Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis

doi:10.1016/S0883-5403(03)00271-7

The Journal of Arthroplasty

Volume 18, Issue 7, October 2003, Pages 897-902

https://doi.org/10.1016/S0883-5403(03)00271-7 Get rights and content

Abstract

Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty (TKA) was evaluated in patients with rheumatoid arthritis (RA). Our findings for 120 RA patients at 28 to 38 months after surgery showed that (i) a significant decrease in the number of patients with anterior aching discomfort despite a lower-lying patella was seen in patients with infrapatellar synovectomy compared with patients without infrapatellar synovectomy, and (ii) an increase in the number of patients with anterior aching discomfort, significant limited motion, slight quadriceps weakness, and significant shortening of patellar tendon length and patella height were noted among patients with infrapatellar synovectomy, including fat pad resection, than in patients without infrapatellar synovectomy.

Section snippets

Patients and methods

The study was approved by the institutional ethics committee, and informed consent was obtained from each patient. One hundred and twenty consecutive patients (29 men and 91 women) with RA who underwent TKA (total, 160 knees) with a posterior stabilized prosthesis (Nex-gen; Zimmer, Warsaw, IN) were enrolled in the study. All of the patients fulfilled the American Rheumatism Association 1987 revised criteria for the diagnosis of RA [9]. Patient age at surgery operation ranged from 45 to 71

Results

Preoperative intergroup comparisons of age, gender, duration of disease and knee symptoms, radiographic grade, follow-up periods, range of motion, quadriceps peak torque, and radiographic assessment of patella position are shown in Table 1. No significant differences were found among 53 knees in the IPS group, 54 knees in the IPS + fat group, and 53 knees in the non-IPS group.

The 1 to 2 months follow-up results are shown in Table 2. Three knees (6%) and 12 knees (27%) had anterior aching

Discussion

The major factors that cause a low-lying patella after TKA are believed to be injury and scarring of infrapatellar tissues such as the fat pad and tendon, a postoperative raised joint line (more than 8 mm of the preoperative joint line), eccentric loading of the domed patella surface, limited knee motion, and quadriceps weakness 2, 6, 12, 16 weakness. In 2 reports 12, 15, lowering of the patella was significantly pronounced when both the infrapatellar fat pad and synovium were completely

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Major Shortening of the Patellar Tendon During Septic Two-Stage Knee Arthroplasty Revision Using Static Spacers
2022, Journal of Arthroplasty
Two-stage septic revision knee arthroplasty (TKA) often results in inferior functional outcome after reimplantation, which might be due to impairments of the extensor mechanism. The aim of the current study was to elucidate possible alterations in extensor mechanisms during septic two-stage revision of TKA treated with a static spacer.
This retrospective study included 87 patients (42 women, 45 men, age 64.5 ± 10.5; range, 29-85 years) undergoing septic two-stage TKA revision using a static spacer. The modified Insall Salvati ratio (mISR) was calculated via calibrated true lateral radiographs by two independent orthopedic surgeons before TKA explantation (G0), 6-8 days after TKA removal (G1), one day before TKA reimplantation (G2) and 6-8 days after TKA reimplantation (G3). Age, sex, body mass index (BMI), index C-reactive protein level, and number of previous surgeries were evaluated to identify the possible correlations.
Overall, mISR significantly decreased within the first 6 days after index surgery from 1.71 ± 0.41 to 1.63 ± 0.41 (G0 versus G1, P < .001) and showed a further decline within the next 6 weeks to 1.54 ± 0.39 (G1 versus G2, P = .002). Conversely, mISR increased after reimplantation of TKA to 1.6 ± 0.43 (G3 versus G2, P = .08), though it did not regain preoperative baseline levels (G0 versus G3, P < .001). The subgroup with mISR decrease ≥10% experienced patellar tendon shortening of 16% between G0 and G1, 19% between G0 and G2 and up to 20% between G0 and G3. There were weak correlations concerning age (r = −0.240, P = .038), preoperative C-reactive protein level (r = 0.239, P = .04) and patellar tendon shortening. Intraclass correlation coefficient (ICC)was 0.88 concerning radiographic measurement.
Septic two-stage TKA revision using static spacers leads to irreversible alterations of the extensor mechanism, specifically a major shortening of the patellar tendon, in one out of 3 patients.
II.
Systemic and local adipose tissue in knee osteoarthritis
2018, Osteoarthritis and Cartilage
Knee osteoarthritis (OA) is the most common joint disease. Body adipose tissue has been shown to be related to the development and progression of knee OA. Among systemic adipose tissues, subcutaneous adipose tissue is significantly and negatively associated with muscle mass and forces, and could be related to the presence and progression of knee OA. Visceral adipose tissue is associated with increased cartilage loss and production of pro-inflammatory cytokines. Intra-muscular adipose tissue is associated with knee osteoarthritic changes, but it remains controversial if inter-muscular adipose tissue has a role to play in the pathogenesis for knee OA. Knee local adipose tissue such as infrapatellar fat pad (IPFP) can interact with neighbouring tissues, and may have a biphasic effect in knee OA. The underlying mechanisms for the roles of the systemic and local fat in knee OA could be related to biomechanical, metabolic, inflammatory factors and fat fibrosis, which may have a separated or combined effect on OA. Tissue engineering from systemic or local adipose tissue is a new research direction, and adipose tissue-derived stem cells from systemic or local adipose tissue may be beneficial for OA cartilage repair. Research on systemic and local adipose tissue would provide novel approaches for prevention and treatment of knee OA, but further studies are required to explore the roles of different adipose tissues in knee OA and the effects of stem cells derived from different adipose tissues on knee OA.
Different Factors Conduct Anterior Knee Pain Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis
2018, Journal of Arthroplasty
Citation Excerpt :
The pain could be caused by the lack of a fat pad, which acts as a cushion between the patellar tendon and anterior surface of the tibial components [74]. Because only 2 studies [33,59] were included in the 1-year follow-up subgroup analysis, and because of the diversity of the population and surgical techniques, additional studies are required. Based on this, we believe that surgeons should retain the fat pad if excellent exposure can be achieved, but resect it if improved exposure is needed during TKA.
A systematic review and meta-analysis was performed to investigate the risks associated with anterior knee pain (AKP) following primary total knee arthroplasty (TKA).
A computerized search was performed of the following databases: MEDLINE, Embase, and Cochrane Central (published prior to July 2017). A total of 37 studies, which included 1641 cases of AKP and 168,090 TKAs, were included in the meta-analysis.
A subgroup analysis revealed that compared with those without the following medical conditions, patients who had an infrapatellar fat pad excision and more than 12 months of follow-up (odds ratio [OR] 12.58, 95% confidence interval [CI] 3.245-48.781) were more likely to have AKP after TKA. Circumpatellar electrocautery (>12 months: OR 0.50, 95% CI 0.326-0.760; ≤12 months: OR 0.59, 95% CI 0.408-0.867) and patellar resurfacing (OR 0.25, 95% CI 0.131-0.485) may decrease the risk of AKP. Other factors, including the prosthesis bearing type (mobile bearing or fixed bearing) and the approach (midvastus compared with the medial parapatellar approach), were not significant risk factors for AKP.
The use of strategies such as patellar denervation and patellar resurfacing in primary TKA is recommended because they are safe and result in good clinical outcomes in preventing AKP. Caution should be taken when using an infrapatellar fat pad excision, because there is an increased risk of AKP at long-term follow-up (>12 months). Future studies should investigate these different strategies to confirm the underlying mechanisms and help prevent the occurrence of AKP after TKA. The timing of AKP onset remains unclear and requires further research.
The role of the patellar tendon angle and patellar flexion angle in the interpretation of sagittal plane kinematics of the knee after knee arthroplasty: A modelling analysis
2018, Knee
Citation Excerpt :
The kinematics of the knee can be altered by both surgical technique and implant design. Undergoing total knee arthroplasty may affect the anterior–posterior position of the femur, the joint line, the patellar thickness (overstuffing/understuffing of the patellofemoral joint) and the patellar tendon shortening post-surgery [4–6]. Knee component designs also play an important part in controlling the kinematics of the knee joint due to their geometry as well as the addition of constraints such as a cam-post mechanism [7–9].
Many different measures have been used to describe knee kinematics. This study investigated the changes of two measures, the patellar tendon angle and the patellar flexion angle, in response to variations in the geometry of the knee due to surgical technique or implant design.
A mathematical model was developed to calculate the equilibrium position of the extensor mechanism for a particular tibiofemoral position. Calculating the position of the extensor mechanism allowed for the determination of the patellar tendon angle and patellar flexion angle relationships to the knee flexion angle. The model was used to investigate the effect of anterior–posterior position of the femur, change in joint line, patellar thickness (overstuffing, understuffing), and patellar tendon length; these parameters were varied to determine the effect on the patellar tendon angle/knee flexion angle and patellar flexion angle/knee flexion angle relationships.
The patellar tendon angle was a good indicator of anterior–posterior femoral position and change in patellar thickness, and the patellar flexion angle a good indicator of change in joint line, and patellar tendon length.
The patellar tendon angle/knee flexion angle relationship was found to be an effective means of identifying abnormal kinematics post-knee arthroplasty. However, the use of both the patellar tendon angle and patellar flexion angle together provided a more informative overview of the sagittal plane kinematics of the knee.
Fat pad excision in total knee arthroplasty does not affect functional outcome or anterior knee pain at 1 year follow-up
2018, Journal of Arthroscopy and Joint Surgery
In total knee arthroplasty (TKA), excision of infra patellar fat pad (IPFP) is usually done to enhance exposure. But effects of this are not clearly understood. A few studies indicate that it may lead to increased incidence of anterior knee pain (AKP). This study was undertaken to determine the effect of excision of IPFP on incidence of AKP (as indicated by Hospital for Special Surgery (HSS) patella score), Knee society score (KSS) and functional score, change in Patellar Tendon length (as measured by Insall-Salvati ratio (ISR)) and, Range of motion (ROM).
135 patients (151 knees) operated by two senior arthroplasty surgeons in the period of January 2014 to December 2015 were followed-up for minimum of 1 year. Group 1 consisted of 106 knees in which complete excision of fat pad was done and group 2 consisted of 45 knees in which fat pad was retained.
There was no significant difference in HSS patella score of two groups during the follow-up of 1 year. KSS and functional score was significantly better for IPFP retention group at 6 week follow-up, but in later follow-ups till 1 year, the difference was not significant. The mean change in patellar tendon length for patients with the fat pad removed (ISR = −0.022) and those with it retained (−0.011) was significantly different (p = 0.026). Average range of flexion in both the groups at 1 year follow-up was beyond 110 degrees. There was a significant difference in range of flexion at 1 year of follow-up (117.07 degrees in group 1 versus 118.44 degrees in group 2, p = 0.04). There were no fracture or avascular necrosis of patella in either group.
AKP and functional outcome is not significantly affected by excision of IPFP. Fat pad can be sacrificed if exposure is compromised.
Effect of preservation of Hoffa's fat pad on patellar height in primary total knee arthroplasty procedures
2024, European Journal of Orthopaedic Surgery and Traumatology

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^☆: No benefits or funds were received in support of this study.

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Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis☆

Abstract

Section snippets

Patients and methods

Results

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

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Total knee replacement in rheumatoid arthritis

Patella baja complicating total knee arthroplastya report of two cases

J Arthroplasty

The influence of tibial-patellofemoral location on function of the knee in patients with the posterior stabilized condylar knee prosthesis

J Bone Joint Surg Am

The early diagnosis and treatment of developmental patella infera syndrome

Clin Orthop

Infrapatellar contracture syndromediagnosis, treatment, and long-term followup

Am J Sports Med