Disclosure I do not have any relationship(s) with commercial interests.

1. Do Patients Do Better With A Nonresurfaced Patella In Total Knee Arthroplasty Using Selective Resurfacing? Sirmon KC MD, Percle J MS, Melancon C MS, Thompson H PhD, Dasa V MDLSU-New Orleans Orthopaedic Department 1

2. Disclosure • I donothave any relationship(s) with commercial interests. • A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

3. Background • Controversy concerning resurfacing the patella when performing a TKA • Patellofemoral joint was an afterthought in early designs • Improvements in designs have made the choice to resurface much easier • Still heavily debated • Malrotation • Navigation • Patellectomy

4. Background • The introduction of patellar replacement in 1974 was monumental but proved to be a challenge • Fracture, osteonecrosis, aseptic loosening, dislocation, maltracking, overstuffing, catastrophic failure, polyethylene wear, patellar clunk, and disruption of the extensor mechanism • Clayton ML, Thirupathi R. Patellar complications after total condylar arthroplasty. Clin Orthop. 1982;170:152-5. • Grace JN, Rand JA. Patellar instability after total knee arthroplasty. Clin Orthop. 1988; 237:184-9.

5. Background • Anterior knee pain must be adequately assessed before arthroplasty • Some of the traditional indications for resurfacing the patella are advanced age, anterior knee pain, patellofemoral radiographic signs of arthritis, inflammatory arthritis, etc. • The ongoing controversy of whether or not to resurface is one that troubles many orthopaedic surgeons • Some follow strict guidelines or follow their past experiences in arthroplasty • Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty 1997

6. Objective • Our objective was to research patients from a database who had undergone a total knee arthroplasty with selective resurfacing by one surgeon • We hypothesized that revision patella resurfacing would be lower than the historical average and patient outcome would be equivalent to those with a resurfaced patella • Secondary hypothesis was that high BMI negatively correlated with patient outcomes and that insurance status would correlate with outcomes scores

7. Methods • Between 5/2008 and 12/2012 all patients with primary osteoarthritis (OA) undergoing a primary total knee arthroplasty (TKA) at a single university-affiliated hospital were considered for inclusion in the study • The study was approved by the university’s IRB • Inclusion criteria • Patients with primary OA • Patients with prior TKA were excluded from the study

8. Methods • A total of 97 patients with 117 TKA’s were included in the study to evaluate retrospective data • 81 pts (101 TKA’s) elected to participate in a phone interview establishing our outcomes scores • Patient satisfaction was based on outcomes scores consisting of the Knee and Osteoarthritis Outcome Score (KOOS), the Oxford knee score, and the Anterior Knee Pain Rating

9. Methods • The anterior knee pain rating used was previously used by Waters 2003 and consisted of whether anterior knee pain was present, whether it interfered with activity, and whether its severity warranted further surgery

10. Methods • Of the patients that were called to participate one elected to not participate and one ended the phone call halfway through the interview • Several (fourteen) patients were unable to be reached or had a nonworking number

11. Methods • Hawker, et al. • To ascertain constant vs intermittent pain using a set of questions administered to 100 pts by phone • Measure of Intermittent and Constant OA Pain (ICOAP), suitable for use by clinicians to document progression or worsening of pain, response to therapy, and indication for need for referral to surgery for consideration of joint replacement • WOMAC, HOOS, KOOS used to test reliability of new tool • Breeman, et al. • Used telephone questionnaires for some participants to determine outcomes scores • Hawker, G.A. et al.Development and preliminary psychometric testing of a new OA pain measure e an OARSI/OMERACT initiative. Osteoarthritis and Cartilage (2008) 16, 409e414 • Breeman, S, et al. Patellar Resurfacing in Total Knee Replacement: Five-Year Clinical and Economic Results of a Large Randomized Controlled Trial. J Bone Joint Surg Am. 2011;93:1473-81

12. Methods • All surgeries were performed by a single surgeon • The patients all had an arthroplasty performed with a posterior stabilized (PS) knee. The patella was resurfaced if the patient was age 65 years or older and was not resurfaced if age 64 or younger • All patients underwent the same protocol postoperatively • All pair-wise comparisons were conducted using alpha level adjusted t tests conducted after an overall analysis of variance

13. Results • Average F/U for resurfaced was 15.7 months and for nonresurfaced was 16.4 months

14. Results • No significant difference was found between the two groups in terms of KOOS, Oxford, and Anterior Knee Pain Rating (AKPR) • 4 out of 45 (8.88%) patients underwent subsequent patellar resurfacing • At 11 months, 2 years, 3 months, and a planned resurfacing at the 6 month f/u visit

15. Results • We found that a significant amount of >70 year old patients had better outcomes scores in some categories when compared to younger nonresurfaced and resurfaced patients

16. Median = 32.4

17. Results • Concerning our secondary outcomes, we found that patients with a higher BMI had lower outcomes scores • In almost all categories the lower BMI’s had a trend towards better outcomes scores

18. Results • Medicaid patients had lower outcomes scores than privately insured patients • Private Insurance vs. Medicaid

19. Conclusions • One of very few studies to use the Anterior Knee Pain Rating • Largest series of medicaid patients concerning resurfacing of patellas in TKA • Commercial insured patients had better outcomes scores than Medicaid patients • No significant difference found between the nonresurfaced and resurfaced groups • >70 year old patients had better outcomes scores compared to both resurfaced and nonresurfaced younger patients • Patients with higher BMI had lower outcomes scores compared to patients with lower BMI

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22. Thank You