# Patellofemoral vs. total knee arthroplasty for isolated patellofemoral osteoarthritis: evidence-based recommendations from a systematic review with GRADE assessment

## TL;DR

This study compares patellofemoral and total knee arthroplasty for patellofemoral osteoarthritis, finding that patellofemoral arthroplasty offers faster recovery and early benefits but has higher long-term revision risks.

## Contribution

The study provides evidence-based recommendations using GRADE assessment to compare outcomes of patellofemoral and total knee arthroplasty for isolated patellofemoral osteoarthritis.

## Key findings

- Patellofemoral arthroplasty (PFA) shows superior early patient-reported outcomes and cost-effectiveness compared to total knee arthroplasty (TKA).
- PFA has a higher long-term revision risk compared to TKA, with 10-year survival rates of 85% for PFA versus 95% for TKA.

## Abstract

Isolated patellofemoral osteoarthritis (PFOA) remains a therapeutic challenge, with patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) representing the main surgical options for end-stage disease. This systematic review applies the GRADE framework to evaluate comparative outcomes of PFA and TKA, providing evidence-based recommendations.

A PRISMA systematic search of Pubmed, Cochrane Library, and Google Scholar was conducted (2010–2025). RCTs, comparative cohort studies, and registry analyses reporting on PFA versus TKA for isolated PFOA were included. Primary outcomes were validated PROMs and implant survival at 2, 5, and 10 years. Secondary outcomes were complications, patient satisfaction, return to sport, and cost-effectiveness. Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty of evidence using GRADE.

Ten studies were included (4 RCTs, 6 cohort studies; approximately 10,000 PFAs comprising registries). Moderate-certainty evidence indicated that PFA provides superior early PROMs, and short-term cost-effectiveness compared with TKA. PROMs converged between groups at mid- to long-term follow-up. Long-term data demonstrated a consistently higher revision risk for PFA with moderate certainty, with registry-based 10-year survival of 85% for PFA vs. 95% for TKA, continuing to worsen for PFA after 10 years. Complication rates were similar or lower after PFA, particularly for systemic medical events. Patient satisfaction and return to sport favored PFA short term but became comparable to TKA at mid-term.

In carefully selected patients with isolated PFOA, modern onlay PFA yields faster recovery, superior early function, and short-term cost-effectiveness, supported by moderate-certainty evidence. These advantages are offset by a higher long-term revision risk compared with TKA, highlighting the need to inform patients of this trade-off. TKA remains the reference standard for patients with tibiofemoral disease or instability, supported by high-certainty evidence, and offers durable, predictable long-term outcomes in more heterogeneous patient populations.

Systematic GRADE (Grading of Recommendations, Assessment, Development and Evaluation) review of RCTs and observational studies.

The online version contains supplementary material available at 10.1007/s00402-026-06217-3.