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Review

Understanding the patellofemoral joint in total knee arthroplasty

Jacob Matz, Brent A. Lanting and James L. Howard
Can J Surg February 01, 2019 62 (1) 57-65; DOI: https://doi.org/10.1503/cjs.001617
Jacob Matz
From the Division of Orthopedic Surgery, London Health Sciences Centre, London, Ont. (Matz, Lanting, Howard)
MD, MSc
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Brent A. Lanting
From the Division of Orthopedic Surgery, London Health Sciences Centre, London, Ont. (Matz, Lanting, Howard)
MD, MSc
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James L. Howard
From the Division of Orthopedic Surgery, London Health Sciences Centre, London, Ont. (Matz, Lanting, Howard)
MD, MSc
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Figures

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  • Fig. 1
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    Fig. 1

    Summary of native (top row) and prosthetic (bottom row) patellofemoral kinematics. (A) Patellar tracking between 0° and 90°. The native patella translates medially in early flexion and translates laterally in further flexion. The patella tracks more medially following total knee arthroplasty (TKA). (B) Frequency-of-contact map showing patellofemoral contact between 0° and 90°. The distal patella initiates contact and, with increasing flexion, the contact area migrates more proximally (adapted and redrawn from reference 5 with permission of Elsevier). (C) Patellar tilt before and after TKA. The patellar tilt appears to be increased following TKA, particularly between 10° and 45° (reproduced from reference 4 with permission of Springer). L = lateral; M = medial; P = proximal.

  • Fig. 2
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    Fig. 2

    Anteroposterior, axial and sagittal photographs of Triathlon (Stryker), Sigma (DePuy Synthes) and Genesis II (Smith & Nephew) femoral components. Modern components share common features, such as proximal extension of the trochlea, raised lateral trochlear flange, lateralized groove and deepened trochlea. L = lateral; M = medial.

  • Fig. 3
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    Fig. 3

    “Overstuffing” may be a factor contributing to anterior knee pain. It can occur when the size of the femoral or patellar component is greater than the amount of bone that was resected. AP = anteroposterior.

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    Fig. 4

    Alignment of the femoral component. The femoral component is placed in 3° external rotation compared to the posterior condylar axis.

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    Fig. 5

    Alignment of the tibial component. The tibial component is placed in external rotation; various landmarks, such as the tibial tubercle or ankle joint, can be used. The centre of the ankle corresponds to the medial and middle thirds of the space between the malleoli.

  • Fig. 6
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    Fig. 6

    Centred (A) and medialized (B) patellar button placement. The latter may allow a reduction in lateral patellar shear forces.

  • Fig. 7
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    Fig. 7

    Patellar clunk is thought to be secondary to the catching of proliferative fibrous tissue at the junction of the distal quadriceps tendon and the superior pole of the patella.

  • Fig. 8
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    Fig. 8

    The intercondylar box ratio of a femoral component (A/B). Implants with a decreased ratio (< 0.7) are associated with decreased patellar clunk. Reproduced from reference 54 with permission of the British Editorial Society of Bone & Joint Surgery.

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    Table 1

    Summary of techniques to avoid patellofemoral complications after total knee arthroplasty

    ComplicationTechnique for avoidance
    Patellar maltracking or instabilityFemoral component design: extended and deepened trochlear groove
    Femoral component rotation (3° external rotation compared to posterior condylar axis)
    Tibial component rotation (central third of tibial tubercle)
    Place patellar button in medialized position
    Lateral patellar facetectomy
    Patellar clunkUse femoral component with low intercondylar box ratio
    Avoid substantial changes in joint line height, decreased patellar thickness or use of small patellar button
    Maintain posterior femoral condylar offset
    Patellar avascular necrosisAvoid unnecessary lateral retinacular release
    Avoid excessive patellar reaming
    Patellar fractureUse all-polyethylene patellar component
    Avoid excessive patellar resection when resurfacing
    Anterior knee painAttempt to minimize any of the above issues
    Select appropriately sized femoral and patellar components; preoperative templating to avoid patellofemoral offset changes
    Circumferential patellar denervation
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In this issue

Canadian Journal of Surgery: 62 (1)
Can J Surg
Vol. 62, Issue 1
1 Feb 2019
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Understanding the patellofemoral joint in total knee arthroplasty
Jacob Matz, Brent A. Lanting, James L. Howard
Can J Surg Feb 2019, 62 (1) 57-65; DOI: 10.1503/cjs.001617

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Understanding the patellofemoral joint in total knee arthroplasty
Jacob Matz, Brent A. Lanting, James L. Howard
Can J Surg Feb 2019, 62 (1) 57-65; DOI: 10.1503/cjs.001617
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