Published: 2020-02-25

Patelloplasty with and without circumpatellar denervation in reducing anterior knee pain in primary total knee arthroplasty: a comparative prospective study

Sandeep Kumar Kanugula, Mallesh Rathod, Venugopal S. M.


Background: Anterior knee pain (AKP) following total knee arthroplasty (TKA) ­­­­­­is one of the complication which cause dissatisfaction in patients. Incidence estimated to be 4-49%. The aim of our study is to know the efficacy of patelloplasty with circumpatellar denervation with diathermy in reducing AKP in primary TKA.

Methods: A total of 130 unilateral TKAs’ are divided into 2 groups. Group I (control) includes 65 patients in which only patelloplasty was done. Group II (intervention) includes 65 patients in which both patelloplasty and circumpatellar denervation with diathermy was done and analysed. Mean follow up period was 18 months. Patients were assessed both preoperatively and postoperatively at final follow up.

Results: The overall incidence of AKP at follow up (18 months) was 16.9%, with 7.7% in the intervention group and 26.1% in the control group (p<0.05).  Western Ontario and McMaster Universities osteoarthritis index scores were significantly  better in intervention group when compared to control group (28.71±3.948 vs 31.40±3.860). Better results were also found in knee society scores for intervention group compared to control group (166.57±7.941 vs 161.23±11.219); Feller patellar score of  intervention group was significantly better when compared to control group (23.28±2.546 vs 20.69±3.729); the range of knee flexion was similar in both the groups (94.62±12.6 vs 93.54±10.7). In terms of pain referred by the patient at 72 hrs postoperatively, there was statistically significant difference observed according to visual analogue scale.

Conclusions: There is statistically significant difference with respect to AKP in patients who have undergone patelloplasty with circumpatellar denervation using diathermy compared with patelloplasty alone.



Total knee arthroplasty, Anterior knee pain, Patelloplasty, Circumpatellar denervation, Diathermy, Range of motion

Full Text:



Ranawat CS, Padgett DE, Ohashi Y. Total knee arthroplasty for patients younger than55 years. Clin Orthop Relat Res. 1989;248:27-33.

Rand JA, Trounsdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am. 2003;85(2):259-65.

Scuderi GR, Insall JN, Windsor RE, Moran MC. Survivorship of cemented knee replacements. J Bone Joint Surg Br. 1989;71(5):798-803.

Gioe TJ, Killeen KK, Grimm K, Mehle S, Scheltema K. Why are total knee replacements revised?Analysis of early revision in a community knee implant registry. Clin Orthop Relat Res. 2004;428:100-6.

Wood DJ, Smith AJ, Collopy D, White B, Brankov B, Bulsara MK. Patellar resurfacing in total knee arthroplasty: a prospective, randomized trial. J Bone Joint Surg Am. 2002;84:187-93.

Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am. 2003;85:212-7.

Popovic N, Lemaire R. Anterior knee pain with a posteriorstabilized mobile bearing knee prosthesis: the effect of femoral component design. J Arthroplasty. 2003;18:396-400.

Burnett RS, Haydon CM, Rorabeck CH, Bourne RB. Patella resurfacing versus nonresurfacing in total knee arthroplasty: results of a randomized controlled clinical trial at a minimum of 10 years follow up. Clin Orthop Relat Res. 2004;428:12-25.

Burnett RS, Boone JL, McCarthy KP, Rosenzweig S, Barrack RL. A prospective randomized clinical trial of patellar resurfacing and non-resurfacing in bilateral TKA. Clin Orthop Relat Res. 2007;464:65-72.

Smith AJ, Wood DJ, Li MG. Total knee replacement with and without patellar resurfacing: a prospective, randomised trial using the profix total knee system. J Bone Joint Surg Br. 2008;90:43-9.

Mori Y, Kuroki Y, Yamamoto R, Fujimoto A, Okumo H, Kubo M. Clinical and histological study of patellar chondropathy in adolescents. Arthroscopy. 1991;7:182-97.

Wilson NA, Press JM, Koh JL, Hendrix RW, Zhang LQ. In vivo noninvasive evaluation of abnormal patellar tracking during squatting in patients with patellofemoral pain. J Bone Joint Surg (Am). 2009;91:558-66.

Skwara A, Tibesku CO, Ostermeier S, Stukenborg-Colsman C, Fuchs-Winkelmann S. Differences in patellofemoral contact stresses between mobile bearing and fixed-bearing total knee arthroplasties: a dynamic in vitro measurement. Arch Orthop Trauma Surg. 2008;129:901-7.

Breugem SJ, Sierevelt IN, Schafroth MU, Blankevoort L, Schaap GR, van Dijk CN. Less anterior knee pain with a mobile-bearing prosthesis compared with a fixed bearing prosthesis. Clin Orthop Relat Res. 2008;466:1959-65.

Barrack RL, Burak C. Patella in total knee arthroplasty. Clin Orthop Relat Res. 2001;389:62-73.

Smith AJ, Lloyd DG, Wood DJ. Pre-surgery knee joint loading patterns during walking predict the presence and severity of anterior knee pain after total knee arthroplasty. J Orthop Res. 2004;22:260-6.

Fern ED, Winson IG, Getty CJ. Anterior knee pain in rheumatoid patients after total knee replacement. Possible selection criteria for patellar resurfacing. J Bone Joint Surg Br. 1992;74:745-8.

Lehner B, Koeck FX, Capellino S, Schubert TE, Hofbauer R, Straub RH. Preponderance of sensory versus sympathetic nerve fibers and increased cellularity in the infrapatellar fat pad in anterior knee pain patients after primary arthroplasty. J Orthop Res. 2008;26:342-50.

Maculé F, Sastre S, Lasurt S, Sala P, Segur JM, Mallofré C. Hoffa’s fat pad resection in total knee arthroplasty. Acta Orthop Belg. 2005;71:714-7.

Cameron HU. Comparison between patellar resurfacing with an inset plastic button and patelloplasty. Can J Surg. 1991;34:49-52.

Wojtys EM, Beaman DN, Glover RA, Janda D. Innervation of the human knee joint by substance-P fibers. Arthroscopy. 1990;6:254-63.

Keblish PA, Varma AK, Greenwald AS. Patellar resurfacing or retention in total knee arthroplasty. A prospective study of patients with bilateral replacements. J Bone Joint Surg (Br). 1994;76:930-7.

Pellengahr C, Maier M, Müller PE, Dürr HR, Schulz C, Zysk S, et al. Surgical and anatomic parameters influencing femoropatellar pain in total knee arthroplasty. Eur J Trauma. 2002;28:242-6.

Kim TH, Lee DH, Bin SI. The NexGen LPS-flex to the knee prosthesis at a minimum of three years. J Bone Joint Surg (Br). 2008;90:1304-10.

van Hemert WL, Senden R, Grimm B, Kester AD, van der Linde MJ, Heyligers IC. Patella retention versus replacement in total knee arthroplasty; functional and clinimetric aspects. Arch Orthop Trauma Surg. 2009;129:259-65.

Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg [Br]. 1961;43-B:752-7.

McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med. 1988;18:1007-19.

Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop. 1989;248:13-4.

Roorda LD, Jones CA, Waltz M, Lankhorst GJ, Bouter LM, van der Eijken JW, et al. Satisfactory cross-cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty. Ann Rheum Dis. 2004;63:36-42.

Feller JA, Bartlett RJ, Lang DM. Patellar resurfacing versus retention in total knee arthroplasty. J Bone Joint Surg Br. 1996;78(2):226-8.

Cemil E, Mehmet AA, Ugur EI. Patelloplasty with patellar decompression to relieve anterior knee pain in total knee arthroplasty. Acta Orthop Traumatol Turc. 2011;45(6):425-30.

Hwang BH, Yang IH, Han CD. Comparison of patellar retention versus resurfacing in LCS mobile-bearing total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012;20:524-31.

Krompinger WJ, Fulkerson JP. Lateral retinacular release for intractable lateral retinacular pain. Clin Orthop Relat Res. 1983;179:191-3.

Witonski D, Wagrowska-Danielewicz M. Distribution of substance-P nerve fibers in the knee joint in patients with anterior knee pain syndrome. A preliminary report. Knee Surg Sports Traumatol Arthrosc. 1999;7:177-83.

Maralcan G, Kuru I, Issi S, Esmer AF, Tekdemir I, Evcik D. The innervation of patella: anatomical and clinical study. Surg Radiol Anat. 2005;27:331-5.

Altay MA, Ertürk C, Altay N, Akmeşe R, Işıkan UE. Patellar denervation in total knee arthroplasty without patellar resurfacing: a prospective, randomized controlled study. Orthop Traumatol Surg Res. 2012;98(4):421-5.

Balinga CJ, McNair KJ, Barnett J, MacLeod RW, Humphry D. Does circumpatellar electrocautery improve the outcome after total knee replacement? A prospective, randomised, blinded controlled trials. Finlayson. J Bone Joint Surg Br. 2012;94B:1228-33.

van Jonbergen HPW, Scholtes VAB, van Kampen A, Poolman RW. A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing. J Bone Joint Surg [Br]. 2011;93:1054-9.

van Jonbergen HPW, Scholtes VA, Poolman RW. A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing: a concise follow-up at a mean of 3.7 years. Bone Joint J. 2014;96(4):473-8.

Cheng T, Zhu C, Guo Y, Shi S, Chen D, Zhang X. Patellar denervation with electrocautery in total knee arthroplasty without patellar resurfacing: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2014;22(11):2648-5.