J Knee Surg 2021; 34(04): 415-421
DOI: 10.1055/s-0039-1696692
Original Article

Infrapatellar Fat Pad Resection or Preservation during Total Knee Arthroplasty: A Systematic Review

Benjamin Yao
1   Case Western Reserve University School of Medicine, Cleveland, Ohio
,
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Alexander J. Acuña
1   Case Western Reserve University School of Medicine, Cleveland, Ohio
,
Mhamad Faour
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Alexander Roth
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Atul F. Kamath
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Michael A. Mont
3   Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
› Author Affiliations

Abstract

Considerations of how to improve postoperative outcomes for total knee arthroplasty (TKA) have included preservation of the infrapatellar fat pad (IPFP). Although the IPFP is commonly resected during TKA procedures, there is controversy regarding whether resection or preservation should be implemented, and how this influences outcomes. Therefore, the purpose of this systematic review was to evaluate how IPFP resection and preservation impacts postoperative flexion, pain, Insall-Salvati Ratio (ISR), Knee Society Score (KSS), patellar tendon length (PTL), and satisfaction in primary TKA. PubMed, EBSCO host, and SCOPUS were queried to retrieve all reports evaluating IPFP resection or preservation during TKA, which resulted into 488 studies. Two reviewers independently reviewed these articles for eligibility based on pre-established inclusion and exclusion criteria. Eleven studies were identified for final analysis, which reported on 11,996 cases. Patient demographics, type of surgical intervention, follow-up duration, and clinical outcome measures were collected and analyzed. Complete resection was implemented in 3,723 cases (31%), partial resection in 5,458 cases (45.5%), and preservation of the IPFP in 2,815 cases (23.5%). Clinical outcome measures included PTL (5 studies), knee flexion (4 studies), pain (6 studies), KSS (3 studies), ISR (3 studies), and patient satisfaction (1 study). No differences were found following IPFP resection for patient satisfaction (p = 0.98), ISR (p > 0.05), and KSS (p > 0.05). There was mixed evidence for PTL, pain, and knee flexion following IPFP resection versus preservation. Studies of shorter follow-up intervals suggested improved pain following resection, while reports of longer follow-up times indicated that resection resulted in increased pain. Given the mixed data available from the current literature, we were unable to conclude that one surgical technique can definitively be considered superior over the other. More extensive research, including randomized controlled trials, is required to better elucidate potential differences between the surgical handling choices. Future studies should focus on patient conditions in which one technique would be best indicated to establish guidelines for best surgical outcomes in those patients.



Publication History

Received: 24 June 2019

Accepted: 22 July 2019

Article published online:
10 September 2019

© 2019. Thieme. All rights reserved.

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  • References

  • 1 Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012; 308 (12) 1227-1236
  • 2 Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100 (17) 1455-1460
  • 3 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage 2017; 25 (11) 1797-1803
  • 4 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. National Joint Registry for England and Wales; Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
  • 5 Anderson JG, Wixson RL, Tsai D, Stulberg SD, Chang RW. Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplasty 1996; 11 (07) 831-840
  • 6 Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which hospital and clinical factors drive 30- and 90-day readmission after TKA?. J Arthroplasty 2016; 31 (10) 2099-2107
  • 7 Khan M, Osman K, Green G, Haddad FS. The epidemiology of failure in total knee arthroplasty: avoiding your next revision. Bone Joint J 2016; 98-B (1, Suppl A): 105-112
  • 8 White L, Hartnell N, Hennessy M, Mullan J. The impact of an intact infrapatellar fat pad on outcomes after total knee arthroplasty. Adv Orthop Surg 2015; 2015: 1-6
  • 9 Lemon M, Packham I, Narang K, Craig DM. Patellar tendon length after knee arthroplasty with and without preservation of the infrapatellar fat pad. J Arthroplasty 2007; 22 (04) 574-580
  • 10 Gandhi R, de Beer J, Leone J, Petruccelli D, Winemaker M, Adili A. Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplasty 2006; 21 (01) 46-52
  • 11 Meneghini RM, Pierson JL, Bagsby D, Berend ME, Ritter MA, Meding JB. The effect of retropatellar fat pad excision on patellar tendon contracture and functional outcomes after total knee arthroplasty. J Arthroplasty 2007; 22 (06) (Suppl. 02) 47-50
  • 12 Pinsornsak P, Naratrikun K, Chumchuen S. The effect of infrapatellar fat pad excision on complications after minimally invasive TKA: a randomized controlled trial. Clin Orthop Relat Res 2014; 472 (02) 695-701
  • 13 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 (06) 714-717
  • 14 Pawar U, Rao KN, Sundaram PS, Thilak J, Varghese J. Scintigraphic assessment of patellar viability in total knee arthroplasty after lateral release. J Arthroplasty 2009; 24 (04) 636-640
  • 15 Mochizuki RM, Schurman DJ. Patellar complications following total knee arthroplasty. J Bone Joint Surg Am 1979; 61 (6A): 879-883
  • 16 McMahon MS, Scuderi GR, Glashow JL, Scharf SC, Meltzer LP, Scott WN. Scintigraphic determination of patellar viability after excision of infrapatellar fat pad and/or lateral retinacular release in total knee arthroplasty. Clin Orthop Relat Res 1990; (260) 10-16
  • 17 Kayler DE, Lyttle D. Surgical interruption of patellar blood supply by total knee arthroplasty. Clin Orthop Relat Res 1988; (229) 221-227
  • 18 Hughes SS, Cammarata A, Steinmann SP, Pellegrini Jr VD. Effect of standard total knee arthroplasty surgical dissection on human patellar blood flow in vivo: an investigation using laser Doppler flowmetry. J South Orthop Assoc 1998; 7 (03) 198-204
  • 19 van Duren BH, Lamb JN, Nisar S, Ashraf Y, Somashekar N, Pandit H. Preservation vs. resection of the infrapatellar fat pad during total knee arthroplasty Part I: a survey of current practice in the UK. Knee 2019; 26 (02) 416-421
  • 20 Chougule SS, Stefanakis G, Stefan SC, Rudra S, Tselentakis G. Effects of fat pad excision on length of the patellar tendon after total knee replacement. J Orthop 2015; 12 (04) 197-204
  • 21 İmren Y, Dedeoğlu SS, Çakar M, Çabuk H, Bayraktar TO, Gürbüz H. Infrapatellar fat pad excision during total knee arthroplasty did not alter the patellar tendon length: a 5-year follow-up study. J Knee Surg 2017; 30 (05) 479-483
  • 22 Moverley R, Williams D, Bardakos N, Field R. Removal of the infrapatella fat pad during total knee arthroplasty: does it affect patient outcomes?. Int Orthop 2014; 38 (12) 2483-2487
  • 23 Sellars H, Yewlett A, Trickett R, Forster M, Ghandour A. Should we resect Hoffa's fat pad during total knee replacement?. J Knee Surg 2017; 30 (09) 894-897
  • 24 Seo JG, Lee SA, Moon Y-W, Lee BH, Ko YH, Chang MJ. Infrapatellar fat pad preservation reduces wound complications after minimally invasive total knee arthroplasty. Arch Orthop Trauma Surg 2015; 135 (08) 1157-1162
  • 25 Tanaka N, Sakahashi H, Sato E, Hirose K, Isima T. Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis. J Arthroplasty 2003; 18 (07) 897-902
  • 26 Insall J, Salvati E. Patella position in the normal knee joint. Radiology 1971; 101 (01) 101-104
  • 27 Sultan AA, Samuel LT, Khlopas A. et al. Robotic-arm assisted total knee arthroplasty more accurately restored the posterior condylar offset ratio and the Insall-Salvati Index compared to the manual technique; a cohort-matched study. Surg Technol Int 2019; 34: 409-413
  • 28 Toussirot E, Streit G, Wendling D. The contribution of adipose tissue and adipokines to inflammation in joint diseases. Curr Med Chem 2007; 14 (10) 1095-1100
  • 29 Ioan-Facsinay A, Kloppenburg M. An emerging player in knee osteoarthritis: the infrapatellar fat pad. Arthritis Res Ther 2013; 15 (06) 225
  • 30 Bryan S, Goldsmith LJ, Davis JC. et al. Revisiting patient satisfaction following total knee arthroplasty: a longitudinal observational study. BMC Musculoskelet Disord 2018; 19 (01) 423
  • 31 Xu B, Xu WX, Lu D, Sheng HF, Xu XW, Ding WG. Application of different patella height indices in patients undergoing total knee arthroplasty. J Orthop Surg Res 2017; 12 (01) 191
  • 32 Grelsamer RP, Meadows S. The modified Insall-Salvati ratio for assessment of patellar height. Clin Orthop Relat Res 1992; (282) 170-176