacing predispose to combination with release of the lateral retinaculum and
instability755. removal of the superior lateral genicular vessels”. If a
The treatment of instability of the patella must be lateral release is performed at least one centimeter from
directed at its cause. A malpositioned or malaligned the patella, there is less interference with the patellar
component must be revised. Proximal realignment with blood supply than if it is performed adjacent to the
release of the lateral retinaculum and advancement of patella4’. Radical excision of the fat pad, combined with
the vastus medialis is recommended in the absence of lateral release, can potentially compromise the patellar
malposition2795. Distal realignment with an osteotomy blood supply”. As demonstrated by technetium bone

VOL. 76-A. NO. 4. APRIL 1994

616 J. A. RAND

scans, the rate of vascularity of the patella has ranged tures disrupt the quadriceps mechanism or the fixation
from three of thirteen to nine of sixteen within two of the implant; Type-lilA fractures involve the inferior
weeks after total knee arthroplasties done with a lateral pole of the patella with disruption of the patellar !iga-
release of the retinaculum, compared with a rate rang- ment; Type-IIIB fractures are non-displaced fractures of
ing from one of twenty-seven to three of twenty after the inferior pole of the patella with an intact patellar
total knee arthroplasties done without a lateral re- ligament; and Type-IV fractures are lateral-fracture dis-
lease537482. By at least one year after a total knee arthro- locations. All of the fourteen Type-I fractures in the
plasty with a lateral release, the technetium bone scans study by Goldberg et al. had a satisfactory result after
of the patella have returned to normal7’. Osteonecrosis non-operative treatment. Two of the six Type-Il frac-
has been identified in some patellae that had a fatigue tures had a satisfactory result after operative treatment.
fracture after total knee arthroplasty73. A patellar frac- Seven of the eight Type-lilA fractures were treated with
ture was identified in seventeen (4 per cent) of 471 an operation, and two of these had a satisfactory re-
knees that had not had a lateral release compared with sult. Both of the Type-IIIB fractures that were treated
one ( 1 per cent) of eighty-four knees that had had such non-operatively had a satisfactory result. Two of the six
a release, which suggests that factors other than vascu- Type-IV fractures that were treated operatively had a
larity are important in the etiology of the fractures10’. satisfactory result.
Increased tension of the lateral retinacu!um may place Therefore, fractures without loosening of the im-
increased stress on the patella and lead to a fracture69. plant and with an intact extensor mechanism respond
Figgie et al.2’ defined radiographic criteria for neu- well to non-operative treatment. Operative treatment is
tral positioning of a total condylar knee prosthesis. Fif- necessary for fractures that are associated with disrup-
teen of sixteen knees that had a pate!!ar fracture and tion of the extensor mechanism, loosening of the pa-
minor malalignment of the component had a good or te!lar implant, and dislocation. A partial patellectomy
excellent result. In contrast, only three of twenty knees with repair of the extensor mechanism provides a bet-
that had a patellar fracture and major malalignment had ter result than attempts at open reduction and internal
a good or excellent result. fixation.
Displacement of the fracture fragments is an im-
Wear
portant determinant of treatment and results. Non-
operative treatment is recommended for fractures that After total knee arthroplasty, in vitro strain over the
are non-displaced327383: however, the definition of dis- anterior aspect of a resurfaced patella is as much as
placement has ranged from more than two millime- three times that in a control, untreated knee52. The mag-
ters32 to two centimeters73n. In a study by Hozack et nitude of the increase of patellar strain varies with the
al.3, the result of non-operative treatment of five pa- design of the implant. As metal backing of the pate!la
tellar fractures, of which two were displaced more than decreases strain in the patella after total knee arthro-
two millimeters, was satisfactory in four knees. The re- plasty, although not to normal levels24, it has been added
sult of operative treatment of sixteen patellar frac- to the design of the patellar implant in an attempt to
tures, of which twelve were displaced and four were improve fixation of the implant.
non-displaced, was satisfactory in eight knees. The re- Wear occurs with both all-polyethylene and metal-
sult was unsuccessful for two fractures treated with backed polyethylene patellar implants. However, cata-
open reduction and internal fixation, and it was suc- strophic failure has been more frequent and a biological
cessful for two of four fractures treated with excision response to the wear debris has been more pronounced
of the fracture fragments and for six of ten fractures with the metal-backed patellar prostheses. The preva-
treated with patel!ectomy32. In another study, all six frac- lence of failure from wear of a metal-backed implant is
tures that had been treated non-operatively and three dependent on the duration of the evaluation. The rate
of nine fractures that had been treated operatively had of failure from clinically symptomatic wear has ranged
a satisfactory result”. The rate of complications with from 5 per cent (seven of 131) to 11 per cent (sixteen
operative management was six of nine. In the study by of 150) within two years after the total knee arthro-
Grace and Sim28, three of four fractures that had been plasty497’79. Failure of a metal-backed patellar implant
treated non-operatively had a satisfactory result com- appears to be a generic problem that affects many dif-
pared with five of seven fractures that had been treated ferent designs34. A metal-backed patellar implant with a
operatively. The over-all rate of complications was five polyethylene articular surface that is free to rotate with
of twelve knees. reference to the metal backing appears to be less sus-
The pattern of the fracture can affect the result. ceptible to wear than other designs; no wear-related
Goldberg et al.23 classified five types of patellar frac- failure was reported in 313 knees that had been fol-
tures after total knee arthroplasty. Type-I fractures are lowed for two to eleven years’4. Factors affecting wear
through the middle of the patel!ar body or through the of the polyethylene include the degree of congruity,
superior pole of the pate!la and do not involve the im- the shear forces associated with maltracking, and the
plant, cement, or quadriceps mechanism; Type-Il frac- high patellofemoral forces33. In vitro, with use of cy-

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 THE PATELLOFEMORAL JOINT IN TOTAL KNEE ARTHROPLASTY 617

clic loading. patellar components made of all polyethyl- includes excessive dissection of the patellar ligament
ene sustained local deformation and osseous failure at the time of the operation, failure of the fixation of
while metal-backed implants failed because polyethyl- the patellar ligament after realignment of the distal
ene wear exposed the metal backing33. Since metal back- extensor mechanism, manipulation of the knee, and
ing must he two to three millimeters thick, it is difficult trauma”#{176}. In the study of Rand et al.’#{176},
only four of
to manufacture a metal-backed resurfacing patellar im- sixteen knees in which a rupture of the patellar ligament
plant and maintain the six to eight-millimeter thickness after a total knee arthroplasty had been treated opera-
of polyethylene that is recommended to avoid high tively had a successful result. After treatment, eleven of
stresses and wear without the resurfaced patella being the knees had a persistent rupture and an infection de-
too thick#{176}. veloped in four knees, leading to an arthrodesis in two
Failure of the metal-backed patellar component and an above-the-knee amputation in one. Of the nine
may occur by wear of the polyethylene exposing the patients originally managed with fixation with sutures,
metal backing, by fracture of the polyethylene with sep- the repair failed in six and an infection developed in
aration from the metal backing, or by fracture of the three. Of the four knees originally treated with fixation
fixation pegs from the metal backing of the patellar with a staple, the result was successful in two. Two knees
implant347’7’. Design features of the implant that can had been reconstructed with use of a xenograft, and the
lead to failure include thin polyethylene over the edge result was successful in both. One knee had been treated
of the metal plate: a lack of bonding of the polyeth- with reconstruction with semitendinosus tendon, and
ylene to the metal plate: thin polyethylene over-all; the resu!t was unsuccessful65. In contrast, in the study
a sharp. angled transition point between the trochlear of Cadambi and Engh’5, a successful result was achieved
surface and the condylar weight-bearing surfaces of in all seven knees that had been treated for a rupture of
the femur: and use of a femoral component made of the patellar ligament (after a total knee arthroplasty)
titanium34Ss77. with an autogenous graft that consisted of the semi-
tendinosus tendon followed by six weeks of immobi-
Soft-Tissue Impingement !ization in a cast. Only three knees achieved more than
Soft-tissue impingement can occur following total 90 degrees of flexion. Late reconstruction of a rupture
knee arthroplasty. The patellar clunk syndrome is pri- of the patellar ligament with use of an allograft that
manly associated with the use of a posterior stabilized consisted of a composite of quadriceps tendon, patella,
prosthesis3’. A prominent fibrous nodule develops at the pate!!ar ligament, and tibial tubercle was reported by
junction of the proximal pole of the patella and the Emerson et al.’8. Three of ten total knee arthroplasties
quadriceps tendon. During flexion of the knee, the fi- that had been treated with this allograft failed.
brous nodule enters the intercondylar notch of the fe- Rupture of the patellar ligament is better avoided
mur and catches in this location on extension of the than treated. A knee that has limited preoperative
knee. Operative removal of the nodule has been suc- motion is at risk. Repair of the patellar ligament with
cessful in the relief of symptoms3. Hypertrophy of the augmentation with the semitendinosus tendon and pro-
fat pad with the development of patella infera can be a longed immobilization in a cast appears to provide the
source of pain after total knee arthroplasty’2. Excision best results.
of the hypertrophic fat pad with freeing of the patellar
ligament from scar tissue has been recommended’8. Pa- Loosening and Revision of the PateUar Implant

tella infera after total knee arthroplasty is not always Loosening of the patellar implant has been reported
symptomatic. A study of sixty-one knees that had at after sixteen (0.6 per cent) of 2887 to five (1.3 per cent)
least a 10 per cent decrease in the Insall-Salvati ratio37 of 396 total knee arthroplasties8’. Factors associated
(the length of the patellar ligament divided by the with loosening of cemented patellar implants include
length of the patella on a lateral radiograph of the knee) use of a thin central fixation peg on the implant, malpo-
after total knee arthroplasty found no association be- sition of the patellar component, and trauma”. With use
tween the range of motion or the strength of the quad- of a three-peg patellar component in 577 total knee
riceps and the degree of patella infera”. Intra-articular arthrop!asties, Mason et a!. reported no loosening at an
fibrous bands that created a tethered patella syndrome average of three years after the arthroplasty55.
were reported after eleven of 635 total knee arthroplas- Revision of a failed patellar prosthesis is difficult. Of
ties9’. After removal of the fibrous bands, all of the thirty-six revisions of only the patellar prosthesis after
symptoms resolved. total knee arthroplasty in the study by Berry and Rand5,
83 per cent (thirty) led to a good or excellent result.
Rupture of the Patellar Ligament However, complications occurred in fourteen (34 per
The prevalence of rupture of the patellar ligament cent) of the forty-one patients. There was a patellar
following total knee arthroplasty has ranged from 0.22 fracture in five patients, patellar instability in three, pe-
per cent (eighteen of 8288 procedures) to 0.55 per cent roneal palsy in two, polyethylene wear in two, infection
(five of 915 procedures)’559. The etiology of the rupture in one, and an extensor lag in one. Lynch et al.5’ reported

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618 J. A. RAND

a 24 per cent rate of complications (nine of thirty-seven frequent reasons for reoperation after insertion of a
knees) after isolated revisions of patellar components. total condylar prosthesis are complications affecting the
. extensor mechanism. The large forces acting on the pa-
Overview tella, combined with a small area of contact, create high
Loosening and instability were frequent mecha- stresses on the resurfaced patella.
nisms of failure of early total knee prostheses. With the Resurfacing of the patella is valuable in selected
current use of total condylar prostheses, improved in- patients. Isolated revision of the patellar component af-
strumentation. and improved operative technique, fail- ter total knee arthroplasty has a 24 to 33 per cent rate
ure from loosening of the prosthesis is infrequent. of complications65’. Complications related to the exten-
Failure of current total knee arthroplasties results from sor mechanism after total knee arthroplasty can be best
deep infection or polyethylene wear. However, the most avoided by meticulous operative technique.

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