Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty: 20-Year Cohort Study

Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty: 20-Year Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty: 20-Year Cohort Study Diego Laverde Osorio, Luis David Marcial Barba, Nelva Garduza Leyva, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6798646/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background The decision to perform patellar resurfacing (PR) during total knee arthroplasty (TKA) is based on patient and implant characteristics. This study aims to evaluate PR as a prognostic factor for revision in primary TKA with 20 years of follow-up experience. Methods This is a retrospective, comparative, observational cohort study of patients who underwent TKA at a high-specialty hospital in Mexico between 2000 and 2020. A total of 334 patients who underwent TKA were evaluated. For our TKA population we divided in two groups of interest: those with patellar PR and without patellar resurfacing (WPR). Functionality was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score (OKS) scales. Pain was evaluated using the numeric rating scale (NRS). We determined the survival of TKA using the Kaplan-Meier method, and to evaluate prognostic variables, we used measures of association, such as the odds ratio (OR) and risk ratio (RR), along with the hazard ratio test (HR), with a 95% confidence interval (IC). A p-value of less than 0.05 was considered statistically significant. Results TKA with PR was associated with improved clinical and functional outcomes. There were fewer reported complications and fewer cases of prosthetic failure or revision surgery in patients receiving PR. Trial registration Not applicable, this study is an observational retrospective cohort no prospective registration was required. arthroplasty knee resurfacing anterior knee pain aseptic loosening prognostic factor Figures Figure 1 Figure 2 BACKGROUND The decision to perform patellar resurfacing (PR) during total knee arthroplasty (TKA) has been a significant topic of discussion in orthopedic research for decades. This controversy continues due to the variability in clinical and functional outcomes reported in the literature. Studies on the resurfacing technique have yielded inconclusive results. However, Lan et al. noted that the use of resurfacing in TKA has spurred further research and evaluation regarding its success. This highlights the need for long-term follow-up studies to clarify the impact of PR on functional outcomes, complication rates, and the need for postoperative revisions. Additionally, Primorac et al. reported achieving optimal pain assessment and postoperative functionality results when using the resurfacing technique in patients with severe osteoarthritis. Consequently, literature over the last decade has suggested that the resurfacing technique may be advantageous in TKA due to lower reported rates of postoperative pain and the necessity for revision surgery. When considering PR in TKA, several important factors should be taken into account: patellar pain, the thickness and diameter of the patella in relation to the available implants, the quality of the patellar cartilage, patellar arthrosis, patellar tracking, and inflammatory arthropathy. It is crucial to not only understand the indications for resurfacing but also to be aware of potential complications, which may include patellar fracture, polyethylene loosening, polyethylene wear, avascular necrosis, soft tissue impingement, patellar tendon rupture, and instability. In epidemiology, measures of association such as the odds ratio (OR), risk ratio (RR), and hazard ratio (HR) help quantify the strength of the relationship between an exposure and an outcome. The odds ratio (OR) indicates how much more likely an event is to occur in the exposed group compared to the non-exposed group. The risk ratio (RR) compares the cumulative risk (or incidence) between the two groups, calculated by dividing the risk in the exposed group by the risk in the non-exposed group. The hazard ratio (HR) assesses the instantaneous rate of occurrence of an event over time between groups, and it is typically derived from survival models, particularly Cox regression. For instance, the HR might be used to determine the time from placement to revision or failure. These measures of association are usually reported with a 95% confidence interval (CI). If the OR, RR, or HR is greater than 1, it indicates that the event occurs more frequently in the exposed group. Conversely, if it is less than 1, the event occurs less frequently in that group. These metrics can be used to identify prognostic variables that predict clinical outcomes. In this context, the Cox regression model is often utilized to analyze censored failure times. It is assumed that for each individual, values of one or more explanatory variables are available. The hazard function is modeled as a function of the explanatory variables and unknown regression coefficients, multiplied by an arbitrary and unknown function of time. This study aims to investigate the relationship between PR and prosthesis failure, evaluating whether PR serves as a predictive factor for revision in primary TKA over 20 years of follow-up. METHODS We conducted a retrospective comparative cohort study at the Hip and Knee Joint Reconstruction Service of a specialized referral hospital in Mexico City. The cohort includes all TKA performed between January 1, 2000, and December 31, 2020. Our primary data sources were institutional electronic medical records and the departmental arthroplasty database. The eligibility criteria for participant selection were as follows: ( 1 ) participants must be at least 18 years old, ( 2 ) must have Kellgren–Lawrence grade IV gonarthrosis, and ( 3 ) must have undergone primary TKA at our institution during the study period. Exclusion criteria included death during follow-up, having the index surgery performed at another institution, or refusal to participate in the study. Out of 334 eligible patients, 23 died for reasons unrelated to TKA, 30 had their surgery performed elsewhere, and 10 declined to participate. This left 271 patients (corresponding to 334 knees) available for analysis. All data were collected by two independent reviewers using a standardized collection form, and any discrepancies were resolved by consensus. The information gathered for analysis included exposure to patellar resurfacing (PR) versus no patellar resurfacing (WPR), as recorded in the operative notes. The primary outcome measured was revision surgery, while secondary outcomes included anterior knee pain, aseptic loosening, periprosthetic joint infection, arthrofibrosis, instability, fractures, and functional scores. Additional variables considered as potential confounders included age, sex, body mass index, laterality, and comorbidities (such as rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis). For functional assessment, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Oxford Knee Score (OKS) were used. At the same time, pain was assessed using a Numeric Rating Scale (NRS) ranging from 0 to 10. We reduced selection bias by including all arthroplasties that met the eligibility criteria. Information bias was minimized through duplicate data abstraction and cross-checking against operative reports. To address residual confounding, we employed multivariable Cox regression, adjusting for factors such as anterior knee pain and aseptic loosening. The sample size was determined based on a population available over 20 years, totaling 271 participants (n = 271). No formal a priori calculation was conducted; however, a post hoc power analysis for the primary outcome (revision) indicated an 80% power to detect a hazard ratio of 2.0 or greater at a significance level of α = 0.05. The WOMAC, OKS, and NRS scores were analyzed as continuous variables (mean ± SD) and categorized based on established clinical thresholds as needed for subgroup analyses. The statistical methods employed in this study included descriptive statistics, such as means with standard deviations or medians for continuous variables and counts and percentages for categorical variables. Comparisons between groups were conducted using t-tests or Mann-Whitney U-tests for continuous data and chi-square or Fisher's exact test for categorical data. Survival analysis was performed with the Kaplan-Meier method, followed by a log-rank test. The measures of association included the odds ratio (OR) and the risk ratio (RR), with 95% confidence intervals (CIs) calculated from two-by-two contingency tables. The hazard ratio (HR) was derived from Cox proportional hazard models, along with multivariable modeling. The Cox regression was adjusted for anterior knee pain and aseptic loosening, and the proportional hazards hypothesis was verified using Schoenfeld residuals (overall test p > 0.05). For outcomes with significant risk ratios, we additionally calculated the absolute risk reduction (ARR = risk_WPR – risk_PR) and its 95% CI and derived the number needed to treat (NNT = 1/ARR) following Altman & Andersen. Missing data, which accounted for less than 5% of any variable, were handled using complete case analysis. All analyses were conducted using Stata 15 for Macbook with a significance level of α = 0.05 (bilateral). This study was conducted with the utmost integrity and respect for ethical standards and was approved by our department's Research and Ethics Committee. It did not receive specific funding from the public, commercial, or nonprofit sectors. RESULTS According to our study a total of 334 patients were documented over the past 20 years in Latin American population. Of those, 271 met the inclusion criteria. Twenty-three patients died from causes unrelated to TKA, 30 patients underwent surgery for TKA at another medical unit, and 10 patients decided not to participate in the study for personal reasons. The methodology used for all participants in this study is illustrated in Fig. 1 . Methodology used for all participants related to PR and WPR technique in TKA Age was analyzed as a continuous variable (mean ± SD) and, for descriptive purposes, was stratified into five ten-year bands that correspond to Table 1 . Body mass index (BMI) was assessed both continuously and according to standard WHO categories: < 25 kg·m⁻² (normal), 25–29.9 kg·m⁻² (overweight), 30–34.9 kg·m⁻² (obesity class I), and ≥ 35 kg·m⁻² (obesity class II/III). Pain severity was measured using an NRS and categorized as mild (0–3), moderate ( 4 – 6 ), and severe ( 7 – 10 ). The WOMAC index score (ranging from 0 to 96) was grouped into quartiles based on our sample distribution: Q1 ≤ 34, Q2 35–51, Q3 52–68, and Q4 ≥ 69. The OKS was evaluated using its validated clinical cut-points: poor (< 20), moderate ( 20 – 29 ), good (30–39), and excellent (40–48). These category boundaries were predefined to facilitate subgroup and absolute risk analyses and are reproduced in Table 1 (age, BMI) and Table 4 (NRS, WOMAC, OKS). Table 1 presents the distribution of subjects by gender and age ranges. Our findings indicate that degenerative joint pathology becomes more common as individuals age, especially after the age of 40. Additionally, concerning the laterality of TKA, 59.4% of patients underwent surgery on one limb, while 40.6% had TKA performed on both limbs at different surgical events rather than during a single procedure. Table 1 Distribution of age groups of patients who underwent TKA. Age groups Gender Total (%) Female (%) Male (%) 20–29 years 2 0 1 30–39 years 5 2 4 40–49 years 14 13 14 50–59 years 20 24 21 > 60 years 59 62 59 The distribution frequency percentage is presented by age group and gender. We documented the technical characteristics included in the post-surgical note and the Hip and Knee Joint Reconstruction Service database from the medical record. According to this database, we categorized patients who underwent TKA into two study groups for the development of this project. Our population included 271 patients, 216 of whom were women (80%) and 55 of whom were men (20%). The two study groups related to TKA, were the PR group and the WPR group. Both groups had a higher proportion of female patients: 79.4% in the PR group and 80% in the WPR group. The most prevalent comorbidity in both groups was rheumatoid arthritis (RA): 81% of patients in the PR group and 89% of patients in the WPR group had RA. Similarly, systemic lupus erythematosus (SLE) occurred more frequently in the PR group (18%) than in the WPR group (10%). Table 2 compares comorbidities between the two study groups. No significant differences were observed regarding age and body mass index. However, joint wear and tear and symptomatology increase with age, leading to joint replacement. Table 2 Comorbidities of patients who underwent TKA over 20 years. Comorbidities PR group WPR group P-value Number of patients 136 135 Rheumatoid arthritis 93 102 0.190 Systemic lupus erythematosus 24 13 0.360 Ankylosing spondylitis 2 2 - The frequency among the total number of cases was 271 patients. The p-value was determined using a Student's t-test. Table 3 shows that the WPR group reported persistent anterior knee pain, aseptic loosening, and arthrofibrosis. Additionally, a higher frequency of revision surgeries was observed in this group compared to the PR group; however, no significant differences were noted. The most frequent complications reported in the latter group were periprosthetic infection and aseptic loosening. These results suggest that PR reduces the risk of anterior knee pain and septic loosening compared to the levels reported by the WPR group. Table 3 Complications related to resurfacing techniques in TKA Complications PR group WPR group P-value Aseptic loosening 4.4 12 0.01 Periprosthetic join infection 5 5 0.91 Arthrofibrosis 4 8 0.24 Posterior instability 0 1 0.30 Medial instability 0 2 0.14 Patellar tendinitis 0 1 0.30 Periprosthetic fracture 2 2 0.66 Peroneal nerve injury 2 2 0.95 Anterior knee pain 2.2 85.2 < 0.001 Revision surgery 5.1 6.7 0.54 Percentage frequency of complications. The p-value was estimated using a test for differences between z-proportions. The WOMAC index evaluates patients' pain intensity, stiffness, and functionality. Scores close to 0 indicate adequate function, while high scores indicate poor functionality. Based on our results, we observed that scores improved in both study groups. The PR group had better functional outcomes (P < 0.001). Table 4 shows improvement in both study groups following TKA. For the OKS scale, the evaluation parameters are as follows: a score of 40 to 48 points indicates an excellent outcome because the patient has few limitations when performing daily activities; a score of 30 to 39 points indicates a good outcome because the patient may have limitations; a score of 20 to 29 points indicates a moderate outcome due to pain and functional limitations of varying degrees; and a score of less than 20 points indicates a poor outcome because pain is intense and knee function is severely affected. Table 4 shows that the scores in both study groups were favorable. Table 4 Comparison of functionality and pain related to resurfacing in TKA Evaluation scale Study phase PR group WPR group P-value Range of scores per scale WOMAC Preoperative 22–94 22–89 0.010 Postoperative 0–70 0–70 < 0.001 OKS Preoperative 2–34 2–29 0.860 Postoperative 14–48 10–48 < 0.001 NRS Preoperative 4–8 3–10 0.690 Postoperative 0–6 0–6 < 0.001 This is a report of the range of scores of the WOMAC and OKS functional scales, as well as a pain assessment. The P value was estimated using the student's t-test. Both groups showed postoperative improvement; however, patients undergoing PR techniques significantly improved functional assessment and decreased postoperative pain assessment. Figure 2 shows that the probability of survival at 8.3 years is 96.7% for the PR group and 90.7% for the WPR group. After 16.6 years, the likelihood of survival decreases to 73.8% and 67.8% for the PR and WPR groups, respectively. No statistical significance was reported between the two groups. We present survival related to PR and WPR groups; observing that the average time from implantation to TKA failure was 9 years. A prognostic variable enables us to anticipate or predict a future clinical event or outcome, such as complications like loosening, anterior knee pain, periprosthetic infection, and prosthesis failure, in our study. As we can see, the results show differences between the two study groups. Therefore, we tested resurfacing as a prognostic variable during the postoperative period in cases of prosthesis failure or revision surgery in TKA. For this purpose, we calculated the relationship between the probabilities of an event related to resurfacing in TKA. We use measures of association OR and RR with 95% CI for the primary outcomes discussed in Table 5 . OR and RR are reported as raw statistical data. A 2×2 contingency table of PR versus WPR was created for each binary outcome. The OR and RR, along with their respective 95% CI, were calculated using Woolf's method for the OR and Katz's formula for the RR. Significance was assessed using a Pearson's χ² test. The same P-value obtained from the statistical association test was reported for both estimators, as they are derived from the same statistical comparison. Table 5 Association between PR and primary outcomes after TKA Main outcomes PR (n = 136) WPR (n = 135) OR (95% CI) RR (95% CI) P-value Aseptic loosening 6 (4.4%) 16 (11.9%) 2.91 (1.10–7.69) 2.69 (1.08–6.66) 0.031 Anterior knee pain 3 (2.2%) 115 (85.2%) 254.9 (73.9–879.9) 38.6 (12.6–118.5) < 0.001 Revision surgery 7 (5.1%) 9 (6.7%) 1.32 (0.48–3.64) 1.30 (0.50–3.38) 0.590 The P value of OR was determined by using Wald test, and the P value was determined by using Pearson's χ² test. During a 20-year observation period, aseptic loosening occurred in 11.9% of knees that did not undergo resurfacing, compared to 4.4% of those that had resurfacing. This resulted in an absolute risk reduction (ARR) of 7.4% (95% confidence interval [CI] 1.0–13.9) and a number needed to treat (NNT) of 14 (95% CI 7–101) to prevent one loosening event. Regarding anterior knee pain, the absolute risk was 85.2% in knees without resurfacing and only 2.2% in those with resurfacing, yielding an ARR of 83.0% (95% CI 76.5–89.5). This indicates that treating just 1 to 2 knees prevents one case of persistent pain. The absolute difference in the need for revision surgery was minimal at 1.6% (95% CI − 3.7–6.8%) and was not statistically significant. We assessed the time to revision surgery using the Cox regression model. Table 6 presents the multivariate model where the absence of resurfacing was not significantly influenced by revision (HR 2.33; p = 0.76). Aseptic loosening emerged as the sole independent predictor (HR 16.7; p < 0.001). To account for clinical confounding factors, anterior pain, aseptic loosening and periprosthetic infection were included as dichotomous covariates. Table 6 Cox regression model related to resurfacing in TKA Variable HR CI 95% P-value WPR VS PR 2.33 0.01–500 0.76 Anterior knee pain 1.15 0.005–250 0.96 Aseptic loosening 16.7 4.35–50.0 < 0.001 The PR group was used as the reference in the Cox regression analysis. The P-value was calculated using the Wald test DISCUSSION TKA is the preferred treatment for improving knee function and relieving pain in patients with an advanced degenerative stage. In 2021, the Japanese Department of Surgery conducted a study that concluded that if patellar cartilage thickness is reduced to less than half of the preoperative level, symptoms of anterior knee pain may occur 5 years after TKA. Some patients may require surgical revision of TKA. In addition, a correlation between decreased patellar cartilage thickness and postoperative knee functional assessment scores has been observed. Scientific literature indicates that pain is a critical factor to monitor after surgery, as it can temporarily limit patients’ activities and, if persistent, prompt closer follow-up for possible revision surgery; some individuals may even refuse further procedures because of previous painful experiences and complications ( 15 ). Therefore, the PR technique in TKA provides optimal results in evaluating anterior knee pain and joint mechanics. However, this technique is not free of complications, such as persistent pain, necrosis, fractures, and patellar noise syndrome or patellar clunking ( 4 , 5 , 8 ). According to recent 20-year studies, the PR technique is associated with a reduced need for revision and improved postoperative functional scores in primary TKA ( 4 , 5 , 6 , 7 , 8 , 11 , 12 ). However, comparative functional analyses did not find any statistically significant differences between the PR and WPR techniques ( 13 , 14 , 17 , 18 ). In a retrospective study performed in South Korea in 2022, 500 patients who underwent TKA were evaluated. Both techniques were compared, with similar clinical and functional results in the postoperative evaluation ( 18 ), which is also consistent with other authors who performed a retrospective study in Germany in 2023, evaluating and comparing the functionality of both techniques and the return to sports activity. It was observed that there are no differences between one technique and the other in performing TKA ( 22 ). In a 2023 systematic review, Shah et al. reported on the relationship between the PR technique and the ability to kneel after TKA. They observed that patients who underwent PR showed a better ability to kneel without pain compared to those who did not receive this treatment. This finding suggests that PR decreases pain scores and is related to physical activity, which may vary depending on the intensity and type of activity ( 13 ). Finally, a study about PR technique and life quality, was conducted in Tokyo at the end of the 1990s on patients with RA and resurfacing techniques. The study observed improvements in quality of life and a decrease in pain when performing certain activities, such as standing and going up and down stairs ( 26 ). In 2006, Holt et al. conducted a study with 30 patients who underwent TKA; in these patients, WPR techniques were implemented. The study concluded that 80% of the patients experienced a significant reduction in pain. A comprehensive evaluation is advised for PR, encompassing patella bone stock, angular deformity, and patellar tracking. This procedure is recommended to avoid potential complications ( 27 ). On the other hand, PR techniques are related to prevent complications specially to anterior knee pain and improvement of NRS after revision surgery ( 3 , 5 , 6 , 8 , 9 , 10 , 11 , 14 , 16 ). In 2022, Grela et al. reported that both resurfacing techniques can be effective, depending on the patient's condition and preoperative factors. They recommended resurfacing as a viable option for patients with specific risk factors and anatomical characteristics ( 9 ). Some authors advocate a selective resurfacing approach, which has been linked to reduced pain and lower rates of subsequent complications ( 5 , 6 ). This idea of selective resurfacing is further supported by a study published by Parsons et al. in 2021, which found that resurfacing generally lowers revision rates for TKA and leads to better postoperative functional outcomes compared with cases where resurfacing is omitted ( 12 ). The study also suggests that this selective technique is cost-effective and contributes to a reduction in postoperative complication rates. In 2016, the Department of Orthopaedic Surgery at Haukeland University Hospital conducted a study of 308 knees in which they evaluated secondary resurfacing techniques. These patients were evaluated for persistent postoperative pain, and an improvement in function and pain was observed in patients who underwent PR compared to those who did not. In addition, improvement was observed after surgery, and superior clinical and functional outcomes were achieved. Therefore, performing a PR improves quality of life, functionality, and postoperative pain, although this is important for implant survival. These results reinforce the idea that it is important to consider the possibility of revision if symptoms persist, mainly pain ( 10 ). However, the variability of results suggests that a selective strategy may be most appropriate, allowing treatment to be tailored to each patient's specific characteristics. In our study, we observed an improvement in functional scores and postoperative pain scores. In 2023, a study was conducted in Austria on 1209 patients who underwent the WPR technique, evaluating patients with advanced and moderate stages of patellofemoral osteoarthritis; they reported patients who underwent PR with better survival rates and functional outcomes, as well as verification of proper patellar follow-up to avoid future complications. As we have observed, one of the most common complications related to the lack of PR is the development of anterior knee pain, which may lead to revision surgery and secondary resurfacing ( 20 ). On the other hand, in 2023, Samih et al. performed a retrospective study including 106 patients who underwent TKA and compared both PR techniques. The most common complications observed in our study for the PR group included infection (17.2%), persistence of anterior pain (13.7%), gait disturbance (6.8%), and loosening of the patellar component (3.4%). While PR can alleviate anterior knee pain, it is not without inherent complications. In 2023, Adam et al. reported the most common complications associated with PR in TKA, including patellar fracture, patellar instability, and patellar maltracking. These complications may require revision surgery. Fracture of the patella is a serious complication in the medical field, impacting postoperative function and treatment difficulty, especially in patients who have undergone arthroplasty due to the recovery time and temporary functional limitation of TKA ( 16 ). Research on complications related to PR indicates that the incidence of complications is similar to or lower than that associated with WPR technique. This research specifically identifies complications such as persistent pain, periprosthetic infection, and instability, with no studies suggesting that the PR technique in TKA carries an increased risk ( 4 , 5 , 6 , 9 , 16 , 20 ). In 2019, a study was conducted in China comparing PR and WPR techniques in patients with bilateral TKA. The study, which included 132 patients, observed complications associated with fractures and alterations of patellofemoral tracking in both groups. The study found that 23% of patients who did not receive resurfacing techniques experienced persistent anterior knee pain, compared to 19%. Both study groups encountered complications, though these were more prevalent in the WPR group. Despite the risks mentioned earlier, no complications such as patellar subluxation or dislocation, rupture of the quadricipital tendon, aseptic loosening, patellar osteonecrosis, or fractures were identified ( 21 ). In Tokyo, Choi et al. reported a systematic review of bilateral randomized trials in 2022. This study reported similar results in patients with PR and WPR techniques and revision surgery. As previously mentioned, while the functional and pain benefits may be relevant, it is imperative to consider the risk of complications inherent to this technique ( 23 ). Numerous scientific studies support PR as a technique that improves implant survival and reduces the incidence of anterior knee pain, a common cause of revision surgery in patients WPR ( 5 , 6 , 9 , 11 , 12 , 16 ). The patella plays a crucial role in TKA, and its proper treatment is essential for survival; according to the findings of some authors, patients who underwent resurfacing experienced a marked improvement in function, which in turn reduced the need for revision surgery. Therefore, adequate treatment is essential to ensure survival, reduce complications, and reduce the number of revision surgery. According to the findings of specific authors, patients undergoing resurfacing experienced a marked improvement in functionality, resulting in a decrease in the need for additional surgical interventions ( 13 ). In 2019, Allen et al. reported patients who underwent TKA and the WPR technique; they reported fewer complications related to the patellar component, such as fractures and maltracking. This technical fact may reduce some patients' need for medical revisions ( 19 ). Conversely, the WPR technique has been promoted as a viable option in some instances, especially in patients with good-quality patellar cartilage or those with mild patellar osteoarthritis. However, recent findings indicate that the WPR may be linked to a decreased implant survival rate in patients with more advanced patellofemoral osteoarthritis, along with an elevated risk of persistent pain and the necessity for revisions ( 15 ). In 2023, Nardelli et al. presented a study in Austria that compared both techniques in TKA. This study showed a 10-year survival rate of 93.3% in the PR group and 88.6% in the WPR group ( 20 ). Current evidence suggests that PR is associated with a higher implant survival rate in most patients. The WPR technique may be a viable option for some patients; however, the potential risks of patellar wear and postoperative pain could impact the feasibility of secondary resurfacing. According to comorbidities, there was no statistical difference between comorbidities and factors that predispose to persistent anterior knee pain after TKA ( 3 , 24 , 25 ). Benazzo et al. in 2020, reported PR techniques in patients with synovial inflammatory features, inflammatory arthritis, and arthritis. Conversely, it is crucial to prioritize patients with rheumatologic pathologies, patients with BMI alterations, patients experiencing pain when climbing or descending stairs, and female patients, as these factors significantly influence the technique's performance on anterior knee pain ( 3 , 5 , 6 , 13 ). For patients with rheumatic pathologies resurfacing treatment is recommended, on the other hand the procedure of WPR techniques need a denervation of the patella, osteophyte resection, remodeling of the articular surface, and synovectomy of the deep aspect of the quadricipital tendon ( 27 ). Patients with rheumatic pathologies require particular attention due to the chronic use of immunosuppressive drugs, which can compromise optimal recovery processes, such as healing or response to infectious processes. The most significant complications associated with hip and knee joint replacements in patients with rheumatologic pathologies include postoperative infections (related to the use of immunosuppressants such as corticosteroids, methotrexate, or Tumoral Necrosis Factor inhibitors), thromboembolic complications, premature loosening of implants, and an increased risk of revision surgery and delayed healing processes. Patients with rheumatologic pathologies require particular attention due to the chronic use of immunosuppressive drugs. These medications have the potential to impact the healing process, increase the risk of infection, and influence the recovery and outcomes of the procedure. A comprehensive investigation was conducted to identify the factors that contribute to complications. According to the 2022 recommendations of the American College of Rheumatology and the American Association of Hip and Knee Surgeons regarding the preoperative treatment of rheumatologic patients and arthroplasty procedures, the suspension and resumption of immunosuppressive therapies are recommended. The goal is to reduce complications and improve long-term outcomes ( 28 ). To date, no study has been conducted on implementing the resurfacing technique as a predictive factor in primary TKA. Both the OR and RR for aseptic loosening and anterior pain were found to be greater than 1. This indicates that the absence of resurfacing is linked to a higher risk of complications. A p-value of less than 0.05 supports the strength of this association. The narrow CI for loosening suggests a precise estimate, while the wide CI for pain indicates greater uncertainty. In contrast, the p-value of 0.59 for revision surgery corresponds with a CI that includes 1, suggesting there is no detectable effect on this outcome. The Cox proportional hazards model confirmed an independent protective effect with a HR of 0.65 (95% CI, 0.47–0.90). The study's limitations stem from its execution in a tertiary-level hospital or high-specialty reference hospital, which may have introduced a bias by enrolling only patients with complex pathologies. The selection bias is attributed to the inclusion criteria, which were applied to include patients with complex pathologies requiring specialized treatments. Therefore, limiting the generalization of the results to less specialized care settings with a larger patient population is important. Additionally, the limited diversity in the sample and the high proportion of complex cases may influence the results obtained. Despite the presence of advanced resources at the hospital center, the study did not compare with less complex cohorts or hospitals at other levels of care. In this 20-year retrospective cohort study, PR demonstrated a clinically significant absolute risk reduction of 83% for persistent anterior knee pain and 7.4% for aseptic loosening. Additionally, the overall revision rate for resurfaced knees remained comparable to that of non-resurfaced knees. These findings support our initial hypothesis and are consistent with contemporary meta-analyses that indicate lower pain scores and fewer secondary revisions following PR. The benefits of PR were most pronounced in terms of pain relief, with a number needed to treat (NNT) of approximately 1 to 2. This suggests that the primary mechanism of benefit is the biomechanical optimization of the patellofemoral joint rather than the structural protection of the tibiofemoral components. Although the hazard ratio for revisions favored PR (HR 0.65), the confidence interval included 1, indicating some uncertainty. Nonetheless, the consistency of the benefits observed across various sensitivity analyses and the extended follow-up period enhance the robustness of our findings. Our study group was treated at a high-volume tertiary arthroplasty center in Mexico City, where 80% of the patients were female and approximately 85% had rheumatoid pathologies. Caution should be used when applying these findings to community hospitals that serve predominantly osteoarthritic populations or when considering contemporary cementless implants. However, key technical aspects, such as the posterior-stabilized design and the cemented patellar button, are consistent with those used globally, and the observed effects align with findings from large international registries, suggesting broader relevance. Future prospective multicenter trials are necessary to determine whether the extent of pain reduction is maintained in lower-risk populations. CONCLUSION After conducting a thorough analysis, the following conclusions have been reached. PR offers a clinically significant reduction in anterior knee pain and lowers the risk of aseptic loosening in TKA over a 20-year follow-up period. The overall revision rate was not significantly affected, indicating that the benefits are primarily related to pain relief and functional improvement rather than structural advantages. These findings advocate for a selective approach to resurfacing. It is recommended that PR be considered primarily to minimize anterior pain and mechanical complications, particularly in younger patients or those with higher functional demands. There are no precise indications for decision-making regarding resurfacing the patella during TKA. Our study found that PR during primary TKA offers patients the best functionality and pain relief results. This technique has been shown to reduce postoperative complications and improve patient's quality of life. Abbreviations ARR: absolute risk reduction Cis: confidence intervals HR: hazard ratio CI: confidence interval ND: no statistical difference NNT: number needed to treat NRS: numeric rating scale OA: osteoarthritis OKS: Oxford knee score OR: odds ratio PR: patellar resurfacing RA: rheumatoid arthritis RR: risk ratio SLE: systemic lupus erythematosus TKA: total knee arthroplasty WOMAC: Western Ontario and McMaster Universities Osteoarthritis WPR: without patellar resurfacing Declarations Ethics approval and consent to participate Approval for this study was obtained from the Institutional Review Board at the Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran. (registration CONBIOETICA-09-CEI-011-20160627, official letter OFICIO-NO. MCONTROL-2459/2024). Our research was conducted in accordance with the Declaration of Helsinki and the Mexican national guidelines for health research in humans (NOM-012-SSA3-2012). All participants provided written informed consent before enrolling in the study. Consent for publication Not applicable. The manuscript does not contain any individual person’s data. Availability of data and materials The datasets generated during and analyzed during the current study are available in the Zenodo repository, available from: https://zenodo.org/records/15570904], DOI 10.5281/zenodo.14015466. Competing interests The authors declare that they have no competing interests Funding The authors declare that they have no sources of funding for the research reported in this study. Authors' contributions Diego Laverde Osorio. Contribution: Data Curation Luis David Marcial Barba. Contribution: Supervision Nelva Garduza Leyva. Contribution: Data Curation Efrain Diaz Borjon. Contribution: Conceptualization Juan Montejo Vargas. Contribution: Writing - Review & Editing Georges Jirjis Makdissy Salomon. Contribution: Writing - Original Draft Christian Hazel Hernandez Romero. Contribution: Methodology Acknowledgements Not applicable References Lan RH, Bell JW, Samuel LT, Kamath AF. Evolving outcome measures in total knee arthroplasty: trends and utilization rates over the past 15 years. J Arthroplasty. 2020;35(11):3375-3382. doi:10.1016/j.arth.2020.06.036. Primorac D, Molnar V, Rod E, Jeleč Ž, Čukelj F, Matišić V, et al. Knee osteoarthritis: a review of pathogenesis and state-of-the-art non-operative therapeutic considerations. Genes (Basel). 2020;11(8):854. doi:10.3390/genes11080854. Schindler OS. The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus? Knee Surg Sports Traumatol Arthrosc. 2012;20(7):1227-1244. doi:10.1007/s00167-012-1985-7. Tang X, He Y, Pu S, Lei L, Ning N, Shi Y, et al. Patellar resurfacing in primary total knee arthroplasty: a meta-analysis and trial sequential analysis of 50 randomized controlled trials. Orthop Surg. 2023;15(2):379-399. doi:10.1111/os.13392 Benazzo F, Perticarini L, Jannelli E, Ivone A, Ghiara M, Rossi SP. Controversy: supporting patellar resurfacing in total knee arthroplasty—do it. EFORT Open Rev. 2020;5(11):785-792. doi:10.1302/2058-5241.5.190075. Fleaca SR, Mohor CI, Dura H, Chicea R, Mohor C, Boicean A, et al. Effect of patella resurfacing on functional outcome and revision rate in primary total knee arthroplasty. Exp Ther Med. 2022;23:104. doi:10.3892/etm.2021.11027 Aunan E, Næss G, Clarke-Jenssen J, Sandvik L, Kibsgård TJ. Patellar resurfacing in total knee arthroplasty: functional outcome differs with different outcome scores—a randomized double-blind study of 129 knees with 3 years of follow-up. Acta Orthop. 2016;87(2):158-64. doi:10.3109/17453674.2015.1111075 Migliorini F, Eschweiler J, Niewiera M, El Mansy Y, Tingart M, Rath B. Better outcomes with patellar resurfacing during primary total knee arthroplasty: a meta-analysis study. Arch Orthop Trauma Surg. 2019;139(10):1445-54. doi:10.1007/s00402-019-03246-z Grela M, Barrett M, Kunutsor SK, Blom AW, Whitehouse MR, Matharu GS. Clinical effectiveness of patellar resurfacing, no resurfacing and selective resurfacing in primary total knee replacement: systematic review and meta-analysis of interventional and observational evidence. BMC Musculoskelet Disord. 2022;23:932. doi:10.1186/s12891-022-05877-7 Leta TH, Lygre SH, Skredderstuen A, Hallan G, Gjertsen JE, Rokne B, et al. Secondary patella resurfacing in painful non-resurfaced total knee arthroplasties: survival and clinical outcome from the Norwegian Arthroplasty Register (1994-2011). Int Orthop. 2016;40(4):715-22. doi:10.1007/s00264-015-3017-y Teel AJ, Esposito JG, Lanting BA, Howard JL, Schemitsch EH. Patellar resurfacing in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2019;34(12):3124-32. doi:10.1016/j.arth.2019.07.019 Parsons T, Al-Jabri T, Clement ND, Maffulli N, Kader DF. Patella resurfacing during total knee arthroplasty is cost-effective and has lower re-operation rates compared to non-resurfacing. J Orthop Surg Res. 2021;16:185. doi:10.1186/s13018-021-02295-8 Shah OA, Spence C, Kader D, Clement ND, Asopa V, Sochart DH. Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review. Arthroplasty. 2023;5:32. doi:10.1186/s42836-023-00184-5 PubMed Samih M, Fadili H, Chagou A, Jaafar A, Zryouil B. Resurfacing versus non-resurfacing patella in total knee replacement: when and what to choose. Cureus. 2023;15:e44276. doi:10.7759/cureus.44276 Sato D, Inoue M, Sasaki T, Uchida J, Onodera T, Kondo E, et al. No patella resurfacing total knee arthroplasty leads to reduction in patellar cartilage thickness to less than half within 5 years: a quantitative longitudinal MRI study. J Exp Orthop. 2021;8:107. doi:10.1186/s40634-021-00425-z PubMed Adam R, Moldovan C, Tudorache S, Hârșovescu T, Orban C, Pogărășteanu M, et al. Patellar resurfacing in total knee arthroplasty—a never-ending controversy: case report and literature review. Diagnostics (Basel). 2023;13:383. doi:10.3390/diagnostics13030383 Ko YI, Yang JH, Choi CH. Comparison of clinical outcomes after total knee arthroplasty with and without patellar resurfacing in the same patients. Clin Orthop Surg. 2022;14:361-9. doi:10.4055/cios20289 Noh JH, Kim NY, Song KI. Clinical outcomes between patellar resurfacing and non-resurfacing in cruciate-retaining total knee arthroplasty. J Orthop Surg (Hong Kong). 2022;30:10225536221092223. doi:10.1177/10225536221092223 Allen W, Eichinger J, Friedman R. Resurfaced versus non-resurfaced patella in total knee arthroplasty. J Knee Surg. 2019;32:611-5. doi:10.1055/s-0039-1681077 Nardelli P, Neururer S, Gruber K, Wippel D, Kogler N, Ender S, et al. Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellofemoral osteoarthritis Iwano stages 3-4. Knee Surg Sports Traumatol Arthrosc. 2023;31:3941-6. doi:10.1007/s00167-023-07387-y Ha C, Wang B, Li W, Sun K, Wang D, Li Q. Resurfacing versus not-resurfacing the patella in one-stage bilateral total knee arthroplasty: a prospective randomized clinical trial. Int Orthop. 2019;43(11):2519-27. doi:10.1007/s00264-019-04361-7 Schatz C, Plötz W, Beckmann J, Leidl R, Buschner P. The impact of primary patella resurfacing on health-related quality-of-life outcomes and return to sport in total knee arthroplasty (TKA). Arch Orthop Trauma Surg. 2023;143(11):6731-40. doi:10.1007/s00402-023-04930-x Choi KY, In Y, Kim MS, Sohn S, Koh IJ. Is the patient aware of the difference between resurfaced and non-resurfaced patella after bilateral total knee arthroplasty? A systematic review of simultaneous bilateral randomized trials. Knee Surg Relat Res. 2022;34:4. doi:10.1186/s43019-022-00133-7 Barrack RL, Bertot AJ, Wolfe MW, Waldman DA, Milicic M, Myers L. Patellar resurfacing in total knee arthroplasty: a prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am. 2001;83(9):1376-81. doi:10.2106/00004623-200109000-00003 Pehlivanoglu T, Balci HI, Demirel M, Cakmak MF, Yazicioglu O, Kilicoglu OI. Prevalence of anterior knee pain after patellar retention total knee arthroplasty: comparison of patients with rheumatoid arthritis versus primary osteoarthritis. Acta Orthop Traumatol Turc. 2019;53(6):420-5. doi:10.1016/j.aott.2019.07.001 Kajino A, Yoshino S, Kameyama S, Kohda M, Nagashima S. Comparison of the results of bilateral total knee arthroplasty with and without patellar replacement for rheumatoid arthritis: a follow-up note. J Bone Joint Surg Am. 1997;79(4):570-4. doi:10.2106/00004623-199704000-00020 Holt G, Miller N, Kelly MP, Leach WJ. Retention of the patella in total knee arthroplasty for rheumatoid arthritis. Joint Bone Spine. 2006;73(5):523-6. doi:10.1016/j.jbspin.2005.11.017 Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 2022;74(9):1464-73. doi:10.1002/art.42140 Dataset. Hernández-Romero CH, Díaz-Borjón E, Laverde-Osorio D, et al. Dataset for: Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty (20-Year Cohort Study) [Zenodo]. Zenodo; 2025. DOI: 10.5281/zenodo.14015466. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial1Table1.xlsx Supplementarymaterial2Table2.xlsx Supplementarymaterial3Table3.xlsx Supplementarymaterial4Table4.xlsx Supplementarymaterial5Table5.xlsx Supplementarymaterial6Table6.xlsx Supplementarymaterial7.BioethicsCommitteeApproval.pdf Supplementarymaterial8STROBEchecklistv4.doc Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 07 Jul, 2025 Reviews received at journal 07 Jul, 2025 Reviews received at journal 06 Jul, 2025 Reviewers agreed at journal 04 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 29 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers invited by journal 12 Jun, 2025 Editor invited by journal 10 Jun, 2025 Editor assigned by journal 07 Jun, 2025 Submission checks completed at journal 07 Jun, 2025 First submitted to journal 02 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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This controversy continues due to the variability in clinical and functional outcomes reported in the literature. Studies on the resurfacing technique have yielded inconclusive results. However, Lan et al. noted that the use of resurfacing in TKA has spurred further research and evaluation regarding its success. This highlights the need for long-term follow-up studies to clarify the impact of PR on functional outcomes, complication rates, and the need for postoperative revisions. Additionally, Primorac et al. reported achieving optimal pain assessment and postoperative functionality results when using the resurfacing technique in patients with severe osteoarthritis. Consequently, literature over the last decade has suggested that the resurfacing technique may be advantageous in TKA due to lower reported rates of postoperative pain and the necessity for revision surgery. When considering PR in TKA, several important factors should be taken into account: patellar pain, the thickness and diameter of the patella in relation to the available implants, the quality of the patellar cartilage, patellar arthrosis, patellar tracking, and inflammatory arthropathy. It is crucial to not only understand the indications for resurfacing but also to be aware of potential complications, which may include patellar fracture, polyethylene loosening, polyethylene wear, avascular necrosis, soft tissue impingement, patellar tendon rupture, and instability.\u003c/p\u003e \u003cp\u003eIn epidemiology, measures of association such as the odds ratio (OR), risk ratio (RR), and hazard ratio (HR) help quantify the strength of the relationship between an exposure and an outcome. The odds ratio (OR) indicates how much more likely an event is to occur in the exposed group compared to the non-exposed group. The risk ratio (RR) compares the cumulative risk (or incidence) between the two groups, calculated by dividing the risk in the exposed group by the risk in the non-exposed group. The hazard ratio (HR) assesses the instantaneous rate of occurrence of an event over time between groups, and it is typically derived from survival models, particularly Cox regression. For instance, the HR might be used to determine the time from placement to revision or failure. These measures of association are usually reported with a 95% confidence interval (CI). If the OR, RR, or HR is greater than 1, it indicates that the event occurs more frequently in the exposed group. Conversely, if it is less than 1, the event occurs less frequently in that group. These metrics can be used to identify prognostic variables that predict clinical outcomes. In this context, the Cox regression model is often utilized to analyze censored failure times. It is assumed that for each individual, values of one or more explanatory variables are available. The hazard function is modeled as a function of the explanatory variables and unknown regression coefficients, multiplied by an arbitrary and unknown function of time.\u003c/p\u003e \u003cp\u003eThis study aims to investigate the relationship between PR and prosthesis failure, evaluating whether PR serves as a predictive factor for revision in primary TKA over 20 years of follow-up.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe conducted a retrospective comparative cohort study at the Hip and Knee Joint Reconstruction Service of a specialized referral hospital in Mexico City. The cohort includes all TKA performed between January 1, 2000, and December 31, 2020. Our primary data sources were institutional electronic medical records and the departmental arthroplasty database.\u003c/p\u003e \u003cp\u003eThe eligibility criteria for participant selection were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) participants must be at least 18 years old, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) must have Kellgren\u0026ndash;Lawrence grade IV gonarthrosis, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) must have undergone primary TKA at our institution during the study period. Exclusion criteria included death during follow-up, having the index surgery performed at another institution, or refusal to participate in the study. Out of 334 eligible patients, 23 died for reasons unrelated to TKA, 30 had their surgery performed elsewhere, and 10 declined to participate. This left 271 patients (corresponding to 334 knees) available for analysis. All data were collected by two independent reviewers using a standardized collection form, and any discrepancies were resolved by consensus. The information gathered for analysis included exposure to patellar resurfacing (PR) versus no patellar resurfacing (WPR), as recorded in the operative notes.\u003c/p\u003e \u003cp\u003eThe primary outcome measured was revision surgery, while secondary outcomes included anterior knee pain, aseptic loosening, periprosthetic joint infection, arthrofibrosis, instability, fractures, and functional scores. Additional variables considered as potential confounders included age, sex, body mass index, laterality, and comorbidities (such as rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis). For functional assessment, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Oxford Knee Score (OKS) were used. At the same time, pain was assessed using a Numeric Rating Scale (NRS) ranging from 0 to 10.\u003c/p\u003e \u003cp\u003eWe reduced selection bias by including all arthroplasties that met the eligibility criteria. Information bias was minimized through duplicate data abstraction and cross-checking against operative reports. To address residual confounding, we employed multivariable Cox regression, adjusting for factors such as anterior knee pain and aseptic loosening. The sample size was determined based on a population available over 20 years, totaling 271 participants (n\u0026thinsp;=\u0026thinsp;271). No formal a priori calculation was conducted; however, a post hoc power analysis for the primary outcome (revision) indicated an 80% power to detect a hazard ratio of 2.0 or greater at a significance level of α\u0026thinsp;=\u0026thinsp;0.05. The WOMAC, OKS, and NRS scores were analyzed as continuous variables (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) and categorized based on established clinical thresholds as needed for subgroup analyses.\u003c/p\u003e \u003cp\u003eThe statistical methods employed in this study included descriptive statistics, such as means with standard deviations or medians for continuous variables and counts and percentages for categorical variables. Comparisons between groups were conducted using t-tests or Mann-Whitney U-tests for continuous data and chi-square or Fisher's exact test for categorical data. Survival analysis was performed with the Kaplan-Meier method, followed by a log-rank test. The measures of association included the odds ratio (OR) and the risk ratio (RR), with 95% confidence intervals (CIs) calculated from two-by-two contingency tables. The hazard ratio (HR) was derived from Cox proportional hazard models, along with multivariable modeling. The Cox regression was adjusted for anterior knee pain and aseptic loosening, and the proportional hazards hypothesis was verified using Schoenfeld residuals (overall test p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). For outcomes with significant risk ratios, we additionally calculated the absolute risk reduction (ARR\u0026thinsp;=\u0026thinsp;risk_WPR \u0026ndash; risk_PR) and its 95% CI and derived the number needed to treat (NNT\u0026thinsp;=\u0026thinsp;1/ARR) following Altman \u0026amp; Andersen. Missing data, which accounted for less than 5% of any variable, were handled using complete case analysis. All analyses were conducted using Stata 15 for Macbook with a significance level of α\u0026thinsp;=\u0026thinsp;0.05 (bilateral).\u003c/p\u003e \u003cp\u003e This study was conducted with the utmost integrity and respect for ethical standards and was approved by our department's Research and Ethics Committee. It did not receive specific funding from the public, commercial, or nonprofit sectors.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAccording to our study a total of 334 patients were documented over the past 20 years in Latin American population. Of those, 271 met the inclusion criteria. Twenty-three patients died from causes unrelated to TKA, 30 patients underwent surgery for TKA at another medical unit, and 10 patients decided not to participate in the study for personal reasons. The methodology used for all participants in this study is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMethodology used for all participants related to PR and WPR technique in TKA\u003c/p\u003e \u003cp\u003eAge was analyzed as a continuous variable (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) and, for descriptive purposes, was stratified into five ten-year bands that correspond to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Body mass index (BMI) was assessed both continuously and according to standard WHO categories: \u0026lt; 25 kg\u0026middot;m⁻\u0026sup2; (normal), 25\u0026ndash;29.9 kg\u0026middot;m⁻\u0026sup2; (overweight), 30\u0026ndash;34.9 kg\u0026middot;m⁻\u0026sup2; (obesity class I), and \u0026ge;\u0026thinsp;35 kg\u0026middot;m⁻\u0026sup2; (obesity class II/III). Pain severity was measured using an NRS and categorized as mild (0\u0026ndash;3), moderate (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and severe (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The WOMAC index score (ranging from 0 to 96) was grouped into quartiles based on our sample distribution: Q1\u0026thinsp;\u0026le;\u0026thinsp;34, Q2 35\u0026ndash;51, Q3 52\u0026ndash;68, and Q4\u0026thinsp;\u0026ge;\u0026thinsp;69. The OKS was evaluated using its validated clinical cut-points: poor (\u0026lt;\u0026thinsp;20), moderate (\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), good (30\u0026ndash;39), and excellent (40\u0026ndash;48). These category boundaries were predefined to facilitate subgroup and absolute risk analyses and are reproduced in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (age, BMI) and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (NRS, WOMAC, OKS).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the distribution of subjects by gender and age ranges. Our findings indicate that degenerative joint pathology becomes more common as individuals age, especially after the age of 40. Additionally, concerning the laterality of TKA, 59.4% of patients underwent surgery on one limb, while 40.6% had TKA performed on both limbs at different surgical events rather than during a single procedure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eDistribution of age groups of patients who underwent TKA.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;59 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe distribution frequency percentage is presented by age group and gender.\u003c/p\u003e \u003cp\u003eWe documented the technical characteristics included in the post-surgical note and the Hip and Knee Joint Reconstruction Service database from the medical record. According to this database, we categorized patients who underwent TKA into two study groups for the development of this project. Our population included 271 patients, 216 of whom were women (80%) and 55 of whom were men (20%). The two study groups related to TKA, were the PR group and the WPR group. Both groups had a higher proportion of female patients: 79.4% in the PR group and 80% in the WPR group. The most prevalent comorbidity in both groups was rheumatoid arthritis (RA): 81% of patients in the PR group and 89% of patients in the WPR group had RA. Similarly, systemic lupus erythematosus (SLE) occurred more frequently in the PR group (18%) than in the WPR group (10%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e compares comorbidities between the two study groups. No significant differences were observed regarding age and body mass index. However, joint wear and tear and symptomatology increase with age, leading to joint replacement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComorbidities of patients who underwent TKA over 20 years.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWPR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic lupus erythematosus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnkylosing spondylitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe frequency among the total number of cases was 271 patients. The p-value was determined using a Student's t-test.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the WPR group reported persistent anterior knee pain, aseptic loosening, and arthrofibrosis. Additionally, a higher frequency of revision surgeries was observed in this group compared to the PR group; however, no significant differences were noted. The most frequent complications reported in the latter group were periprosthetic infection and aseptic loosening. These results suggest that PR reduces the risk of anterior knee pain and septic loosening compared to the levels reported by the WPR group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComplications related to resurfacing techniques in TKA\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWPR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriprosthetic join infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthrofibrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatellar tendinitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriprosthetic fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeroneal nerve injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior knee pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePercentage frequency of complications. The p-value was estimated using a test for differences between z-proportions.\u003c/p\u003e \u003cp\u003eThe WOMAC index evaluates patients' pain intensity, stiffness, and functionality. Scores close to 0 indicate adequate function, while high scores indicate poor functionality. Based on our results, we observed that scores improved in both study groups. The PR group had better functional outcomes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows improvement in both study groups following TKA. For the OKS scale, the evaluation parameters are as follows: a score of 40 to 48 points indicates an excellent outcome because the patient has few limitations when performing daily activities; a score of 30 to 39 points indicates a good outcome because the patient may have limitations; a score of 20 to 29 points indicates a moderate outcome due to pain and functional limitations of varying degrees; and a score of less than 20 points indicates a poor outcome because pain is intense and knee function is severely affected. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that the scores in both study groups were favorable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of functionality and pain related to resurfacing in TKA\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation scale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy phase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWPR group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eRange of scores per scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWOMAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u0026ndash;94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u0026ndash;89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOKS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026ndash;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis is a report of the range of scores of the WOMAC and OKS functional scales, as well as a pain assessment. The P value was estimated using the student's t-test.\u003c/p\u003e \u003cp\u003eBoth groups showed postoperative improvement; however, patients undergoing PR techniques significantly improved functional assessment and decreased postoperative pain assessment. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that the probability of survival at 8.3 years is 96.7% for the PR group and 90.7% for the WPR group. After 16.6 years, the likelihood of survival decreases to 73.8% and 67.8% for the PR and WPR groups, respectively. No statistical significance was reported between the two groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe present survival related to PR and WPR groups; observing that the average time from implantation to TKA failure was 9 years.\u003c/p\u003e \u003cp\u003eA prognostic variable enables us to anticipate or predict a future clinical event or outcome, such as complications like loosening, anterior knee pain, periprosthetic infection, and prosthesis failure, in our study. As we can see, the results show differences between the two study groups. Therefore, we tested resurfacing as a prognostic variable during the postoperative period in cases of prosthesis failure or revision surgery in TKA. For this purpose, we calculated the relationship between the probabilities of an event related to resurfacing in TKA. We use measures of association OR and RR with 95% CI for the primary outcomes discussed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. OR and RR are reported as raw statistical data. A 2\u0026times;2 contingency table of PR versus WPR was created for each binary outcome. The OR and RR, along with their respective 95% CI, were calculated using Woolf's method for the OR and Katz's formula for the RR. Significance was assessed using a Pearson's χ\u0026sup2; test. The same P-value obtained from the statistical association test was reported for both estimators, as they are derived from the same statistical comparison.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eAssociation between PR and primary outcomes after TKA\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePR (n\u0026thinsp;=\u0026thinsp;136)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWPR (n\u0026thinsp;=\u0026thinsp;135)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.91\u003c/b\u003e\u0026nbsp;(1.10\u0026ndash;7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.69\u003c/b\u003e\u0026nbsp;(1.08\u0026ndash;6.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior knee pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e254.9\u003c/b\u003e\u0026nbsp;(73.9\u0026ndash;879.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e38.6\u003c/b\u003e\u0026nbsp;(12.6\u0026ndash;118.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.32 (0.48\u0026ndash;3.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.30 (0.50\u0026ndash;3.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe P value of OR was determined by using Wald test, and the P value was determined by using Pearson's χ\u0026sup2; test.\u003c/p\u003e \u003cp\u003eDuring a 20-year observation period, aseptic loosening occurred in 11.9% of knees that did not undergo resurfacing, compared to 4.4% of those that had resurfacing. This resulted in an absolute risk reduction (ARR) of 7.4% (95% confidence interval [CI] 1.0\u0026ndash;13.9) and a number needed to treat (NNT) of 14 (95% CI 7\u0026ndash;101) to prevent one loosening event. Regarding anterior knee pain, the absolute risk was 85.2% in knees without resurfacing and only 2.2% in those with resurfacing, yielding an ARR of 83.0% (95% CI 76.5\u0026ndash;89.5). This indicates that treating just 1 to 2 knees prevents one case of persistent pain. The absolute difference in the need for revision surgery was minimal at 1.6% (95% CI \u0026minus;\u0026thinsp;3.7\u0026ndash;6.8%) and was not statistically significant.\u003c/p\u003e \u003cp\u003eWe assessed the time to revision surgery using the Cox regression model. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the multivariate model where the absence of resurfacing was not significantly influenced by revision (HR 2.33; p\u0026thinsp;=\u0026thinsp;0.76). Aseptic loosening emerged as the sole independent predictor (HR 16.7; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). To account for clinical confounding factors, anterior pain, aseptic loosening and periprosthetic infection were included as dichotomous covariates.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox regression model related to resurfacing in TKA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCI 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWPR VS PR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior knee pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.005\u0026ndash;250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.35\u0026ndash;50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe PR group was used as the reference in the Cox regression analysis. The P-value was calculated using the Wald test\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTKA is the preferred treatment for improving knee function and relieving pain in patients with an advanced degenerative stage. In 2021, the Japanese Department of Surgery conducted a study that concluded that if patellar cartilage thickness is reduced to less than half of the preoperative level, symptoms of anterior knee pain may occur 5 years after TKA. Some patients may require surgical revision of TKA. In addition, a correlation between decreased patellar cartilage thickness and postoperative knee functional assessment scores has been observed. Scientific literature indicates that pain is a critical factor to monitor after surgery, as it can temporarily limit patients\u0026rsquo; activities and, if persistent, prompt closer follow-up for possible revision surgery; some individuals may even refuse further procedures because of previous painful experiences and complications (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Therefore, the PR technique in TKA provides optimal results in evaluating anterior knee pain and joint mechanics. However, this technique is not free of complications, such as persistent pain, necrosis, fractures, and patellar noise syndrome or patellar clunking (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). According to recent 20-year studies, the PR technique is associated with a reduced need for revision and improved postoperative functional scores in primary TKA (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, comparative functional analyses did not find any statistically significant differences between the PR and WPR techniques (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In a retrospective study performed in South Korea in 2022, 500 patients who underwent TKA were evaluated. Both techniques were compared, with similar clinical and functional results in the postoperative evaluation (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), which is also consistent with other authors who performed a retrospective study in Germany in 2023, evaluating and comparing the functionality of both techniques and the return to sports activity. It was observed that there are no differences between one technique and the other in performing TKA (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In a 2023 systematic review, Shah et al. reported on the relationship between the PR technique and the ability to kneel after TKA. They observed that patients who underwent PR showed a better ability to kneel without pain compared to those who did not receive this treatment. This finding suggests that PR decreases pain scores and is related to physical activity, which may vary depending on the intensity and type of activity (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Finally, a study about PR technique and life quality, was conducted in Tokyo at the end of the 1990s on patients with RA and resurfacing techniques. The study observed improvements in quality of life and a decrease in pain when performing certain activities, such as standing and going up and down stairs (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2006, Holt et al. conducted a study with 30 patients who underwent TKA; in these patients, WPR techniques were implemented. The study concluded that 80% of the patients experienced a significant reduction in pain. A comprehensive evaluation is advised for PR, encompassing patella bone stock, angular deformity, and patellar tracking. This procedure is recommended to avoid potential complications (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). On the other hand, PR techniques are related to prevent complications specially to anterior knee pain and improvement of NRS after revision surgery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In 2022, Grela et al. reported that both resurfacing techniques can be effective, depending on the patient's condition and preoperative factors. They recommended resurfacing as a viable option for patients with specific risk factors and anatomical characteristics (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Some authors advocate a selective resurfacing approach, which has been linked to reduced pain and lower rates of subsequent complications (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis idea of selective resurfacing is further supported by a study published by Parsons et al. in 2021, which found that resurfacing generally lowers revision rates for TKA and leads to better postoperative functional outcomes compared with cases where resurfacing is omitted (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The study also suggests that this selective technique is cost-effective and contributes to a reduction in postoperative complication rates. In 2016, the Department of Orthopaedic Surgery at Haukeland University Hospital conducted a study of 308 knees in which they evaluated secondary resurfacing techniques. These patients were evaluated for persistent postoperative pain, and an improvement in function and pain was observed in patients who underwent PR compared to those who did not. In addition, improvement was observed after surgery, and superior clinical and functional outcomes were achieved. Therefore, performing a PR improves quality of life, functionality, and postoperative pain, although this is important for implant survival. These results reinforce the idea that it is important to consider the possibility of revision if symptoms persist, mainly pain (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, the variability of results suggests that a selective strategy may be most appropriate, allowing treatment to be tailored to each patient's specific characteristics. In our study, we observed an improvement in functional scores and postoperative pain scores.\u003c/p\u003e \u003cp\u003eIn 2023, a study was conducted in Austria on 1209 patients who underwent the WPR technique, evaluating patients with advanced and moderate stages of patellofemoral osteoarthritis; they reported patients who underwent PR with better survival rates and functional outcomes, as well as verification of proper patellar follow-up to avoid future complications. As we have observed, one of the most common complications related to the lack of PR is the development of anterior knee pain, which may lead to revision surgery and secondary resurfacing (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). On the other hand, in 2023, Samih et al. performed a retrospective study including 106 patients who underwent TKA and compared both PR techniques. The most common complications observed in our study for the PR group included infection (17.2%), persistence of anterior pain (13.7%), gait disturbance (6.8%), and loosening of the patellar component (3.4%).\u003c/p\u003e \u003cp\u003eWhile PR can alleviate anterior knee pain, it is not without inherent complications. In 2023, Adam et al. reported the most common complications associated with PR in TKA, including patellar fracture, patellar instability, and patellar maltracking. These complications may require revision surgery. Fracture of the patella is a serious complication in the medical field, impacting postoperative function and treatment difficulty, especially in patients who have undergone arthroplasty due to the recovery time and temporary functional limitation of TKA (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Research on complications related to PR indicates that the incidence of complications is similar to or lower than that associated with WPR technique. This research specifically identifies complications such as persistent pain, periprosthetic infection, and instability, with no studies suggesting that the PR technique in TKA carries an increased risk (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In 2019, a study was conducted in China comparing PR and WPR techniques in patients with bilateral TKA. The study, which included 132 patients, observed complications associated with fractures and alterations of patellofemoral tracking in both groups. The study found that 23% of patients who did not receive resurfacing techniques experienced persistent anterior knee pain, compared to 19%. Both study groups encountered complications, though these were more prevalent in the WPR group. Despite the risks mentioned earlier, no complications such as patellar subluxation or dislocation, rupture of the quadricipital tendon, aseptic loosening, patellar osteonecrosis, or fractures were identified (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In Tokyo, Choi et al. reported a systematic review of bilateral randomized trials in 2022. This study reported similar results in patients with PR and WPR techniques and revision surgery. As previously mentioned, while the functional and pain benefits may be relevant, it is imperative to consider the risk of complications inherent to this technique (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Numerous scientific studies support PR as a technique that improves implant survival and reduces the incidence of anterior knee pain, a common cause of revision surgery in patients WPR (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe patella plays a crucial role in TKA, and its proper treatment is essential for survival; according to the findings of some authors, patients who underwent resurfacing experienced a marked improvement in function, which in turn reduced the need for revision surgery. Therefore, adequate treatment is essential to ensure survival, reduce complications, and reduce the number of revision surgery. According to the findings of specific authors, patients undergoing resurfacing experienced a marked improvement in functionality, resulting in a decrease in the need for additional surgical interventions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In 2019, Allen et al. reported patients who underwent TKA and the WPR technique; they reported fewer complications related to the patellar component, such as fractures and maltracking. This technical fact may reduce some patients' need for medical revisions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Conversely, the WPR technique has been promoted as a viable option in some instances, especially in patients with good-quality patellar cartilage or those with mild patellar osteoarthritis. However, recent findings indicate that the WPR may be linked to a decreased implant survival rate in patients with more advanced patellofemoral osteoarthritis, along with an elevated risk of persistent pain and the necessity for revisions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In 2023, Nardelli et al. presented a study in Austria that compared both techniques in TKA. This study showed a 10-year survival rate of 93.3% in the PR group and 88.6% in the WPR group (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Current evidence suggests that PR is associated with a higher implant survival rate in most patients. The WPR technique may be a viable option for some patients; however, the potential risks of patellar wear and postoperative pain could impact the feasibility of secondary resurfacing.\u003c/p\u003e \u003cp\u003eAccording to comorbidities, there was no statistical difference between comorbidities and factors that predispose to persistent anterior knee pain after TKA (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Benazzo et al. in 2020, reported PR techniques in patients with synovial inflammatory features, inflammatory arthritis, and arthritis. Conversely, it is crucial to prioritize patients with rheumatologic pathologies, patients with BMI alterations, patients experiencing pain when climbing or descending stairs, and female patients, as these factors significantly influence the technique's performance on anterior knee pain (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor patients with rheumatic pathologies resurfacing treatment is recommended, on the other hand the procedure of WPR techniques need a denervation of the patella, osteophyte resection, remodeling of the articular surface, and synovectomy of the deep aspect of the quadricipital tendon (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Patients with rheumatic pathologies require particular attention due to the chronic use of immunosuppressive drugs, which can compromise optimal recovery processes, such as healing or response to infectious processes. The most significant complications associated with hip and knee joint replacements in patients with rheumatologic pathologies include postoperative infections (related to the use of immunosuppressants such as corticosteroids, methotrexate, or Tumoral Necrosis Factor inhibitors), thromboembolic complications, premature loosening of implants, and an increased risk of revision surgery and delayed healing processes. Patients with rheumatologic pathologies require particular attention due to the chronic use of immunosuppressive drugs. These medications have the potential to impact the healing process, increase the risk of infection, and influence the recovery and outcomes of the procedure. A comprehensive investigation was conducted to identify the factors that contribute to complications. According to the 2022 recommendations of the American College of Rheumatology and the American Association of Hip and Knee Surgeons regarding the preoperative treatment of rheumatologic patients and arthroplasty procedures, the suspension and resumption of immunosuppressive therapies are recommended.\u003c/p\u003e \u003cp\u003eThe goal is to reduce complications and improve long-term outcomes (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, no study has been conducted on implementing the resurfacing technique as a predictive factor in primary TKA. Both the OR and RR for aseptic loosening and anterior pain were found to be greater than 1. This indicates that the absence of resurfacing is linked to a higher risk of complications. A p-value of less than 0.05 supports the strength of this association. The narrow CI for loosening suggests a precise estimate, while the wide CI for pain indicates greater uncertainty. In contrast, the p-value of 0.59 for revision surgery corresponds with a CI that includes 1, suggesting there is no detectable effect on this outcome. The Cox proportional hazards model confirmed an independent protective effect with a HR of 0.65 (95% CI, 0.47\u0026ndash;0.90).\u003c/p\u003e \u003cp\u003eThe study's limitations stem from its execution in a tertiary-level hospital or high-specialty reference hospital, which may have introduced a bias by enrolling only patients with complex pathologies. The selection bias is attributed to the inclusion criteria, which were applied to include patients with complex pathologies requiring specialized treatments. Therefore, limiting the generalization of the results to less specialized care settings with a larger patient population is important. Additionally, the limited diversity in the sample and the high proportion of complex cases may influence the results obtained. Despite the presence of advanced resources at the hospital center, the study did not compare with less complex cohorts or hospitals at other levels of care.\u003c/p\u003e \u003cp\u003eIn this 20-year retrospective cohort study, PR demonstrated a clinically significant absolute risk reduction of 83% for persistent anterior knee pain and 7.4% for aseptic loosening. Additionally, the overall revision rate for resurfaced knees remained comparable to that of non-resurfaced knees. These findings support our initial hypothesis and are consistent with contemporary meta-analyses that indicate lower pain scores and fewer secondary revisions following PR. The benefits of PR were most pronounced in terms of pain relief, with a number needed to treat (NNT) of approximately 1 to 2. This suggests that the primary mechanism of benefit is the biomechanical optimization of the patellofemoral joint rather than the structural protection of the tibiofemoral components. Although the hazard ratio for revisions favored PR (HR 0.65), the confidence interval included 1, indicating some uncertainty. Nonetheless, the consistency of the benefits observed across various sensitivity analyses and the extended follow-up period enhance the robustness of our findings.\u003c/p\u003e \u003cp\u003eOur study group was treated at a high-volume tertiary arthroplasty center in Mexico City, where 80% of the patients were female and approximately 85% had rheumatoid pathologies. Caution should be used when applying these findings to community hospitals that serve predominantly osteoarthritic populations or when considering contemporary cementless implants. However, key technical aspects, such as the posterior-stabilized design and the cemented patellar button, are consistent with those used globally, and the observed effects align with findings from large international registries, suggesting broader relevance. Future prospective multicenter trials are necessary to determine whether the extent of pain reduction is maintained in lower-risk populations.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAfter conducting a thorough analysis, the following conclusions have been reached. PR offers a clinically significant reduction in anterior knee pain and lowers the risk of aseptic loosening in TKA over a 20-year follow-up period. The overall revision rate was not significantly affected, indicating that the benefits are primarily related to pain relief and functional improvement rather than structural advantages. These findings advocate for a selective approach to resurfacing. It is recommended that PR be considered primarily to minimize anterior pain and mechanical complications, particularly in younger patients or those with higher functional demands.\u003c/p\u003e \u003cp\u003eThere are no precise indications for decision-making regarding resurfacing the patella during TKA. Our study found that PR during primary TKA offers patients the best functionality and pain relief results. This technique has been shown to reduce postoperative complications and improve patient's quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARR: absolute risk reduction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCis: confidence intervals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHR: hazard ratio\u003c/p\u003e\n\u003cp\u003eCI: confidence interval\u003c/p\u003e\n\u003cp\u003eND: no statistical difference\u003c/p\u003e\n\u003cp\u003eNNT: number needed to treat\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNRS: numeric rating scale\u003c/p\u003e\n\u003cp\u003eOA: osteoarthritis\u003c/p\u003e\n\u003cp\u003eOKS: Oxford knee score\u003c/p\u003e\n\u003cp\u003eOR: odds ratio\u003c/p\u003e\n\u003cp\u003ePR: patellar resurfacing\u003c/p\u003e\n\u003cp\u003eRA: rheumatoid arthritis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRR: risk ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSLE: systemic lupus erythematosus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTKA: total knee arthroplasty\u003c/p\u003e\n\u003cp\u003eWOMAC: Western Ontario and McMaster Universities Osteoarthritis\u003c/p\u003e\n\u003cp\u003eWPR: without patellar resurfacing\u003c/p\u003e"},{"header":"Declarations","content":"\u003col\u003e\n\u003cli\u003eEthics approval and consent to participate \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eApproval for this study was obtained from the Institutional Review Board at the Instituto Nacional de Ciencias M\u0026eacute;dicas y Nutricion Salvador Zubiran. (registration CONBIOETICA-09-CEI-011-20160627, official letter OFICIO-NO. MCONTROL-2459/2024). Our research was conducted in accordance with the Declaration of Helsinki and the Mexican national guidelines for health research in humans (NOM-012-SSA3-2012). All participants provided written informed consent before enrolling in the study.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003eConsent for publication\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eAvailability of data and materials\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe datasets generated during and analyzed during the current study are available in the Zenodo repository, available from: https://zenodo.org/records/15570904], DOI 10.5281/zenodo.14015466. \u003c/p\u003e\n\u003col start=\"4\"\u003e\n\u003cli\u003eCompeting interests\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003col start=\"5\"\u003e\n\u003cli\u003eFunding \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that they have no sources of funding for the research reported in this study. \u003c/p\u003e\n\u003col start=\"6\"\u003e\n\u003cli\u003eAuthors\u0026apos; contributions \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDiego Laverde Osorio. Contribution: Data Curation\u003c/p\u003e\n\u003cp\u003eLuis David Marcial Barba. Contribution: Supervision\u003c/p\u003e\n\u003cp\u003eNelva Garduza Leyva. Contribution: Data Curation\u003c/p\u003e\n\u003cp\u003eEfrain Diaz Borjon. Contribution: Conceptualization\u003c/p\u003e\n\u003cp\u003eJuan Montejo Vargas. Contribution: Writing - Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eGeorges Jirjis Makdissy Salomon. Contribution: Writing - Original Draft\u003c/p\u003e\n\u003cp\u003eChristian Hazel Hernandez Romero. Contribution: Methodology\u003c/p\u003e\n\u003col start=\"7\"\u003e\n\u003cli\u003eAcknowledgements\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLan RH, Bell JW, Samuel LT, Kamath AF. Evolving outcome measures in total knee arthroplasty: trends and utilization rates over the past 15 years. J Arthroplasty. 2020;35(11):3375-3382. doi:10.1016/j.arth.2020.06.036.\u003c/li\u003e\n \u003cli\u003ePrimorac D, Molnar V, Rod E, Jeleč Ž, Čukelj F, Mati\u0026scaron;ić V, et al. Knee osteoarthritis: a review of pathogenesis and state-of-the-art non-operative therapeutic considerations. Genes (Basel). 2020;11(8):854. doi:10.3390/genes11080854.\u003c/li\u003e\n \u003cli\u003eSchindler OS. The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus? Knee Surg Sports Traumatol Arthrosc. 2012;20(7):1227-1244. doi:10.1007/s00167-012-1985-7.\u003c/li\u003e\n \u003cli\u003eTang X, He Y, Pu S, Lei L, Ning N, Shi Y, et al. Patellar resurfacing in primary total knee arthroplasty: a meta-analysis and trial sequential analysis of 50 randomized controlled trials. Orthop Surg. 2023;15(2):379-399. doi:10.1111/os.13392\u003c/li\u003e\n \u003cli\u003eBenazzo F, Perticarini L, Jannelli E, Ivone A, Ghiara M, Rossi SP. Controversy: supporting patellar resurfacing in total knee arthroplasty\u0026mdash;do it. EFORT Open Rev. 2020;5(11):785-792. doi:10.1302/2058-5241.5.190075.\u003c/li\u003e\n \u003cli\u003eFleaca SR, Mohor CI, Dura H, Chicea R, Mohor C, Boicean A, et al. Effect of patella resurfacing on functional outcome and revision rate in primary total knee arthroplasty. Exp Ther Med. 2022;23:104. doi:10.3892/etm.2021.11027\u003c/li\u003e\n \u003cli\u003eAunan E, N\u0026aelig;ss G, Clarke-Jenssen J, Sandvik L, Kibsg\u0026aring;rd TJ. Patellar resurfacing in total knee arthroplasty: functional outcome differs with different outcome scores\u0026mdash;a randomized double-blind study of 129 knees with 3 years of follow-up. Acta Orthop. 2016;87(2):158-64. doi:10.3109/17453674.2015.1111075\u003c/li\u003e\n \u003cli\u003eMigliorini F, Eschweiler J, Niewiera M, El Mansy Y, Tingart M, Rath B. Better outcomes with patellar resurfacing during primary total knee arthroplasty: a meta-analysis study. Arch Orthop Trauma Surg. 2019;139(10):1445-54. doi:10.1007/s00402-019-03246-z\u003c/li\u003e\n \u003cli\u003eGrela M, Barrett M, Kunutsor SK, Blom AW, Whitehouse MR, Matharu GS. Clinical effectiveness of patellar resurfacing, no resurfacing and selective resurfacing in primary total knee replacement: systematic review and meta-analysis of interventional and observational evidence. BMC Musculoskelet Disord. 2022;23:932. doi:10.1186/s12891-022-05877-7\u003c/li\u003e\n \u003cli\u003eLeta TH, Lygre SH, Skredderstuen A, Hallan G, Gjertsen JE, Rokne B, et al. Secondary patella resurfacing in painful non-resurfaced total knee arthroplasties: survival and clinical outcome from the Norwegian Arthroplasty Register (1994-2011). Int Orthop. 2016;40(4):715-22. doi:10.1007/s00264-015-3017-y\u003c/li\u003e\n \u003cli\u003eTeel AJ, Esposito JG, Lanting BA, Howard JL, Schemitsch EH. Patellar resurfacing in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2019;34(12):3124-32. doi:10.1016/j.arth.2019.07.019\u003c/li\u003e\n \u003cli\u003eParsons T, Al-Jabri T, Clement ND, Maffulli N, Kader DF. Patella resurfacing during total knee arthroplasty is cost-effective and has lower re-operation rates compared to non-resurfacing. J Orthop Surg Res. 2021;16:185. doi:10.1186/s13018-021-02295-8\u003c/li\u003e\n \u003cli\u003eShah OA, Spence C, Kader D, Clement ND, Asopa V, Sochart DH. Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review. Arthroplasty. 2023;5:32. doi:10.1186/s42836-023-00184-5 PubMed\u003c/li\u003e\n \u003cli\u003eSamih M, Fadili H, Chagou A, Jaafar A, Zryouil B. Resurfacing versus non-resurfacing patella in total knee replacement: when and what to choose. Cureus. 2023;15:e44276. doi:10.7759/cureus.44276\u003c/li\u003e\n \u003cli\u003eSato D, Inoue M, Sasaki T, Uchida J, Onodera T, Kondo E, et al. No patella resurfacing total knee arthroplasty leads to reduction in patellar cartilage thickness to less than half within 5 years: a quantitative longitudinal MRI study. J Exp Orthop. 2021;8:107. doi:10.1186/s40634-021-00425-z PubMed\u003c/li\u003e\n \u003cli\u003eAdam R, Moldovan C, Tudorache S, H\u0026acirc;rșovescu T, Orban C, Pogărășteanu M, et al. Patellar resurfacing in total knee arthroplasty\u0026mdash;a never-ending controversy: case report and literature review. Diagnostics (Basel). 2023;13:383. doi:10.3390/diagnostics13030383\u003c/li\u003e\n \u003cli\u003eKo YI, Yang JH, Choi CH. Comparison of clinical outcomes after total knee arthroplasty with and without patellar resurfacing in the same patients. Clin Orthop Surg. 2022;14:361-9. doi:10.4055/cios20289\u003c/li\u003e\n \u003cli\u003eNoh JH, Kim NY, Song KI. Clinical outcomes between patellar resurfacing and non-resurfacing in cruciate-retaining total knee arthroplasty. J Orthop Surg (Hong Kong). 2022;30:10225536221092223. doi:10.1177/10225536221092223\u003c/li\u003e\n \u003cli\u003eAllen W, Eichinger J, Friedman R. Resurfaced versus non-resurfaced patella in total knee arthroplasty. J Knee Surg. 2019;32:611-5. doi:10.1055/s-0039-1681077\u003c/li\u003e\n \u003cli\u003eNardelli P, Neururer S, Gruber K, Wippel D, Kogler N, Ender S, et al. Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellofemoral osteoarthritis Iwano stages 3-4. Knee Surg Sports Traumatol Arthrosc. 2023;31:3941-6. doi:10.1007/s00167-023-07387-y\u003c/li\u003e\n \u003cli\u003eHa C, Wang B, Li W, Sun K, Wang D, Li Q. Resurfacing versus not-resurfacing the patella in one-stage bilateral total knee arthroplasty: a prospective randomized clinical trial. Int Orthop. 2019;43(11):2519-27. doi:10.1007/s00264-019-04361-7\u003c/li\u003e\n \u003cli\u003eSchatz C, Pl\u0026ouml;tz W, Beckmann J, Leidl R, Buschner P. The impact of primary patella resurfacing on health-related quality-of-life outcomes and return to sport in total knee arthroplasty (TKA). Arch Orthop Trauma Surg. 2023;143(11):6731-40. doi:10.1007/s00402-023-04930-x\u003c/li\u003e\n \u003cli\u003eChoi KY, In Y, Kim MS, Sohn S, Koh IJ. Is the patient aware of the difference between resurfaced and non-resurfaced patella after bilateral total knee arthroplasty? A systematic review of simultaneous bilateral randomized trials. Knee Surg Relat Res. 2022;34:4. doi:10.1186/s43019-022-00133-7\u003c/li\u003e\n \u003cli\u003eBarrack RL, Bertot AJ, Wolfe MW, Waldman DA, Milicic M, Myers L. Patellar resurfacing in total knee arthroplasty: a prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am. 2001;83(9):1376-81. doi:10.2106/00004623-200109000-00003\u003c/li\u003e\n \u003cli\u003ePehlivanoglu T, Balci HI, Demirel M, Cakmak MF, Yazicioglu O, Kilicoglu OI. Prevalence of anterior knee pain after patellar retention total knee arthroplasty: comparison of patients with rheumatoid arthritis versus primary osteoarthritis. Acta Orthop Traumatol Turc. 2019;53(6):420-5. doi:10.1016/j.aott.2019.07.001\u003c/li\u003e\n \u003cli\u003eKajino A, Yoshino S, Kameyama S, Kohda M, Nagashima S. Comparison of the results of bilateral total knee arthroplasty with and without patellar replacement for rheumatoid arthritis: a follow-up note. J Bone Joint Surg Am. 1997;79(4):570-4. doi:10.2106/00004623-199704000-00020\u003c/li\u003e\n \u003cli\u003eHolt G, Miller N, Kelly MP, Leach WJ. Retention of the patella in total knee arthroplasty for rheumatoid arthritis. Joint Bone Spine. 2006;73(5):523-6. doi:10.1016/j.jbspin.2005.11.017\u003c/li\u003e\n \u003cli\u003eGoodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 2022;74(9):1464-73. doi:10.1002/art.42140\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDataset. Hern\u0026aacute;ndez-Romero CH, D\u0026iacute;az-Borj\u0026oacute;n E, Laverde-Osorio D, et al. Dataset for: Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty (20-Year Cohort Study) [Zenodo]. Zenodo; 2025. DOI: 10.5281/zenodo.14015466.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"arthroplasty, knee resurfacing, anterior knee pain, aseptic loosening, prognostic factor","lastPublishedDoi":"10.21203/rs.3.rs-6798646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6798646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe decision to perform patellar resurfacing (PR) during total knee arthroplasty (TKA) is based on patient and implant characteristics. This study aims to evaluate PR as a prognostic factor for revision in primary TKA with 20 years of follow-up experience.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a retrospective, comparative, observational cohort study of patients who underwent TKA at a high-specialty hospital in Mexico between 2000 and 2020. A total of 334 patients who underwent TKA were evaluated. For our TKA population we divided in two groups of interest: those with patellar PR and without patellar resurfacing (WPR). Functionality was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score (OKS) scales. Pain was evaluated using the numeric rating scale (NRS). We determined the survival of TKA using the Kaplan-Meier method, and to evaluate prognostic variables, we used measures of association, such as the odds ratio (OR) and risk ratio (RR), along with the hazard ratio test (HR), with a 95% confidence interval (IC). A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTKA with PR was associated with improved clinical and functional outcomes. There were fewer reported complications and fewer cases of prosthetic failure or revision surgery in patients receiving PR.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eNot applicable, this study is an observational retrospective cohort no prospective registration was required.\u003c/p\u003e","manuscriptTitle":"Patellar Resurfacing as a Prognostic Factor in Total Knee Arthroplasty: 20-Year Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-17 09:21:46","doi":"10.21203/rs.3.rs-6798646/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-07T07:02:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T05:12:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-06T18:41:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146067983402777224217274403778063959798","date":"2025-07-04T06:03:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T18:59:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82332678002693288835513562169242500335","date":"2025-06-29T10:58:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229053824682439484077345930122974650916","date":"2025-06-25T11:07:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-12T15:20:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-10T11:02:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-07T06:30:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-07T06:29:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-06-02T04:10:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6342e00f-7299-4e26-9684-ce961e1f6ccb","owner":[],"postedDate":"June 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:08:49+00:00","versionOfRecord":{"articleIdentity":"rs-6798646","link":"https://doi.org/10.1186/s12891-025-09076-y","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-01-13 16:31:03","publishedOnDateReadable":"January 13th, 2026"},"versionCreatedAt":"2025-06-17 09:21:46","video":"","vorDoi":"10.1186/s12891-025-09076-y","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09076-y","workflowStages":[]},"version":"v1","identity":"rs-6798646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6798646","identity":"rs-6798646","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}