Different modalities of patellar management in primary total knee arthroplasty: a Bayesian network meta-analysis of randomized controlled trials

Abstract

Background: The primary management modalities for the patella in TKA include patellar resurfacing, patellar non-resurfacing, patellar resurfacing with denervation, and patellar non-resurfacing with denervation. Traditionally, meta-analyses have predominantly focused on examining comparisons between two management modalities. However, this study performed a network meta-analysis to compare all four patellar management interventions to identify the most optimal approach for patellar management in TKA.

Methods: A computer-based search of PubMed, China National Knowledge Infrastructure (CNKI), The Cochrane Library, Web of science, Embase, and MEDLINE databases was performed to identify randomized controlled trials focusing on the four management interventions for the patella in TKA. Comparisons included two-by-two comparisons as well as those involving more than two concurrent comparisons. The search timeframe spanned from inception to June 30, 2023. Two independent authors extracted the data and evaluated the quality of the literature. The Cochrane Collaboration Risk of Bias (ROB) tool was used to evaluate the overall quality of the literature. Subsequently, a network meta-analysis was conducted using the "gemtc" package of the R-4.2.3 software. Outcome measures such as anterior knee pain (AKP), reoperation rate, and patient satisfaction rate were evaluated using odd ratio (OR) and 95% confidence intervals (CI). Additionally, the knee society score (KSS), function score (FS), and range of motion (ROM) were evaluated using mean differences (MD) with associated 95% CI. The different treatment measures were ranked using the surfaces under the cumulative ranking curves (SUCRA).

Results: A total of 50 randomized controlled trials involving 9,283 patients were included in the analysis. The findings from this network meta-analysis revealed that patellar resurfacing exhibited significantly lower postoperative reoperation rate (OR 0.44, 95% CI 0.24-0.63) and AKP (OR 0.58, 95% CI 0.32-1) compared to non-resurfacing. Additionally, patellar resurfacing exhibited higher postoperative KSS clinical scores in comparison with non-resurfacing (MD: 1.13, 95% CI 0.18-2.11). However, for postoperative FS, ROM, and patient satisfaction, no significant differences were observed among the four management interventions.

Conclusion: Patellar resurfacing emerges as the optimal management modality in primary TKA. However, future studies should aim to reduce sources of heterogeneity and minimize the influence of confounding factors on outcomes.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023434418 identifier: CRD42023434418.

Keywords: Denervation; Patellar non-resurfacing; Patellar resurfacing; Total knee arthroplasty.

Fig. 1

The flow diagram of study selection

Fig. 2

Risk of graph of the included studies

Fig. 3

Risk of bias assessment of included studies

Fig. 4

Network evidence maps. A: Patellar resurfacing, B: patellar non-resurfacing, C: patellar resurfacing with denervation, D: patellar non-resurfacing with denervation. RP reoperation, AKP anterior knee pain, KSS knee society score, FS function score, ROM range of motion

Fig. 5

Comparison between direct and indirect evidence—RP

Fig. 6

Comparison between direct and indirect evidence—AKP

Fig. 7

Comparison between direct and indirect evidence—KSS

Fig. 8

Comparison between direct and indirect evidence—FS

Fig. 9

Comparison between direct and indirect evidence—ROM

Fig. 10

Surfaces under the cumulative ranking curves (SUCRA) for reoperation, anterior knee pain, knee society score, function score, range of motion, satisfaction. The graph displays the distribution of probabilities for each treatment. The X-axis represents the rank, and the Y-axis represents probabilities

Fig. 11

Comparison-correction funnel plot