Understanding the patellofemoral joint in total knee arthroplasty

Total knee arthroplasty (TKA) is one of the most successful procedures in orthopedic surgery. Nevertheless, postoperative patellofemoral complications remain a challenging problem, affecting a substantial proportion of patients. Complications involving the patellofemoral joint (PFJ) can occur in both resurfaced and nonresurfaced patellae. Types of PFJ complications include anterior knee pain, maltracking, fracture, avascular necrosis and patellar clunk. The causes of patellofemoral complications can be categorized into patient-, surgeon- and implant-related factors. Patient characteristics such as female sex, young age, depression and increased body mass index have been linked with increased complications. Important technical considerations to avoid complications include achieving appropriate rotational alignment of the femoral and tibial components, maintaining joint line height, medializing the patellar button and avoiding "overstuffing" the PFJ. Component design features such as conformity, shape and depth of the femoral trochlea have also been shown to be important. Although the cause of patellofemoral complications after TKA may sometimes be unknown, it remains important to minimize errors that can lead to these complications.