Knee Research Australia, Benowa, Queensland, Australia.
Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia.
J Bone Joint Surg Am. 2019 Jul 17;101(14):1261-1270. doi: 10.2106/JBJS.18.01350.
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.
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.
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.
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.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在全膝关节置换术（TKR）中，关于髌骨再成形的最佳策略仍存在争议，且在国内外存在广泛的差异。为了最小化直接比较有或没有髌骨再成形术病例的混杂因素，我们进行了一项工具变量分析，根据外科医生对 TKR 中髌骨再成形术的偏好，检查翻修风险，具体检查了在有选择地进行再成形术的外科医生与倾向于常规再成形术或很少进行再成形术的外科医生相比，其病例的髌骨翻修风险和所有原因翻修风险。
从 1999 年至 2016 年，我们从澳大利亚矫形协会全国关节置换登记处获得数据，以评估 3 个队列的累积翻修百分比、风险比和翻修诊断，这些队列根据外科医生的髌骨再成形术偏好进行分组：不频繁（<10%的时间）、选择性（10%至<90%的时间）或常规（≥90%的时间）。为了避免植入物设计或外科医生手术的混杂因素，仅纳入使用混合或水泥固定的最小稳定 TKR 手术，并且由每年进行≥50 次 TKR 手术的外科医生进行。
共纳入 136116 例手术，所有 3 个队列的患者具有相似的人口统计学特征。与常规再成形术队列相比，选择性再成形术队列的髌骨翻修风险更高，在初次手术的前 4.5 年内风险最大，包括前 1.5 年内风险增加 306%，4.5 年后风险增加 50%。在亚组分析中，男性、女性、<65 岁和≥65 岁的患者观察到更高的翻修风险。不频繁再成形术队列的后续髌骨翻修风险最高，高达 482%，与常规再成形术队列相比，首次发生在初次手术的前 1.5 年内。此外，选择性再成形术队列的全因翻修风险比常规再成形术队列高 20%。
与有常规髌骨再成形术偏好的外科医生相比，更倾向于选择性髌骨再成形术的外科医生有更高的髌骨翻修风险。总体而言，对再成形术的偏好程度越高，髌骨翻修的风险越低。
治疗水平 III。有关证据水平的完整描述，请参阅作者说明。
