scispace - formally typeset
Search or ask a question
Journal ArticleDOI

Patellar resurfacing versus patellar retention in primary total knee arthroplasty: a systematic review of overlapping meta-analyses

TL;DR: Comparable outcomes were found when comparing patellar resurfacing and non-resurfacing in TKA and the higher risk of re-operations after non-Resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses.
Abstract: The need of patellar resurfacing in total knee arthroplasty (TKA) is a subject of debate. This systematic review of overlapping meta-analyses aimed to assess and analyze current evidence regarding patellar resurfacing and non-resurfacing in TKA. A systematic literature search was performed in March 2017 in PubMed, CINAHL and Cochrane Library. Inclusion criteria were meta-analysis of randomized controlled trials that compared TKA with and without patellar resurfacing considering as outcomes re-operations rate, complications, anterior knee pain, functional scores. The quality of meta-analyses was evaluated with AMSTAR score and the most relevant meta-analysis was determined by applying the Jadad algorithm. Ten meta-analyses, published between 2005 and 2015, were included in the systematic review. Two studies found a significantly increased Knee Society Score in the resurfacing group. According to four meta-analyses, anterior knee pain incidence was lower in resurfacing group. Six of the included studies described a greater risk of re-intervention in the non-resurfacing groups. The overall quality of included studies was moderate. The most relevant meta-analysis reported no differences in functional scores and incidence of anterior knee pain between the groups. Comparable outcomes were found when comparing patellar resurfacing and non-resurfacing in TKA. The higher risk of re-operations after non-resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses regarding search criteria, heterogeneity and the inherent bias of easier indication to reoperation when the patella is not resurfaced. There is no clear superiority of patellar resurfacing compared to patellar retention. Level II, systematic review of meta-analyses.

Summary (3 min read)

Introduction

  • The need of resurfacing the patella in total knee arthroplasty (TKA) is an unresolved controversy.
  • General indications for selective resurfacing have been reported in literature, however there are still no universally accepted guidelines [2, 35, 49].
  • In order to resolve this issue, a number of studies have been published, including randomized controlled trials (RCTs) and high level quality studies [5, 10, 11, 16, 24, 25].
  • The Jadad algo- rithm [22] has been employed to "select the most relevant and valid of the conflicting reviews".

Material and Methods

  • Search strategy and inclusion criteria: Present study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [31] guidelines.
  • The keywords used were “patella*”, combined with “TKA” OR “total knee replacement” OR “total knee prosthesis” OR “total knee arthroplasty” AND “meta-analysis”.
  • The references of the included studies were manually checked to find any relevant meta- analyses missed by the electronic search.
  • Disagreements were settled by discussion, and the senior author was consulted when necessary.
  • The Grading of Recommendations Assessment, Development and Evaluation [19] guidelines were applied during data extraction.

Quality evaluation:

  • The quality of the included meta-analyses was evaluated by the Oxford Levels of Evidence [58, 62].
  • Additionally, A Measurement Tool to Assess Systematic Reviews [52] was applied.
  • This is an eleven items score, ranging from a minimum of zero to a maximum of eleven points, indicating the highest quality.
  • Potential disagreements between authors were settled by discussion, and the senior author was consulted if necessary.

Results

  • The initial search yielded a total of 484 results.
  • After duplicate removal, 428 papers were screened.
  • Of these, 418 studies were excluded because not meeting the inclusion criteria.
  • The most frequently used software for data analysis in included meta-analyses was RevMan (Open source software, Cochrane collaboration).

Quality appraisal

  • Three meta-analyses included both RCTs and quasi-randomized controlled trials, however, all meta- analyses were determined as level of evidence II due to the low quality of several of the included RCTs.
  • Four meta-analyses did not perform any form of quality appraisal of the included RCTs, while only two meta-analyses used the PRISMA guidelines and no one reported the evidence ac- cording to the GRADE guidelines (Table 1).
  • All the meta-analyses reported some entity of heterogeneity for at least one of the investigated out- comes.
  • Four studies performed a sensitivity analysis, three studies performed a subgroup analysis, one performed a meta-regression and four investigated publication bias.
  • The outcome with the low- est heterogeneity was the risk of re-operation, either in general or related to patello-femoral prob- lems.

Subjective outcomes:

  • Concerning postoperative scores, all meta-analyses analyzed different scales for reporting of clinical outcomes, also known as Functional scores.
  • Two studies found a significantly increased KSS score in the resurfacing group compared to the non-resurfacing.
  • No dif- ferences concerning subjective satisfaction were found when analyzed in three articles (29, 39, 45).
  • According to four meta-analyses, the incidence of anterior knee pain was lower in the resurfacing group.
  • In the re- maining six articles, no statistically significance was found.

Reoperations:

  • Six of the included studies concluded a greater risk of re-intervention in the non-resurfacing group.
  • Four studies described a greater risk of re-operation specifically related to patello-femoral prob- lems.
  • No meta-analysis clearly addressed the non patello-femoral related risk of re-intervention.
  • No article reported a lower risk for reoperation with the patellar non-resurfacing approach.

Complications:

  • Complications related to patello-femoral joint: Considering general complications related to pa- tella-femoral problems, one study found that patellar resurfacing led to significantly less complica- tions compared to non-resurfacing.
  • One study reported no significant difference, and the other stud- ies did not report data on this topic.
  • According to two meta-analyses there were no difference in risk of infection between the groups, also known as Others.
  • One meta-analysis addressed both post-operative patellar tilt and patellar shift without find- ing any significant difference between the groups.

Results of Jadad Decision Algorithm:

  • This study did not find differences in KSS score and KSS function, incidence of anterior knee pain and pain scale according to the Standardized Mean Difference (SMD) between patellar resurfacing and non-resurfacing.
  • Risk of re-operation was higher after non-resurfacing, however, when the authors considered only high quality RCTs, no differences were reported.

Discussion

  • The aim of this study was to perform a systematic review of overlapping meta-analyses on clinical and functional outcomes of patellar resurfacing compared with non-resurfacing in order to identify and evaluate controversies among meta-analyses of this topic.
  • It was shown that a majority of the meta-analyses unanimously reported equivalent results after patellar resurfacing compared with non-resurfacing in terms of functional scores and complication rates, however, an increased risk of reoperation after patellar non-resurfacing was reported.
  • The mean differences compared with the non-resurfacing group were trivial and not clinically meaning- ful.
  • It should be noted that, despite this, not all the studies performed a sen- sitivity analysis or a publication bias evaluation to address the problem of heterogeneity of these outcomes.
  • One of the most effective approaches for evaluation of current evidence in scientific literature is still to perform meta-analyses.

Conclusion

  • This evaluation of meta-analyses of clinical and functional outcomes after patellar resurfacing and non-resurfacing showed comparable results between the two techniques.
  • The generally higher risk of reoperations after non-resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses regarding search criteria, heterogeneity, quality of the included RCTs and the inherent bias of easier indication to reoperation when the patella is not resurfaced at the index TKA.

Did you find this useful? Give us your feedback

Content maybe subject to copyright    Report

Citations
More filters
Journal ArticleDOI
TL;DR: The proposed graphical techniques may assist methodologists and authors in identifying overlap, which in turn may improve validity and transparency in OoSRs.

36 citations

Journal ArticleDOI
TL;DR: Twenty-five% of patients had anterior knee pain at 10 years following a single-radius cruciate-retaining TKA without routine patellar resurfacing, with sagittal plane positioning and alignment of the femoral component being a major risk factor.
Abstract: Background:Anterior knee pain is the most common complication of total knee arthroplasty (TKA). The purpose of this study was to assess whether sagittal femoral component position is an independent predictor of anterior knee pain after cruciate-retaining single-radius TKA without routine patellar re

31 citations

Journal ArticleDOI
Chengzhi Ha, Baoxin Wang, Wei Li, Kang Sun1, Dawei Wang, Qicai Li1 
TL;DR: Patellar resurfacing is superior to non-resurfacing in osteoarthritis patients undergoing total knee arthroplasty (TKA) with the Scorpio NRG knee prosthesis, and should be performed in OA patients during TKA.
Abstract: Resurfacing the patella in one-stage bilateral total knee arthroplasty (TKA) remains debatable. This study aimed to assess the mid-term outcomes of patients after one-stage bilateral TKA performed with and without patellar resurfacing, respectively, with at least five years of follow-up. Sixty-six patients (132 knees) scheduled for first-ever one-stage bilateral TKA due to osteoarthritis received patellar resurfacing and retention, respectively, on one knee and the other, randomly selected. All patients received Scorpio NRG knee prostheses and were evaluated by radiology (anteroposterior, lateral, and axial views) pre-operatively and yearly post-operatively, for at least five years. Knee Society Score and Feller Score values were measured. Anterior knee pain, patellar clunk, and patient satisfaction were assessed. One patient died within five years of operation and four were lost to follow-up. One patient developed severe dementia and could not be constructively questioned. Therefore, 60 patients (120 knees) were finally analyzed. There were significantly improved Knee Society and Feller scores (P < 0.001) in the resurfacing group compared with the non-resurfacing group post-operatively. Anterior knee pain and patellar clunk rates were lower on the resurfaced side compared with the non-resurfaced side (P < 0.001). Meanwhile, 47% and only 7% patients preferred the resurfaced and non-resurfaced sides, respectively, at final follow-up. No revision was performed for patellofemoral complications, and no significant differences were found between the two groups in radiographic outcomes. Using the Scorpio NRG knee prosthesis, patellar resurfacing is superior to non-resurfacing in patients with osteoarthritis observed for ≥ five years. NCT03600922 • Findings Patellar resurfacing is superior to non-resurfacing in osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) with the Scorpio NRG knee prosthesis. • Implications Patellar resurfacing should be performed in OA patients during TKA. • Caution Several prosthesis types should be assessed in the same study setting, and multicenter studies are required before generalizability of the present findings.

23 citations


Cites background from "Patellar resurfacing versus patella..."

  • ...no-resurfacing in early 1970s, to systematic resurfacing in the 1980s, and are currently moving toward selective indications [3]....

    [...]

Journal ArticleDOI
TL;DR: For non-resurfaced TKRs, the authors estimated what the revision rate would have been if the patella had bee re-surfaced during total knee replacement.
Abstract: Aims Debate remains whether the patella should be resurfaced during total knee replacement (TKR). For non-resurfaced TKRs, we estimated what the revision rate would have been if the patella had bee...

20 citations

Journal ArticleDOI
TL;DR: An instrumental variable analysis examining revision risk on the basis of surgeon preference for patellar resurfacing in TKR found that surgeons who preferred selective resurfacing of the patella had a higher risk of patellars revision than those who had preference for routine resurfacing.
Abstract: Background:The optimum strategy regarding resurfacing the patella in total knee replacement (TKR) remains debated, with wide national and international variability. To minimize the confounders of a direct comparison of cases with or without resurfacing, we performed an instrumental variable analysis

18 citations

References
More filters
Journal ArticleDOI
TL;DR: An Explanation and Elaboration of the PRISMA Statement is presented and updated guidelines for the reporting of systematic reviews and meta-analyses are presented.
Abstract: Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

25,711 citations

Journal ArticleDOI
21 Jul 2009-BMJ
TL;DR: The meaning and rationale for each checklist item is explained, and an example of good reporting is included and, where possible, references to relevant empirical studies and methodological literature are included.
Abstract: Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

13,813 citations


"Patellar resurfacing versus patella..." refers methods in this paper

  • ...Four meta-analyses did not perform any form of quality appraisal of the included RCTs, while only two meta-analyses used the PRISMA guidelines and no one reported the evidence according to the GRADE guidelines (Table 4)....

    [...]

  • ...The present study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [31] guidelines....

    [...]

Journal ArticleDOI
TL;DR: The GRADE process begins with asking an explicit question, including specification of all important outcomes, and provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect.

6,093 citations


"Patellar resurfacing versus patella..." refers methods in this paper

  • ...The Grading of Recommendations Assessment, Development and Evaluation (GRADE) [19] guidelines were applied during data extraction....

    [...]

  • ...Four meta-analyses did not perform any form of quality appraisal of the included RCTs, while only two meta-analyses used the PRISMA guidelines and no one reported the evidence according to the GRADE guidelines (Table 4)....

    [...]

Journal ArticleDOI
TL;DR: A measurement tool for the 'assessment of multiple systematic reviews' (AMSTAR) was developed that consists of 11 items and has good face and content validity for measuring the methodological quality of systematic reviews.
Abstract: Our objective was to develop an instrument to assess the methodological quality of systematic reviews, building upon previous tools, empirical evidence and expert consensus. A 37-item assessment tool was formed by combining 1) the enhanced Overview Quality Assessment Questionnaire (OQAQ), 2) a checklist created by Sacks, and 3) three additional items recently judged to be of methodological importance. This tool was applied to 99 paper-based and 52 electronic systematic reviews. Exploratory factor analysis was used to identify underlying components. The results were considered by methodological experts using a nominal group technique aimed at item reduction and design of an assessment tool with face and content validity. The factor analysis identified 11 components. From each component, one item was selected by the nominal group. The resulting instrument was judged to have face and content validity. A measurement tool for the 'assessment of multiple systematic reviews' (AMSTAR) was developed. The tool consists of 11 items and has good face and content validity for measuring the methodological quality of systematic reviews. Additional studies are needed with a focus on the reproducibility and construct validity of AMSTAR, before strong recommendations can be made on its use.

3,583 citations


"Patellar resurfacing versus patella..." refers methods in this paper

  • ...The result of AMSTAR score ranged from 3 to 9, with none of the meta-analyses presenting a priori design (Table 5)....

    [...]

  • ...Additionally, A Measurement Tool to Assess Systematic Reviews (AMSTAR) [52] was applied....

    [...]

  • ...The AMSTAR has been widely used to evaluate the quality of systematic reviews [30, 47, 59–61]....

    [...]

Journal ArticleDOI
TL;DR: This article is the first of a series providing guidance for the use of the GRADE system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments, and clinical practice guidelines addressing alternative management options.

695 citations

Frequently Asked Questions (1)
Q1. What are the contributions in "Knee surgery, sports traumatology, arthroscopy is patellar resurfacing superior to patellar retention in primary tka? a systematic review of overlapping meta-analyses" ?

This systematic review of overlapping meta-analyses aimed to assess and analyze current evidence regarding patellar resurfacing and non-resurfacing in TKA. The most relevant meta-analysis reported no differences in functional scores and incidence of anterior knee pain between the groups.