Patellofemoral Tracking After Total Knee Arthroplasty: Etiology, Diagnosis, Management, and the Emerging Role of Robotic-Assisted Alignment
DOI:
https://doi.org/10.33533/jpm.v19i2.14095Keywords:
Total knee arthroplasty;, Patellofemoral tracking; , Patellar maltracking; , Robotic-assisted TKA; , Component rotationAbstract
Patellofemoral maltracking remains a major cause of pain, instability, poor function, and dissatisfaction after total knee arthroplasty (TKA). Despite advances in implant design and surgical technique, patellofemoral complications continue to contribute to revision surgery and inferior outcomes. This review summarizes the etiology, diagnosis, prevention, and management of patellofemoral tracking abnormalities after TKA, including a comparison between conventional and robotic-assisted techniques.
The most common causes of maltracking include internal rotation of the femoral or tibial component, excessive valgus alignment, soft-tissue imbalance, patella baja, anterior overstuffing, and implant design mismatch. Internal femoral malrotation is consistently identified as the leading factor causing lateral patellar tilt, subluxation, and instability. Clinical evaluation includes anterior knee pain, crepitus, apprehension, and extensor lag, while radiographs and computed tomography are important for assessing patellar tilt, shift, and component rotation.
Treatment depends on the underlying cause. Revision of malrotated components, lateral release, tibial tubercle transfer, medial patellofemoral ligament reconstruction, and secondary patellar resurfacing may be required. Robotic-assisted TKA improves component alignment and intra-operative assessment, but current evidence has not shown superior functional outcomes compared with conventional TKA.
References
Ferri R, Digennaro V, Panciera A, Bulzacki Bogucki BD, Cecchin D, Manzetti M, et al. Management of patella maltracking after total knee arthroplasty: a systematic review. Musculoskelet Surg. 2022;107(2):143–157.DOI: https://doi.org/10.1007/s12306-022-00764-9
Younis Z, Hamid MA, Ravi B, Verma R, Devasia T. Patellar instability following total knee arthroplasty: a review of etiology, diagnosis, and management strategies. Cureus. 2025 Aug;17(8):e89213. DOI: https://doi.org/10.7759/cureus.89213
Donell S. Patellar tracking in primary total knee arthroplasty. EFORT Open Rev. 2018;3(4):106–113. DOI: https://doi.org/10.1302/2058-5241.3.170036
Dahlmann S, Ziegeler K, Mau‑Möller A, Mittelmeier W, Bergschmidt P. Patellar tracking in total knee arthroplasty—Influence on clinical and functional outcome. Diagnostics (Basel). 2022;12(5):1082. DOI: https://doi.org/10.3390/diagnostics12051082
Petersen W, Rembitzki IV, Brüggemann GP, Ellermann A, Best R, Gösele‑Koppenburg A, et al. Anterior knee pain after total knee arthroplasty: a narrative review. Int Orthop. 2014;38(2):319–328. DOI: https://doi.org/10.1007/s00264-013-2081-4
Iordache S, Costache M, Cursaru A, Serban B, Spiridonica R, Popa M, et al. A narrative review of patellar resurfacing versus non‑resurfacing in total knee arthroplasty. Cureus. 2023;15(5):e39362. DOI: https://doi.org/10.7759/cureus.39362
Diquattro E, Andriollo L, Koutserimpas C, Baltzer J, Servien E, Batailler C, et al. Patellofemoral alignment safe zones in robotic‑assisted total knee arthroplasty do not affect outcomes but do influence patellar resurfacing rates. Knee Surg Sports Traumatol Arthrosc. 2026;34(1):153–163. DOI: https://doi.org/10.1002/ksa.12786
Sacco R, Tecame A, Lalevée M, Perrier A, Massa E, Kouyoumdjian P, et al. Robotic vs. conventional total knee arthroplasty over two decades: evolving trends toward personalised alignment without significant clinical superiority in predominantly mild varus deformity—a systematic review of RCTs. J Exp Orthop. 2025;12(4):e70452. DOI: https://doi.org/10.1002/jeo2.70452
Abbas AA, Loh KW, Varatharaja Pillai S, Sulaiman MA, Lee CM. Comparative analysis of femoral component rotational accuracy in robotic‑assisted versus navigation‑assisted total knee arthroplasty. J Orthop Surg Res. 2025;20:707. DOI: https://doi.org/10.1186/s13018-025-06101-7
Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res. 1998;(356):144-153.DOI: https://doi.org/10.1097/00003086-199811000-00021
Barrack RL, Schrader T, Bertot AJ, Wolfe MW, Myers L. Component rotation and anterior knee pain after total knee arthroplasty. Clin Orthop Relat Res. 2001;(392):46-55.DOI: https://doi.org/10.1097/00003086-200111000-00006
Matsuda S, Miura H, Nagamine R, Urabe K, Hirata G, Iwamoto Y. Anatomical analysis of the femoral condyle in normal and osteoarthritic knees. J Orthop Res. 2004;22(1):104-109.DOI: https://doi.org/10.1016/S0736-0266(03)00134-7
Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H, et al. Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res. 1999;(366):155-163.DOI: https://doi.org/10.1097/00003086-199909000-00019
Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE. Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res. 2001;(392):38-45.DOI: https://doi.org/10.1097/00003086-200111000-00005
Nicoll D, Rowley DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br. 2010;92(9):1238-1244.DOI: https://doi.org/10.1302/0301-620X.92B9.23516
Hofmann AA, Tkach TK, Evanich CJ, Camargo MP. Patellar component medialization in total knee arthroplasty. J Arthroplasty. 1997;12(2):155-160.DOI: https://doi.org/10.1016/S0883-5403(97)90061-9
Feller JA, Bartlett RJ, Lang DM. Patellar resurfacing versus retention in total knee arthroplasty. J Bone Joint Surg Br. 1996;78(2):226-228.DOI: https://doi.org/10.1302/0301-620X.78B2.0780226
Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Am. 2003;85(2):212-217.DOI: https://doi.org/10.2106/00004623-200302000-00005
Burnett RS, Bourne RB. Indications for patellar resurfacing in total knee arthroplasty. Instr Course Lect. 2004;53:167-186.
Matsuda S, Ishinishi T, Whiteside LA. Contact stresses with an unresurfaced patella in total knee arthroplasty. J Arthroplasty. 2000;15(7):927-932.
Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res. 1995;(321):168-172. DOI: https://doi.org/10.1097/00003086-199512000-00026
Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD. Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res. 2007;458:131-136. DOI: https://doi.org/10.1097/BLO.0b013e3180332d97
Matsen Ko L, Chen AF, Deirmengian GK, Hozack WJ, Sharkey PF. Catastrophic patellar instability after total knee arthroplasty. J Arthroplasty. 2015;30(9 Suppl):135-138.
Baldini A, Anderson JA, Cerulli-Mariani P, Kalyvas J, Pavlov H, Sculco TP. Patellofemoral evaluation after total knee arthroplasty. Validation of a new weight-bearing axial radiographic view. J Bone Joint Surg Am. 2007;89(8):1810-1817. DOI: https://doi.org/10.2106/00004623-200708000-00020
https://doi.org/10.2106/JBJS.E.00432
Merican AM, Ghosh KM, Iranpour F, Deehan DJ, Amis AA. The effect of femoral component rotation on the kinematics of the tibiofemoral and patellofemoral joints after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011;19(9):1479-1487. DOI:
https://doi.org/10.1007/s00167-011-1499-8
Matsumoto T, Muratsu H, Kawakami Y, Takayama K, Ishida K, Matsushita T, et al. Soft tissue balance and patellar tracking in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1359-1364.
Dennis DA, Komistek RD, Mahfouz MR. In vivo fluoroscopic analysis of patellofemoral kinematics after total knee arthroplasty. Clin Orthop Relat Res. 2003;(410):114-130. DOI: https://doi.org/10.1097/01.blo.0000062385.79828.72
Stiehl JB, Dennis DA, Komistek RD, Keblish PA. In vivo kinematic analysis of patellofemoral contact position after total knee arthroplasty. J Arthroplasty. 2001;16(6):738-745. DOI: https://doi.org/10.1054/arth.2001.24443
Thein R, Haviv B, Kidron A, Bronak S, Hofman S. Medial patellofemoral ligament reconstruction for patellar instability after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1236-1241.
Heesterbeek PJ, Wymenga AB. Patellar component overstuffing in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2008;16(8):805-810.
van Jonbergen HP, Boeddha AV, M van Raaij JJ. Patient satisfaction and functional outcome after secondary patellar resurfacing. J Arthroplasty. 2010;25(4):547-551.
Parvizi J, Rapuri VR, Saleh KJ, Kuskowski MA, Sharkey PF, Mont MA. Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery. Clin Orthop Relat Res. 2005;(438):191-196.DOI: https://doi.org/10.1097/01.blo.0000166903.69075.8d
Sensi L, Buzzi R, Giron F, De Luca L, Aglietti P. Patellofemoral function after total knee arthroplasty: gender-related differences. J Arthroplasty. 2011;26(8):1475-1480. DOI: https://doi.org/10.1016/j.arth.2011.01.016
Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patellar tilt after total knee arthroplasty. Clin Orthop Relat Res. 2012;470(1):127-134. DOI: https://doi.org/10.1007/s11999-012-2533-y
Meneghini RM, Pierson JL, Bagsby D, Ziemba-Davis M, Berend ME, Ritter MA. Is robotic-assisted total knee arthroplasty better than conventional total knee arthroplasty? A matched-pair analysis. J Arthroplasty. 2014;29(9 Suppl):44-49.
Marchand RC, Sodhi N, Khlopas A, Sultan AA, Harwin SF, Malkani AL, et al. Patient satisfaction outcomes after robotic arm-assisted total knee arthroplasty: a short-term evaluation. J Knee Surg. 2017;30(9):849-853. DOI: https://doi.org/10.1055/s-0037-1607450
Kayani B, Konan S, Tahmassebi J, Pietrzak JRT, Haddad FS. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced pain compared with conventional jig-based total knee arthroplasty. Bone Joint J. 2018;100-B(7):930-937. DOI: https://doi.org/10.1302/0301-620X.100B7.BJJ-2017-1449.R1
Sultan AA, Piuzzi NS, Khlopas A, Chughtai M, Harwin SF, Mont MA. Utilization of robotic-arm assisted total knee arthroplasty for soft tissue protection. Expert Rev Med Devices. 2017;14(12):925-927. DOI: https://doi.org/10.1080/17434440.2017.1392237
Batailler C, White N, Ranaldi FM, Neyret P, Servien E, Lustig S. Improved implant position and lower revision rate with robotic-assisted unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1232-1240. DOI: https://doi.org/10.1007/s00167-018-5081-5
Bell SW, Anthony I, Jones B, MacLean A, Rowe P, Blyth M. Improved accuracy of component positioning with robotic-assisted total knee arthroplasty. J Bone Joint Surg Am. 2016;98(8):627-635.DOI: https://doi.org/10.2106/JBJS.15.00664
Liow MHL, Xia Z, Wong MK, Tay KJ, Yeo SJ, Chin PL. Robot-assisted total knee arthroplasty accurately restores the joint line and mechanical axis. A prospective randomised study. J Arthroplasty. 2014;29(12):2373-2377. DOI: https://doi.org/10.1016/j.arth.2013.12.010
Song EK, Seon JK, Yim JH, Netravali NA, Bargar WL. Robotic-assisted TKA reduces postoperative alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop Relat Res. 2013;471(1):118-126. DOI: https://doi.org/10.1007/s11999-012-2407-3
Hampp EL, Chughtai M, Scholl LY, Sodhi N, Sultan AA, Harwin SF, et al. Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared with manual techniques. J Knee Surg. 2019;32(3):239-250. DOI: https://doi.org/10.1055/s-0038-1641729
Parratte S, Pagnano MW. Instability after total knee arthroplasty. J Bone Joint Surg Am. 2008;90(1):184-194.
Vince KG. Why knees fail. J Arthroplasty. 2003;18(3 Suppl 1):39-44. DOI: https://doi.org/10.1054/arth.2003.50102
Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am. 2005;87 Suppl 1(Pt 2):271-284. DOI: https://doi.org/10.2106/JBJS.E.00308
Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat Award: Is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res. 2012;470(1):45-53. DOI: https://doi.org/10.1007/s11999-011-1936-5
Howell SM, Papadopoulos S, Kuznik KT, Hull ML. Accurate alignment and high function after kinematically aligned TKA performed with patient-specific guides. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2271-2280.DOI: https://doi.org/10.1007/s00167-013-2621-x
Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements. Bone Joint J. 2014;96-B(7):907-913. DOI: https://doi.org/10.1302/0301-620X.96B7.32812
O’Bryan E, Jones C, Joseph S. A novel robotic technique for mapping patellofemoral kinematics in total knee arthroplasty. Arthroplast Today. 2025;31:101610.DOI: https://doi.org/10.1016/j.artd.2024.101610
Whiteside LA. Selective ligament release in total knee arthroplasty of the knee in valgus. Clin Orthop Relat Res. 1999;(367):130-140. DOI: https://doi.org/10.1097/00003086-199910000-00016
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