Dear Sir,
I do of course wish to highly commend the excellent efforts of the contributors and indeed the concept and look of Bone & Joint360. However, I am concerned about the effect that Roundup360 in particular might have upon a young enquiring orthopaedic mind!
Taking the comments about patellar resurfacing in TKR as an example, I am reminded of a comment by the late, great Richard Laskin, military surgeon in the Vietnam War and latterly Chief of Service at the Hospital for Special Surgery, New York. A middle-aged patient with an unresurfaced and badly eroded patella sat in his consulting rooms complaining of severe anterior knee pain. Politely put as I recall it, he said “yet another victim of statistical fog!” This was then followed by further comments about lawyers. Indeed, in sincere agreement with this man who dedicated his life to knee surgery, my opinion is that the meta-analyses quoted in Roundup360 only prove that the management of the patellofemoral compartments in each set of patients was performed as badly as the other.
Having been a revision knee surgeon for many years, my consistent observation is that the majority of unresurfaced patellae can perform well, but often where variable periods of swelling, pain and stiffness are associated with episodic chondrolysis. These symptoms are usually ignored by the original surgeon and the patients often seek further opinions. These painful periods are often followed by long periods of remission, and conservative measures should be used and can work well. However, the end stage can result in marked bone remodelling associated with episodic severe pain and loss of ability to load the patella in a small but significant percentage of patients. This can happen even without obvious prior patellar maltracking, overstuffing or component positioning problems. The literature also states that at least 50% of those secondarily resurfaced have significant improvements in pain and function. Identification of patellar tendonitis and baja can help avoid unnecessary revisions.
The solution therefore seems to be to try to choose which patients should manage without resurfacing, such as osteoarthritic elderly males with well-preserved patellar cartilage and a stable patella. To leave a young, female, valgus, rheumatoid, osteoporotic patient already complaining of anterior knee pain associated with a subluxed and eroded patella without a patellar button seems at best unwise. Indeed, the Oxford Dictionary definition of sanity happens to be “the tendency to avoid extreme views”. It therefore seems prudent to never say never to anything. Life is never that simple and perhaps Roundup360 should therefore give both sides of any argument?
Robin K Strachan, FRCS, Consultant Orthopaedic Surgeon, Imperial College NHS Trust, Charing Cross Hospital, London, UK.
Editor's comment: Thank you Mr Strachan and, of course, point taken. For reference, the papers quoted in the Roundup360 are those selected by our Editorial Board, not by ourselves. In addition, a view is a view, not a recommendation.
