Accuracy of patellar resection in total knee replacement

A series of 80 patellae were randomly allocated to osteotomy by sawing or milling while implanting the medial pivot knee. Three landmarks were used to control the plane of the cut in the coronal plane. The lateral edge of the patellar tendon distally, and both medial and lateral edges of the quadriceps tendon proximally. A line drawn across the widest points if the patella (the patellar horizon) was used to analyse the slope of the cut (P angle) and the orientation of the patella relative to the trochlear groove both pre- and post-operatively (PF angle) on 45° skyline views. No patellae were under resected. The mean thickness of the remnant was 16 mm (range 14–19).There was no difference between sawing and milling, but the former was technically preferable. No patellae were found to be subluxed. The mean P angle was 2° (S.D. 3.2). The maximum P angle was 10°, but in no cases did obliquity of cut with under resection of the medial patellar facet lead to lateral tilt of the patellar horizon. The mean post-operative PF angle was 2.3° (S.D. 2.6). The majority of patellae retained a similar orientation to the patellar groove post-operatively. In three patients, the patella tilted laterally with respect to the groove. One resulted from under resection of the lateral patellar facet and two in which the slope of the cut was good, probably resulted from an error in femoral rotation. In all 80 knees, the patellar dome remained in full contact with the groove.

Use of three fixed landmarks provides consistent patellar resection in terms of depth and slope. Errors in slope of up to 10° do not cause patellar tilt but may lead to medial overload due to increasing thickness of the patella. Errors in femoral sizing and rotation are more potent causes of lateral tilt and overload.