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The Effect of Surgeon Preference for Selective Patellar Resurfacing on Revision Risk in Total Knee Replacement

An Instrumental Variable Analysis of 136,116 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry

Vertullo, Christopher J. MBBS, PhD, FRACS(Orth)1,2; Graves, Stephen E. MBBS, DPhil, FRACS(Orth)3; Cuthbert, Alana R. BMathSc(Hons)3; Lewis, Peter L. MBBS, FRACS(Orth)3

doi: 10.2106/JBJS.18.01350
Scientific Articles
Supplementary Content

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 examining revision risk on the basis of surgeon preference for patellar resurfacing in TKR, specifically examining the subsequent patellar revision risk and all-cause revision risk among cases of surgeons preferring to perform resurfacing on a selective basis compared with those whose preference is to routinely resurface or who infrequently perform resurfacing.

Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1999 to 2016 were obtained to assess the cumulative percent revision, hazard ratio, and revision diagnoses for 3 cohorts, grouped according the surgeons’ patellar-resurfacing preferences: infrequently (<10% of the time), selectively (10% to <90% of the time), or routinely (≥90% of the time). To avoid confounding from implant design or surgeon performance, only minimally stabilized TKRs using hybrid or cemented fixation and performed by surgeons performing ≥50 TKR procedures per year were included.

Results: A total of 136,116 procedures were included, with patients in all 3 cohorts having similar demographics. The selectively resurfaced cohort had a higher patellar revision risk compared with the routinely resurfaced cohort, with this risk being greatest in the first 4.5 years following the primary procedure, including 306% higher in the first 1.5 years, and remaining 50% higher after 4.5 years. In a subgroup analysis, increased revision risk was observed among males, females, those <65 years of age, and those ≥65 years of age. The infrequently resurfaced cohort had the highest risk of subsequent patellar revision, up to 482% higher, as seen in the first 1.5 years after the primary procedure, compared with the routinely resurfaced cohort. Additionally, the risk of all-cause revision was 20% higher for the selectively resurfaced cohort compared with routinely resurfaced.

Conclusions: Surgeons who preferred selective resurfacing of the patella had a higher risk of patellar revision than those who had preference for routine resurfacing of the patella. Overall, a greater preference for resurfacing resulted in a lower risk of patellar revision.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Knee Research Australia, Benowa, Queensland, Australia

2Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia

3Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia

E-mail address for C.J. Vertullo:

Investigation performed at the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia

Disclosure: The AOANJRR is funded by the Commonwealth of Australia’s Department of Health and Ageing. None of the authors received payment or services from a third party in support of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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