髌骨表面置换在总膝关节置换术中的20年临床和经济结果：英国大型多中心随机对照试验

David W Murray, Jemma Hudson, Helen Dakin, Graeme MacLennan, Matthew Little, Alastair Gray, Suzanne Breeman, Marion K Campbell SummaryBackgroundThere is conflicting evidence regarding the merits of patellar resurfacing during total knee replacement (TKR), as previous randomised controlled trials (RCTs) have been under-powered and with follow-up of ten years orless. Lancet2026; 408: 52–61 PublishedOnlineJune 17, 2026https://doi.org/10.1016/S0140-6736(26)00652-5 MethodsA pragmatic, multicentre, open-label RCT was initiated in 1999 in the UK. Within a partial-factorial design,participants were randomly allocated to receive or not receive patellar resurfacing during primary TKR and werefollowed up for 20 years. Adult (aged ≥18 years) patients due to have a primary TKR under the care of a collaboratingsurgeon were eligible. Participants were allocated (1:1) using an automated telephone service stratified by surgeon,with minimisation according to the patients’ age (<60 years, 60–79 years, ≥80 years), sex, and location of d isease. Theprimary outcome measure was the Oxford Knee Score (OKS), analysed using repeated measures mixed-effects linearregression analysis with marginal differences reported. Secondary measures included the 12-Item Short Form HealthSurvey (SF-12), the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L), costs, cost-effectiveness, andsubsequent knee surgery. This trial is registered with ISRCTN Registry, ISRCTN45837371. SeeCommentpage 6 Nuffield Department ofOrthopaedics, Rheumatology,and Musculoskeletal Sciences,Botnar Institute forMusculoskeletal Sciences,(Prof D W Murray MD)andNuffield Department ofPopulation Health(H Dakin DPhil, M Little PhD,Prof A Gray PhD), University ofOxford, Oxford, UK; AberdeenCentre for Evaluation,University of Aberdeen,Aberdeen, UK(J Hudson PhD,Prof G MacLennan MSc,S Breeman PhD,Prof M K Campbell PhD) FindingsBetween April 8, 1999, and Jan 13, 2003, 1715 participants (955 female and 760 male; mean age 70 years[SD 8], mean BMI 29∙7 kg/m²) were randomly assigned: 861 to patellar resurfacing and 854 to no resurfacing. At the20-year follow-up, 132 participants in the patellar resurfacing group and 110 participants in the non-resurfacinggroup provided outcome data, although marginal differences included earlier data for participants who died or hadmissing 20-year data. The marginal difference in OKS over the whole 20-year follow-up was 0·76(95% CI–0·08to 1·59; p=0·076) in favour of patellar resurfacing. During the 20-year follow-up period, although notsignificant, differences in OKS, SF-12, and EQ-5D-3L, readmissions, minor or intermediate operations, patella-related operations, major operations, and complications all favoured patellar resurfacing. At 20 years, the resurfacedgroup accrued significantly more quality-adjusted life-years (QALYs) than the non-resurfaced group (7·295vs6·884;difference 0·380, 95% CI 0·061 to 0·700; p=0·020). However, QALY differences were smaller in a sensitivity analysisassuming no difference in mortality (7·209vs6·964; difference 0·183, 95% CI –0·034 to 0·400; p=0·10). The cost ofreadmissions was non-significantly lower in the resurfaced group and offset the higher cost of primary TKR;therefore, overall 20-year health-care costs per participant were similar (£10825vs£10889; difference –£6,95% CI–£721to£708;p=0·99). Correspondence to:Prof David W Murray, NuffieldDepartment of Orthopaedics,Rheumatology, andMusculoskeletal Sciences, BotnarInstitute for MusculoskeletalSciences, University of Oxford,Oxford OX3 7LD, UKdavid.murray@ndorms.ox.ac.uk InterpretationThere was no significant difference in primary outcome (OKS) or other clinical endpoints. However, asclinical differences tend to support patellar resurfacing, the resurfacing group had significantly higher QALYs. Therewas no difference in costs over the 20-year period, and patellar resurfacing had a 99% probability of being cost-effective at any threshold above£10000 per QALY gained. The evidence is therefore weighted towards resurfacingbeing the approach of first choice. FundingUK National Institute for Health and Care Research Health Technology Assessment Programme. Copyright© 2026 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. IntroductionTotalknee replacement(TKR)is one of the most replacement. Although patellar resurfacing can decreasepatellofemoral joint related pain, it can fail, requiringfurther surgery. Previous small, randomised controlledtrials(RCTs),non-randomised cohort studies,andsystematic reviews have not resolved the uncertaintyregarding the benefits of patellar resurfacing.2–18Manyprevious RCTs had insufficient sample sizes to detectclinically meaningful differences in outcomes. There isevidence from the National Joint Registry that there are common and effective orthopaedic operations, yet up to20% of patients are not satisfied with the result of theirknee replacement and have poor functional ou