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J Knee Surg
DOI: 10.1055/a-2638-9752
Letter to the Editor

Letter to the Editor on “Contemporary Cementless Patellar Implant Survivorship: A Systematic Review and Meta-Analysis of 3,005 Patellae”

Authors

  • Nosaibah Razaqi 

    1   Afghanistan Center for Epidemiological Studies, Herat, Afghanistan
    2   Faculty of Medicine, Ghalib University, Herat, Afghanistan

  • Rachana Mehta

    3   Department of Clinical Microbiology, RDC, Manav Rachna International Institute of Research and Studies, Faridabad, Haryana, India

  • Shubham Kumar

    4   Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India

  • Ranjana Sah

    5   Department of Paediatrics, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed-to-be-University), Pimpri, Pune, Maharashtra, India
    6   Department of Public Health Dentistry, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed-to-be-University), Pimpri, Pune, Maharashtra, India

Funding None.
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Dear Editor,

We read with great interest the article titled “Contemporary Cementless Patellar Implant Survivorship: A Systematic Review and Meta-Analysis of 3,005 Patellae.”[1] The authors provide an insightful analysis of the performance of modern cementless patellar implants, addressing an important topic in the field of total knee arthroplasty (TKA). Their findings regarding the low revision rates and high survivorship of these implants are highly encouraging, and we commend their thorough systematic review and meta-analysis. However, we would like to highlight a few aspects of the study that we believe warrant further discussion or exploration to enhance the robustness and applicability of its conclusions.

First, the authors performed a quality assessment of the included studies using the Newcastle–Ottawa Scale, which is a robust tool for evaluating the methodological rigor of observational studies. While this is a critical step, the study quality scores were not factored into the synthesis of results. Incorporating a sensitivity analysis based on study quality could provide additional clarity on how variations in study design and execution may have influenced the reported outcomes. For example, recalculating pooled revision rates after excluding studies of lower quality or high risk of bias might demonstrate the stability of the conclusions and offer greater confidence in the analyses of the results.[2]

Second, the study quantifies heterogeneity among included studies using the I 2 statistic, which is a standard approach in meta-analyses. However, we suggest the addition of a 95% prediction interval as it provides a more comprehensive perspective on heterogeneity by predicting the range of effects expected in future studies.[2] [3] This could offer valuable insights into the potential variability of cementless patellar implant performance across diverse clinical settings, making the findings more actionable for surgeons and clinicians.

Third, publication bias is a critical factor that could influence the validity of the pooled estimates, particularly in systematic reviews and meta-analyses. While the authors have not explicitly addressed publication bias, we recommend its assessment using methods such as funnel plots, Egger's test, or the Doi plot and LFK index.[4] These techniques can help identify whether smaller studies with negative or null results are underrepresented in the analysis, thereby ensuring that the conclusions drawn are as robust and unbiased as possible.

Finally, the study highlights the promising results of contemporary cementless patellar implants, with a revision rate of 1 per 1,000 person-years for any patellar failure. This finding shows the advancements in implant technology, including improved polyethylene characteristics, porous coatings, and compression molding techniques, which have likely contributed to the observed durability. However, it would be valuable to explore additional factors, such as patient selection criteria (e.g., BMI, age, and bone quality), which may influence implant outcomes. Understanding these nuances can help guide clinicians in tailoring treatment to individual patient profiles.

We appreciate the authors' valuable contribution to the field of TKA and recognize the significance of their findings. This study provides compelling evidence supporting the long-term utility of cementless patellar implants in contemporary practice. We look forward to future contributions from the authors and ongoing advancements in the field of knee surgery.



Publication History

Received: 10 January 2025

Accepted: 17 June 2025

Accepted Manuscript online:
18 June 2025

Article published online:
24 October 2025

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