A Novel Infrapatellar Fat Pad Preservation Technique in Total Knee Arthroplasty Reduced Postoperative Pain and Wound Complications

Abstract

Objective: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) remains controversial. This study aimed to evaluate a novel IPFP preservation technique—“the medially pedicled IPFP flap”—for reducing postoperative pain, wound complications, and improving functional recovery after TKA.

Methods: A retrospective analysis was conducted on TKA cases at our institution from 2018 to 2021, including those with IPFP preservation (medially pedicled flap) versus IPFP complete resection. Patient demographics, perioperative parameters (blood loss, operative time, length of hospital stay, visual analogue scale [VAS] score, white cell count [WBC], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], and wound oozing), and postoperative follow-up data (VAS, Knee Society [KSS], or Knee Society functional assessment [KSFA] scores) were compared between groups. Independent sample t-tests were used to compare continuous data and chi-squared tests were used to compare categorical data between groups.

Results: Six hundred thirty patients were included, with 278 in the medial pedicled IPFP flap group (preservation group) and 352 in the IPFP resection group (resection group). The operative time was significantly shorter in the preservation versus resection group (125.5 ± 23.2 vs 130.3 ± 28.7 mins, p = 0.03), as was the length of hospital stay (8.4 ± 2.7 vs 9.2 ± 2.3 days, p < 0.01). Regarding pain, the preservation group had significantly lower VAS scores on postoperative day 2 (2.0 ± 0.8 vs 2.4 ± 1.2, p < 0.001) and day 3 (1.5 ± 0.5 vs 1.8 ± 1.0, p < 0.001). CRP and ESR levels on postoperative day 5 were also significantly lower in the preservation group. Wound oozing rates were significantly lower in the preservation versus resection group (0.7% vs 2.8%, p = 0.04). No significant differences existed in VAS, KSS, or KSFA scores at the last follow-up.

Conclusion: The novel IPFP preservation technique significantly improved surgical exposure, shortened operative time and length of hospital stay. It also reduced wound pain and oozing compared to IPFP resection.

Keywords

Infrapatellar fat pad (IPFP) / Pain / Periprosthetic joint infection / Total knee arthroplasty (TKA) / Wound oozing

References

[1] Kulm S, Kolin DA, Langhans MT, Kaidi AC, Elemento O, Bostrom MP, et al. Characterization of genetic risk of end-stage knee osteoarthritis treated with Total knee arthroplasty: a genome-wide association study. J Bone Joint Surg Am. 2022; 104: 1814–1820.

[2] Klug A, Gramlich Y, Rudert M, Drees P, Hoffmann R, Weißenberger M, et al. The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years. Knee Surg Sports Traumatol Arthrosc. 2021; 29: 3287–3298.

[3] Karzon AL, Kadakia RJ, Coleman MM, Bariteau JT, Labib SA. The rise of Total ankle arthroplasty use: a database analysis describing case volumes and incidence trends in the United States between 2009 and 2019. Foot Ankle Int. 2022; 43: 1501–1510.

[4] Rullán PJ, Emara AK, Zhou G, Pasqualini I, Klika AK, Koroukian S, et al. National Inpatient Datasets may No Longer Be Appropriate for overall Total hip and knee arthroplasties projections after removal from inpatient-only lists. J Knee Surg. 2024; 37: 214–219.

[5] Feng B, Zhu W, Bian YY, Chang X, Cheng KY, Weng XS. China artificial joint annual data report. Chin Med J (Engl). 2021; 134: 752–753.

[6] Almeida RP, Mokete L, Sikhauli N, Sekeitto AR, Pietrzak J. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Rev. 2021; 6: 872–880.

[7] Kurien T, Kerslake RW, Graven-Nielsen T, Arendt-Nielsen L, Auer DP, Edwards K, et al. Chronic postoperative pain after total knee arthroplasty: the potential contributions of synovitis, pain sensitization and pain catastrophizing—an explorative study. Eur J Pain. 2022; 26: 1979–1989.

[8] Ghoshal A, Bhanvadia S, Singh S, Yaeger L, Haroutounian S. Factors associated with persistent postsurgical pain after total knee or hip joint replacement: a systematic review and meta-analysis. Pain Rep. 2023; 8: e1052.

[9] Gausden EB, Shirley MB, Abdel MP, Sierra RJ. Increased risk of periprosthetic joint infection after acute, traumatic wound dehiscence following primary total knee arthroplasty. Bone Joint J. 2021; 103-B: 191–195.

[10] Lo LWT, Suh J, Chen JY, Liow MHL, Allen JC, Lo NN, et al. Early postoperative pain after Total knee arthroplasty is associated with subsequent poorer functional outcomes and lower satisfaction. J Arthroplasty. 2021; 36: 2466–2472.

[11] Lavand’homme PM, Kehlet H, Rawal N, Joshi GP, PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). Pain management after total knee arthroplasty: PROcedure SPEcific postoperative pain ManagemenT recommendations. Eur J Anaesthesiol. 2022; 39: 743.

[12] Sellevold VB, Steindal SA, Lindberg MF, Småstuen MC, Aamodt A, Lerdal A, et al. Many patients with persistent pain 1 year after TKA report improvement by 5 to 7 years: a mixed-methods study. Clin Orthop Relat Res. 2022; 480: 2075–2088.

[13] Sharma V, Tsailas PG, Maheshwari AV, Ranawat AS, Ranawat CS. Does patellar eversion in total knee arthroplasty cause patella baja? Clin Orthop Relat Res. 2008; 466: 2763–2768.

[14] Seo JG, Lee SA, Moon YW, Lee BH, Ko YH, Chang MJ. Infrapatellar fat pad preservation reduces wound complications after minimally invasive total knee arthroplasty. Arch Orthop Trauma Surg. 2015; 135: 1157–1162.

[15] Cankaya D, Akti S, Yasar NE, Karakus D, Unal KO, Karhan TE, et al. Total infrapatellar fat pad excision leads to worse isokinetic performance in Total knee arthroplasty: a randomized controlled trial. J Knee Surg. 2022; 35: 1544–1548.

[16] İmren Y, Dedeoğlu SS, Çakar M, Çabuk H, Bayraktar TO, Gürbüz H. Infrapatellar fat pad excision during Total knee arthroplasty did not Alter the patellar tendon length: a 5-year follow-up study. J Knee Surg. 2017; 30: 479–483.

[17] Yao B, Samuel LT, Acuña AJ, Faour M, Roth A, Kamath AF, et al. Infrapatellar fat pad resection or preservation during Total knee arthroplasty: a systematic review. J Knee Surg. 2021; 34: 415–421.

[18] Klingenstein GG, Schoifet SD, Jain RK, Reid JJ, Porat MD, Otegbeye MK. Rapid discharge to home after Total knee arthroplasty is safe in eligible Medicare patients. J Arthroplasty. 2017; 32: 3308–3313.

[19] Odum SM, Fehring TK. Can original knee society scores Be used to estimate new 2011 knee society scores? Clin Orthop Relat Res. 2017; 475: 160–167.

[20] Sellars H, Yewlett A, Trickett R, Forster M, Ghandour A. Should we resect Hoffa’s fat pad during Total knee replacement? J Knee Surg. 2017; 30: 894–897.

[21] Pinsornsak P, Naratrikun K, Chumchuen S. The effect of infrapatellar fat pad excision on complications after minimally invasive TKA: a randomized controlled trial. Clin Orthop Relat Res. 2014; 472: 695–701.

[22] Van Beeck A et al. Does infrapatellar fat pad resection in total knee arthroplasty impair clinical outcome? A systematic review. Knee. 2013; 20: 226–231.

[23] Maculé F, Sastre S, Lasurt S, Sala P, Segur JM, Mallofré C. Hoffa’s fat pad resection in total knee arthroplasty. Acta Orthop Belg. 2005; 71: 714–717.

[24] Meneghini RM, Pierson JL, Bagsby D, Berend ME, Ritter MA, Meding JB. The effect of Retropatellar fat pad excision on patellar tendon contracture and functional outcomes after Total knee arthroplasty. J Arthroplasty. 2007; 22: 47–50.

[25] Moverley R, Williams D, Bardakos N, Field R. Removal of the infrapatella fat pad during total knee arthroplasty: does it affect patient outcomes? Int Orthop. 2014; 38: 2483–2487.

[26] An investigation into the cellular-level adverse effects of tourniquet use on the infrapatellar fat pad in primary total knee arthroplasty: a prospective randomized study. Acta Orthop Traumatol Turc. 2023; 57: 283–288.

[27] Nemschak G, Pretterklieber ML. The patellar arterial supply via the infrapatellar fat pad (of Hoffa): a combined anatomical and Angiographical analysis. Anat Res Int. 2012; 2012: 1–10.

[28] Ye C, Zhang W, Wu W, Xu M, Nonso NS, He R. Influence of the infrapatellar fat pad resection during total knee arthroplasty: a systematic review and meta-analysis. PLoS One. 2016; 11: 1–14.

[29] Koff M et al. Mavric based T2 mapping assessment of infrapatellar fat pad scarring in patients with total knee arthroplasty. J Orthop Res. 2022; 0–1: 1299–1309.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.