Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails

Abstract

To investigate the effects of patellar denervation (PD) and non-patellar denervation (NPD) after primary total knee arthroplasty (TKA) without patellar resurfacing, this study conducted systematic electronic searches in November 2023 using PubMed, Embase, Web of Science, Cochrane, and Scopus, adhering to Cochrane Collaboration recommendations. Only randomized controlled trials (RCTs) were included. Additionally, a manual search was performed to identify potentially eligible studies from the reference lists of review articles. Two researchers independently conducted literature reviews, data extraction, and risk of bias assessments. The outcome analysis encompassed the incidence of anterior knee pain (AKP), visual analogue scale (VAS), range of motion (ROM), American Knee Society Score (KSS), Oxford Knee Score (OKS), patellar score (PS), complications, and reoperations. Meta-analysis was executed using RevMan 5.3 software. To enhance the credibility of the study, TSA v0.9 software was utilized to perform power analysis on the overall efficacy of primary and secondary outcomes. Twelve studies involving 1745 patients (1587 knees) were included, with 852 undergoing PD and 893 undergoing NPD. Results indicated a superior reduction in AKP incidence in the PD group compared to the NPD group. Statistically significant differences were observed between PD and NPD in KSS, OKS, and PS. However, the upper limit of the 95% confidence interval for each outcome fell below the minimal clinically important difference (MCID). No significant differences were found in VAS and ROM between PD and NPD. Additionally, PD was not associated with an increased incidence of complications or reoperations. Within 12 months and beyond, PD was proven to be a beneficial intervention in reducing AKP following TKA without patellar resurfacing, achieved without an increase in complications or reoperations. Regarding KSS, OKS, and PS, the minimal advantage achievable through PD may not be clinically significant.

Keywords

Anterior knee pain / Electrocautery / Meta-analysis / Patellar denervation / Total knee arthroplasty

References

[1] Lespasio MJ, Piuzzi NS, Husni ME, Muschler GF, Guarino A, Mont MA. Knee osteoarthritis: a primer. Perm J. 2017; 21: 16–183.

[2] Price AJ, Alvand A, Troelsen A, Katz JN, Hooper G, Gray A, et al. Knee replacement. Lancet. 2018; 392: 1672–1682.

[3] Scott CE, Howie CR, MacDonald D, et al. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Jt Surg Br. 2010; 92: 1253–1258.

[4] Teel AJ, Esposito JG, Lanting BA, Howard JL, Schemitsch EH. Patellar resurfacing in primary Total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2019; 34: 3124–3132.

[5] Duan G, Liu C, Lin W, Shao J, Fu K, Niu Y, et al. Different factors conduct anterior knee pain following primary Total knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty. 2018; 33: 1962–1971.e1963.

[6] Zhang P, Liu H, Yan WS, Wang WL. Is patellar denervation necessary in total knee arthroplasty without patellar resurfacing? Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2541–2549.

[7] Vega J, Golanó P, Pérez-Carro L. Electrosurgical arthroscopic patellar denervation. Arthroscopy. 2006; 22: 1028.

[8] Dellon AL, Mont MA, Mullick T, Hungerford DS. Partial denervation for persistent neuroma pain around the knee. Clin Orthop Relat Res. 1996; 329: 216–222.

[9] van Jonbergen HP, Barnaart AF, Verheyen CC. A dutch survey on circumpatellar electrocautery in total knee arthroplasty. Open Orthop J. 2010; 4: 201–203.

[10] Stärke C, Röpke EF, Lohmann CH. The third compartment in knee endoprosthetics: from denervation to replacement, which therapy is correct? Orthopade. 2011; 40(896–898): 896–901.

[11] Sun YQ, Yang B, Tong SL, Sun J, Zhu YC. Patelloplasty versus traditional total knee arthroplasty for osteoarthritis. Orthopedics. 2012; 35: e343–e348.

[12] Kim TH, Lee DH, Bin SI. The NexGen LPS-flex to the knee prosthesis at a minimum of three years. J Bone Jt Surg Br. 2008; 90: 1304–1310.

[13] Baliga S, McNair CJ, Barnett KJ, et al. Does circumpatellar electrocautery improve the outcome after total knee replacement?: a prospective, randomised, blinded controlled trial. J Bone Jt Surg Br. 2012; 94: 1228–1233.

[14] Kwon SK, Nguku L, Han CD, Koh YG, Kim DW, Park KK. Is electrocautery of patella useful in patella non-resurfacing Total knee arthroplasty?: a prospective randomized controlled study. J Arthroplasty. 2015; 30: 2125–2127.

[15] Peng L, Luo Y, Liu J, Li Z. The efficacy of patellar denervation with electrocautery after total knee replacement: a meta-analysis of randomized controlled trials. Int J Surg. 2020; 78: 126–137.

[16] Spencer SJ, Jamal B, Abram SGF, Kane N, Mohammed A. Patella denervation with circumferential electrocautery in primary knee arthroplasty: a randomized controlled trial. J Arthroplasty. 2023; 38: 1057–1062.

[17] van Jonbergen HP, Scholtes VA, Poolman RW. 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. Bone Jt J. 2014; 96: 473–478.

[18] Qin Y, Pu C, Zhou Y, Yu J, Tang J. Influence of patellar denervation on anterior knee pain and knee function following total knee replacement: a systematic review and meta-analysis. ANZ J Surg. 2021; 91: E690–e695.

[19] Wang Y, Feng W, Zang J, Gao H. Effect of patellar denervation on anterior knee pain and knee function in Total knee arthroplasty without patellar resurfacing: a meta-analysis of randomized controlled trials. Orthop Surg. 2020; 12: 1859–1869.

[20] Yuan MC, Ding ZC, Ling TX, Zhou Z. Patellar denervation with electrocautery reduces anterior knee pain within 1 year after Total knee arthroplasty: a meta-analysis of randomized controlled trials. Orthop Surg. 2021; 13: 14–27.

[21] Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg. 2021; 88: 105906.

[22] Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017; 358: j4008.

[23] Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill pain questionnaire (MPQ), short-form McGill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short Form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP). Arthritis Care Res. 2011; 63(Suppl 11): S240–S252.

[24] Lizaur-Utrilla A, Gonzalez-Parreño S, Martinez-Mendez D, Miralles-Muñoz FA, Lopez-Prats FA. Minimal clinically important differences and substantial clinical benefits for knee society scores. Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1473–1478.

[25] Beard DJ, Harris K, Dawson J, Doll H, Murray DW, Carr AJ, et al. Meaningful changes for the Oxford hip and knee scores after joint replacement surgery. J Clin Epidemiol. 2015; 68: 73–79.

[26] Crosby RD, Kolotkin RL, Williams GR. Defining clinically meaningful change in health-related quality of life. J Clin Epidemiol. 2003; 56: 395–407.

[27] Lydick E, Epstein RS. Interpretation of quality of life changes. Qual Life Res. 1993; 2: 221–226.

[28] Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003; 41: 582–592.

[29] Napier RJ, Bennett D, McConway J, Wilson R, Sykes AM, Doran E, et al. The influence of immediate knee flexion on blood loss and other parameters following total knee replacement. Bone Jt J. 2014; 96: 201–209.

[30] Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: d5928.

[31] Alomran A. Effect of patellar denervation on mid-term results after non-resurfaced total knee arthroplasty a randomised, controlled trial. Acta Orthop Belg. 2015; 81: 609–613.

[32] Altay MA, Erturk C, Altay N, et al. Patellar denervation in total knee arthroplasty without patellar resurfacing: a prospective, randomized controlled study. Orthop Traumatol. 2012; 98: 421–425.

[33] Budhiparama NC, Hidayat H, Novito K, Utomo DN, Lumban-Gaol I, Nelissen RGHH. Does circumferential patellar denervation result in decreased knee pain and improved patient-reported outcomes in patients undergoing nonresurfaced, simultaneous bilateral TKA? Clin Orthop Relat Res. 2020; 478: 2020–2033.

[34] Ji X, Huang X, Zhang Y, Zhao M, Liu Y, Cheng Y. Peripheral patellar denervation has a better effect in reducing postoperative anterior knee pain than patellar resurfacing in TKA. Medicine. 2022; 101: e31584.

[35] Motififard M, Nazem K, Zarfeshani A, Zarfeshani K. Effect of patellar electrocautery neurectomy on postoperative pain among patients referred for Total knee arthroplasty. Adv Biomed Res. 2018; 7: 9.

[36] Pulavarti RS, Raut VV, McLauchlan GJ. Patella denervation in primary total knee arthroplasty—a randomized controlled trial with 2 years of follow-up. J Arthroplasty. 2014; 29: 977–981.

[37] van Jonbergen HP, Scholtes VA, van Kampen A, et al. A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing. J Bone Jt Surg Br. 2011; 93: 1054–1059.

[38] Yim SJ, Jang MS, Kim WJ, Lee SH, Kang HK. The effect of electrocautery around the patellar rim in patellar non-resurfacing Total knee arthroplasty. Knee Surg Relat Res. 2012; 24: 104–107.

[39] Xie X, Pei F, Huang Z, Tan Z, Yang Z, Kang PD. Does patellar denervation reduce post-operative anterior knee pain after total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc. 2015; 23: 1808–1815.

[40] Husby VS, Foss OA, Husby OS, Winther SB. Randomized controlled trial of maximal strength training vs. standard rehabilitation following total knee arthroplasty. Eur J Phys Rehabil Med. 2018; 54: 371–379.

[41] Rodríguez-Merchán EC, Gómez-Cardero P. The outerbridge classification predicts the need for patellar resurfacing in TKA. Clin Orthop Relat Res. 2010; 468: 1254–1257.

[42] Smith AJ, Lloyd DG, Wood DJ. Pre-surgery knee joint loading patterns during walking predict the presence and severity of anterior knee pain after total knee arthroplasty. J Orthop Res. 2004; 22: 260–266.

[43] van Jonbergen HP, Reuver JM, Mutsaerts EL, et al. Determinants of anterior knee pain following total knee replacement: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 478–499.

[44] Malo M, Vince KG. The unstable patella after total knee arthroplasty: etiology, prevention, and management. J Am Acad Orthop Surg. 2003; 11: 364–371.

[45] Becher C, Heyse TJ, Kron N, Ostermeier S, Hurschler C, Schofer MD, et al. Posterior stabilized TKA reduce patellofemoral contact pressure compared with cruciate retaining TKA in vitro. Knee Surg Sports Traumatol Arthrosc. 2009; 17: 1159–1165.

[46] Ashford S, Williard J. Osteoarthritis: a review. Nurse Pract. 2014; 39: 1–8.

[47] Koh IJ, Kim MS, Sohn S, Song KY, Choi NY, in Y. Patients undergoing total knee arthroplasty using a contemporary patella-friendly implant are unaware of any differences due to patellar resurfacing. Knee Surg Sports Traumatol Arthrosc. 2019; 27: 1156–1164.

[48] Spencer BA, Cherian JJ, Margetas G, Chughtai M, Harwin SF, Elmallah RK, et al. Patellar resurfacing versus circumferential denervation of the patella in Total knee arthroplasty. Orthopedics. 2016; 39: e1019–e1023.

[49] Putman S, Boureau F, Girard J, Migaud H, Pasquier G. Patellar complications after total knee arthroplasty. Orthop Traumatol Surg Res. 2019; 105: S43–s51.

[50] Russell RD, Huo MH, Jones RE. Avoiding patellar complications in total knee replacement. Bone Jt J. 2014; 96: 84–86.

[51] Fu Y, Wang G, Fu Q. Patellar resurfacing in total knee arthroplasty for osteoarthritis: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1460–1466.

[52] Schindler OS. The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus? Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1227–1244.

[53] Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989; 10: 407–415.

[54] Sedaghat AR. Understanding the minimal clinically important difference (MCID) of patient-reported outcome measures. Otolaryngol Head Neck Surg. 2019; 161: 551–560.

[55] Cheng T, Zhu C, Guo Y, Shi S, Chen D, Zhang X. Patellar denervation with electrocautery in total knee arthroplasty without patellar resurfacing: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2648–2654.

[56] Fan L, Ge Z, Zhang C, Li J, Yu Z, Dang X, et al. Circumferential electrocautery of the patella in primary total knee replacement without patellar replacement: a meta-analysis and systematic review. Sci Rep. 2015; 5: 9393.

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