Patellar resurfacing versus nonresurfacing in total knee arthroplasty: an updated meta-analysis of randomized controlled trials

Background Whether resurface the patella or not in total knee arthroplasty (TKA) was controversial. In 2013, we conducted a meta-analysis of randomized controlled trials (RTCs). After that, plenty of studies have been carried out, but there still existed a great deal of controversy. In order to update our previous study, we conducted this update meta-analysis to evaluate the efficacy of patellar resurfacing in TKA. Methods Databases were searched for RCTs comparing the outcomes of patellar resurfacing and nonresurfacing in TKA. Outcomes of knee relevant indicators were analysed. To see the short- and long-term effects, we calculated the data in total and divided the patients who were followed up for ≤ 3 years and ≥ 5 years into two subgroups as well. Results Thirty-two trials assessing 6887 knees were eligible. There was a significant difference in terms of reoperation (in total and ≥ 5 years), Knee Society Score (KSS), function score (in total and ≥ 5 years) and noise. While no significant difference was found in the following items: reoperation (≤ 3 years), anterior knee pain (AKP), function score (≤ 3 years), range of motion (ROM), Oxford score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analogue score (VAS), Feller score, patellar tilt and the patients’ satisfaction. Conclusions We found that patellar resurfacing could reduce the occurrence of reoperation and noise after surgery, as well as increase the KSS and function score, while it might not influence the outcomes such as AKP, ROM, Oxford score, KOOS, VAS, Feller score, patellar tilt and the patients’ satisfaction. The results are different from our previous finding in the meta-analysis. In conclusion, we prefer patellar resurfacing in TKA.


Introduction
Total knee arthroplasty (TKA) is one of the most common treatments for patients suffered knee arthritis. Nevertheless, the management of patella during TKA operation still remains controversial [1]. In previous literature reports, there are 3 strategies adopted by different surgeons: patellar resurfacing, patellar nonresurfacing and selective resurfacing [2,3]. But no consensus on the best management has been reached [4]. The outcome indicators such as Knee Society Score (KSS), function score of KSS, range of motion (ROM), anterior knee pain (AKP) postoperative and the ratio of reoperation are different in various studies [1][2][3][4][5]. The different outcomes of previous studies provide the basis for different choices of patellar resurfacing or not. In 2013, the author conducted a meta-analysis of randomized controlled trials [5]. We found that patellar resurfacing could reduce the risk of reoperation. And in a long-term follow-up, patellar resurfacing might make a difference of KSS. While in other aspects, the benefit of patellar resurfacing was limited. The limitation of our previous meta-analysis is the amount of high-quality randomized controlled trials. Since 2013, more and more RCTs, retrospective studies, even meta-analysis and systematic reviews have been carried out. Still, no clear conclusion has been drawn. In order to see if the result of our previous study has changed and update the latest data, we conducted this update meta-analysis of available RCTs to evaluate the efficacy of patellar resurfacing in TKA. Especially, we evaluated the items as follows: reoperation, AKP, KSS, function score, ROM, Oxford score, the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analogue score (VAS) of pain, Feller score, patella tilt, noise after operation and patients' satisfaction. Data in total, follow-up no more than 3 years and no less than 5 years were calculated separately.

Identification and eligibility of relevant RCTs
We carried out a literature search using MEDLINE, Ovid and Cochrane Library databases to identify all papers published from January 2013 to May 2020 that evaluated the outcome of patients undertaking TKA with patellar resurfacing or not. Utilizing the methodology of our previously published meta-analysis, the inclusion criteria for this study included [5] (1) English publications, (2) adults undergoing primary TKA, (3) all available RCTs comparing TKAs with and without patellar resurfacing and (4) data for the ratio of reoperation, AKP, knee scores (KSS, function score, Oxford score, KOOS, VAS, Feller score), ROM, patella tilt and noise after operation such as crepitus and patients' satisfaction. The exclusion criteria were non-English language articles, proceedings of meetings, unpublished data, nonrandomized controlled studies, studies of body specimens and researches of TKA but not about patellar resurfacing. To avoid double-counting, multiple publications of the same patient population were pooled as one study. In order to avoid the loss of included literatures, we did not use advanced search strategy this time. And our search words were "patellar resurfacing", "patellar replacement", "total knee arthroplasty" and "total knee replacement". The references of present meta-analysis, systematic reviews and review articles were also been searched from the databases for any missed studies. In the end, we added the 14 RCTs before 2013 in our previous study into this study.

Outcomes
The researchers sorted the data successively for further analysis as follows: the number of reoperation, the number of patients suffered AKP postoperative, KSS, function score, ROM, Oxford score, KOOS, VAS, Feller score, patella tilt, noise after operation and patients' satisfaction. To see the short-and long-term effects, we calculated the data in total, follow-up no more than 3 years and no less than 5 years separately.

Data extraction
Two of the authors extracted the relevant data from each article independently. And a third researcher checked the data against the original information to avoid anthropic mistakes. The extracted data included publication and patients' characteristics, length of follow-up and numbers of lost to follow-up, knee prosthesis used in TKA and clinical outcomes (AKP, ROM, KSS, Function score and so on).

Assessment of methodological quality
Included studies were independently rated for methodological quality by two of the authors. Any controversy was cross-checked and resolved by a third author to reach a final consensus. The risks of bias in included studies were accessed using the Cochrane Risk of Bias Tool (Review Manager 5.4). The items assessed were (1) random sequence generation (selection bias), (2) allocation concealment (selection bias), (3) blinding of participants and personnel (performance bias), (4) blinding of outcome assessment (detection bias), (5) incomplete outcome data (attrition bias), (6) selective reporting (reporting bias) and (7) other biases.

Statistical analysis
The software Review Manager 5.4 (Cochrane Library) was used to analyse the included data. Fixed model or random-effects model were chosen based on the heterogeneity of the studies. A P value of < 0.1 and I 2 < 25% were considered suggestive of statistical heterogeneity. The mean difference and 95% confidence (95%CI) were used for continuous data (such as ROM, scores, patellar tilt), while the risk ratios and 95%CI were used for dichotomous outcomes such as reoperation and AKP.

Results
A flow chart of the recruited studies was shown in Fig.  1. Thirty-two trials [4, assessing 6887 knees were selected for inclusion in this meta-analysis. Details on all the studies are shown in Table 1. The methodological quality is shown in Fig. 2 to see the bias risk of each study. Reoperation A total of 5391 knees were included when comparing the ratio of reoperation for any reason postoperative which was described in 30 studies. The funnel plot showed low publication bias of the 30 researches (Fig.  3). The risk ratio (RR) (RR = 0.63, 95%CI 0.54~0.73, P < 0.00001, Fig. 4) implied that there was a significant difference between the two groups. And the test for homogeneity was not significant (P = 0.75). We could draw a conclusion that patellar resurfacing could reduce the reoperation rate postoperative. In addition, we analysed reoperation of 10 studies with a follow-up of no more than 3 years. The test for homogeneity showed no significant difference (P = 0.72). No significant difference was found between the reoperation data of the 2 groups (RR = 0.57, 95%CI 0.26~1.25, P = 0.16, Fig. 5). Eighteen studies included data no less than 5 years. The test for homogeneity showed no significant difference (P = 0.44). A significant difference was found between the reoperation data of the 2 groups (RR = 0.62, 95%CI 0.53~0.72, P < 0.00001, Fig. 6).

Knee Society Score
Eighteen studies included 2265 knees reported on the necessary data of KSS. The mean difference (MD) for KSS was significant in total (MD = 1.04, 95%CI 0.54~1.54, P < 0.00001, Fig. 10). And the test for homogeneity showed no significant difference (P = 0.24). Thirteen studies reported on data ≤ 3 years (MD = 0.77, 95%CI 0.08~1.47, P = 0.03, Fig. 11), and 6 studies reported on data ≥ 5 years (MD = 1.31, 95%CI 0.70~1.93, P < 0.00001, Fig. 12). All the analyses showed that there was a significant difference of KSS between the resurfacing group and the nonresurfacing group. It seemed that the patellar resurfacing group might get higher KSS scores after primary surgery. Function score The function score was the function component of KSS. In our study, 16 studies of 1989 knees showed a function score. There was a significant difference between the two groups in total and for ≥ 5 years, while the difference ≤ 3 years was not significant (in total MD = 1.91, 95%CI 1.06~2.77, P < 0.00001, Fig. 13

Range of motion
Six studies included 829 knees reported on necessary data of ROM. It seemed that there was no significant difference between the two groups after operation (in

The Knee Injury and Osteoarthritis Outcome Score
Three studies included 277 knees reported on necessary data of KOOS score. There was no significant difference between the two groups (in total MD = 2.16, 95%CI − 1.91~6.23, P = 0.30, Fig. 18).

Feller score
Three studies included 274 knees reported on necessary data of Feller score. There was no significant difference between the two groups (in total MD = 0.31, 95%CI − 0.8~1.43, P = 0.59).

Patellar tilt
Five studies included 444 knees reported on necessary data of patellar tilt angle. There was no significant difference between the two groups (in total MD = − 0.03, 95%CI − 0.36~0.30, P = 0.86).

Noise after operation
Five studies included 503 knees reported on necessary data of the appearance of noise such as clunk, crepitus and so on. There was a significant difference between the two groups (in total RR = 0.47, 95%CI 0.32~0.68, P < 0.00001). It seemed that patellar resurfacing might reduce the occurrence of noise postoperative.

Patients satisfaction
We got 10 studies of 1382 knees showing the number of patients satisfied with the operation (Fig. 19). It seemed that there was no significant difference between the two groups (in total RR = 1.24, 95%CI 0.73~2.10, P = 0.44), while the P value of heterogeneity was 0.007, which showed high heterogeneity.

Discussion
In this meta-analysis, 32 randomized controlled trials assessing 6887 knees were adopted. We analysed the data by different statistical indicators and follow-up periods (3 subgroups: in total, ≤ 3 years and ≥ 5 years ). In summary, we found that there was a significant difference between the two groups in terms of reoperation (in total and ≥ 5 years), KSS (all 3 subgroups), function score (in total and ≥ 5 years) and noise postoperation, while no significant difference was found between the resurfacing and the nonresurfacing group in the following items: reoperation (≤ 3 years), AKP (all 3 subgroups), function score (≤ 3 years), ROM, Oxford score, KOOS, VAS, Feller score, patellar tilt and the patients' satisfaction. We could conclude that patellar resurfacing might reduce the occurrence of reoperation and noise after surgery, as well as increase the KSS and function score. Especially, the noise syndrome, such as clunk, crepitus and so on, was seen in some of the latest studies. Ha et al. and we got the same conclusion that patellar resurfacing might reduce the ratio of noise after primary TKA surgery [32], while the relationship between noise and other scores was not clear.  [37,38]. During the implementation process of our study, we searched a great many literatures comparing patellar resurfacing versus nonresurfacing in TKA. Though the non-RCTs were excluded from this study, we still read the literature as well as previous meta-analysis and systemic reviews thoroughly. Twenty-two non-RCTs  and 15 meta-analysis or systemic reviews [2,5,37,38,[61][62][63][64][65][66][67][68][69][70][71] were singled out ever since 2013. In the non-RCT studies, nine stated that there was no difference between patellar resurfacing and    [37], patellar resurfacing got the advantage in the following aspects: better KSS and function scores and lower reoperation rate. These 4 studies were carried out in the last 3 years including the latest RCTs preceding 2018. It showed the necessity for high-quality RCT research. Some limitations of this study should be acknowledged: (1) data of RCTs were not fully reported; (2) the sample size and follow-up time were not close in different RCTs, which might cause heterogeneity; (3) some studies did not provide standard deviation, and this might cause the loose of some studies; (4) still we could not get the full text of few RCTs, which might cause bias; (5) the kind of knee prosthesis and the race of the patients may affect the clinical outcomes as well as the result of this meta-analysis; and (6) the skills of surgeons might also influence the outcomes of each group, so a standard to assess the surgery skills was needed to avoid surgeon bias. Compared with the above literatures, our study analysed more outcome indicators, included the latest RCTs until May 2020 and got updated conclusions. In addition, we suggested further research directions as follows: (1) more high-quality RCTs of large sample size and long-term follow-up (such as 5-10 years or even longer), (2) more RCTs about the influence of TKA prosthetic type on outcomes of patellar resurfacing, (3) more studies about different patellar resurfacing outcomes of osteoarthritis and rheumatoid arthritis, (4) RCTs about the influence of different grade of patellofemoral arthritis, (5) RCTs focus on the relationship between radiograph measurement (such as angles) and outcome indicators (such as complication, scores and pain), and (6) studies about different race.

Conclusion
This study is an update meta-analysis of our previous study. We included more high-quality RCTs and analyse more outcomes. Subgroup analysis of different follow-up time is conducted. In conclusion, we find that patellar resurfacing could reduce the occurrence of reoperation and noise after surgery, as well as increase the KSS and function score, while it may not influence the results such as AKP, ROM, Oxford score, KOOS, VAS, Feller score, patellar tilt and the patients' satisfaction. The result is different from our previous meta-analysis. As a result of this new study, we prefer patellar resurfacing in TKA, while, still, more high-quality RCTs are expected eagerly.
Abbreviations TKA: Total knee arthroplasty; KSS: Knee society score; AKP: Anterior knee pain; ROM: Range of motion; RCTs: Randomized controlled trials; KOOS: Knee injury and osteoarthritis outcome score; VAS: Visual analogue score