The ideal treatment of the patella in primary total knee arthroplasty (TKA) for osteoarthritis (OA) remains unclear. Although data exist in the literature to support either resurfacing or not resurfacing the patella, evidence continues to emerge that unresurfaced patellas deteriorate with time. Recent prospective, randomized studies also favor patellar resurfacing over retaining the native patella, reporting reoperation rates to convert unresurfaced to resurfaced patellas exceeding those for complications after patellar resurfacing. In addition, the incidence of residual patellofemoral pain after secondary resurfacing is substantially higher than when patellofemoral resurfacing is done primarily. Patient selection criteria are critical in the decision-making process. Patellofemoral complications, the greatest argument against resurfacing, have been diminished with improved surgical techniques and implant design.