THEKNE-01948; No of Pages 5

The Knee xxx (2014) xxxxxx

Contents lists available at ScienceDirect

The Knee

Medial patellofemoral ligament (MPFL) reconstruction improves

radiographic measures of patella alta in children
Peter D. Fabricant a,, Hannah N. Ladenhauf a, Eduardo A. Salvati b, Daniel W. Green a,
a
Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, United States
b
Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Patellofemoral instability has previously been associated with patella alta. The purpose of this study
Received 28 January 2014 was to evaluate adolescents undergoing MPFL reconstruction for standardized indices of patellar height on pre-
Received in revised form 13 May 2014 and post-operative radiographs to determine if these radiographic parameters change after MPFL reconstruction.
Accepted 21 July 2014 Methods: Twenty-seven children (mean age 14.9 years old) who underwent MPFL reconstruction without a
Available online xxxx
distal realignment procedure were evaluated pre- and post-operatively for InsallSalvati Ratio, Modied
InsallSalvati Ratio, and CatonDeschamps Index by three blinded raters. Intrarater reliability and interrater
Keywords:
InsallSalvati
reliability were calculated for each index, and means of each were compared pre- and post-operatively to
CatonDeschamps determine if MPFL reconstruction was associated with improved patellar height.
Adolescent Results: All three indices of patellar height indicated that there was patella alta present in this cohort preopera-
Pediatric tively. Furthermore, all three measures were signicantly improved postoperatively (paired t-tests, P b 0.001
MPFL for all) to within normal childhood ranges. Interrater reliability was excellent for both the InsallSalvati Ratio
(ICC = 0.89) and CatonDeschamps Index (ICC = 0.78), and adequate for the Modied InsallSalvati Ratio
(ICC = 0.57); intrarater reliability was excellent for all three (ICCs: 0.91, 0.82, 0.80 respectively).
Conclusions: MPFL reconstruction in children using hamstring autograft was associated with consistently
improved patellar height indices to within normal childhood ranges. This associated improvement of patellar
height as measured on a lateral radiograph may subsequently improve patellofemoral mechanics by drawing
the patella deeper and more medially into the trochlear groove.
Level of Evidence: Level 4.
2014 Elsevier B.V. All rights reserved.

1. Introduction tissue laxity, incompetent collagen supporting structures, trochlear

Patellofemoral dislocation is a common knee injury in children and
adolescents. It accounts for up to 2% to 3% of all knee injuries, and occurs
at a rate of 29 to 43 per 100,000 in the population aged 10 to 17 years
old [1]. Further, it is the second leading cause of hemathrosis in
adolescents aged 13 to 16 years old [2]. Despite its common diagnosis,
patellofemoral dislocation represents a diverse variety of pathology:
Green's classication of patellofemoral instability in children and
adolescents notes syndromic, obligatory, xed lateral, and traumatic
types, with traumatic dislocations representing the greatest majority
of reported pediatric cases [3]. While syndromic dislocators are
predisposed to frequent or xed patellar dislocation due to connective
Correspondence to: Division of Pediatric Orthopaedic Surgery, Hospital for Special
Surgery, 535 East 70th Street, New York, NY 10021, United States. Tel.: + 1 212 606
1466; fax: +1 212 606 1477.
Corresponding author.
E-mail addresses: FabricantP@hss.edu (P.D. Fabricant), greendw@hss.edu
(D.W. Green).
dysplasia, and lower extremity deformity [3], traumatic dislocators by
denition have an inciting event which disrupts the normal supporting
structures of the patellofemoral joint, causing lateral patellar
dislocation. With subsequent dislocation events, the medial supporting
structures weaken and lower energy trauma is required to cause
instability.
In addition to the attenuation of the medial supporting structures,
patella alta has been historically postulated to increase the risk of
patellofemoral dislocation. Patella alta draws the patella out of the
osseous connes of the trochlear groove, requiring increased knee ex-
ion angles to engage the trochlea and decreasing its inherent stability
thereby placing more emphasis on the medial patellofemoral ligament
(MPFL) to act as a check reign and hold the patella in a reduced position.
Numerous studies [416] and meta-analysis [17] have reported that
patella alta is a predisposing factor for patellar instability and recurrent
dislocation, and recent literature favors MPFL reconstruction to restore
these patellar kinematics [3,1826].
While it has been widely published that patella alta is associated
with patellar instability, it remains unclear if MPFL reconstruction
increases stability through an indirect correction of patella alta. The

http://dx.doi.org/10.1016/j.knee.2014.07.023
0968-0160/ 2014 Elsevier B.V. All rights reserved.

Please cite this article as: Fabricant PD, et al, Medial patellofemoral ligament (MPFL) reconstruction improves radiographic measures of patella
alta in children, Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.07.023
2 P.D. Fabricant et al. / The Knee xxx (2014) xxxxxx

purpose of this study is to evaluate adolescents undergoing MPFL

reconstruction for standardized indices of patella alta on pre- and
post-operative radiographs to determine if these parameters are
associated with correction after MPFL reconstruction. We hypothesized
that existing preoperative patella alta would improve postoperatively,
which would indicate that MPFL reconstruction may stabilize the
patella by two complimentary mechanisms: reconstruction of the
major dynamic medial supporting structure as well as the indirect
improvement of patellar height. Optimizing patellar height could poten-
tially restore static osseous congruity by drawing the patella deeper into
the trochlear groove over a greater range of exion angles.

2. Patients

This study was approved by the hospital's Institutional Review

Board. Hospital records of a single surgeon at an urban tertiary care
academic orthopedic hospital were reviewed for eligible cases from
the inception of the current surgical technique (May 2008) through
three months prior to the beginning of data analysis (August 2012).
This allowed for the collection of preoperative and three month postop-
erative radiographs of a uniform surgical technique for comparison.
Cases were included if patients were under age 18 and underwent an
index primary MPFL reconstruction without concomitant procedures
of the tibial tubercle (e.g. Fulkerson osteotomy, Maquet osteotomy,
ElmslieTrillat procedure, distal soft tissue realignment) for traumatic
recurrent patellofemoral instability. This yielded 27 children for inclu-
sion in the study. Of the included patients, there were ve boys and
22 girls with a mean age of 14.9 years old. Distal femoral physeal closure
was complete in 10 of the 27 patients (37%).

3. Methods

3.1. Surgical indications and technique

For children who sustain a primary traumatic patellofemoral

dislocation without an intraarticular loose body noted on MRI, initial
treatment is nonsurgical, and focuses on quadriceps strengthening
and improving core stability. Children are indicated for MPFL recon-
struction if they sustain recurrent patellofemoral dislocations despite
an organized course of conservative treatment (e.g. physical therapy)
after their rst dislocation.
The surgical technique employed in this study has been previously
described [27], and is a modication of the technique described by
Schottle et al. [28]. In short, a doubled hamstring autograft was used
to reconstruct the MPFL with tenodesis screws placed under uoroscop-
ic guidance between the superior half of the medial aspect of the patella
and a femoral attachment site, which was determined by the patients'
skeletal maturity (Fig. 1). In patients who are skeletally mature, the
patellar limbs were xed rst, with length set by adjusting the amount
of tendon graft placed into the femoral socket which is xed second. In
children with open physes, the femoral limb is attached rst 5 mm distal
to the distal femoral physis via a tenodesis technique, with graft length
adjusted at the medial border of patella while the patella is held in a
reduced position. The double limb graft is xed in the superior half of
the patella via two sockets and a tenodesis technique. As previously
described, this femoral position prevents the graft origin from migrating
proximally with longitudinal bone growth. Graft tension was adjusted
with the knee in approximately 20 of exion. Postoperatively, all
patients were immobilized with a knee brace locked in extension and
weight bearing as tolerated. Early range of motion was encouraged,
with quadriceps strength and range of motion exercises performed
under supervision by a physical therapist. Bracing was discontinued 3
to 6 weeks postoperatively once quadriceps strength reached grade 4
on manual muscle testing.
Fig. 1. Technique of MPFL reconstruction used in the study. The technique of MPFL recon-
struction used in the study for those with open physes (A, B) and those with a closed distal
femoral physis (C, D). In children with open physes, the femoral limb is attached rst, with
tensioning adjusted by varying the graft length and subsequent docking into the patellar
sockets. The femoral socket is placed distal to the physis in line with the posterior femoral
cortex. In patients who are skeletally mature, the patellar limbs were xed rst, with ten-
sion set via the femoral limb which was xed second. In the skeletally mature, the femoral
socket is placed in line with the posterior femoral cortex at the level of the physeal scar.
3.2. Radiographic evaluation
All patients had preoperative and three month postoperative knee
radiographs which were evaluated by three raters (the treating
orthopedic surgeon and two orthopedic residents) for each of three in-
dices of patellar height: InsallSalvati Ratio [29], Modied InsallSalvati
Ratio [30], and CatonDeschamps Index (Fig. 2) [31]. All images were
de-identied and randomized in order to blind the raters. Each rater
evaluated each radiograph, which was placed in random order and
blinded by an independent third party, and each measure of patellar
height was calculated and recorded. Intrarater reliability and interrater
reliability were calculated for each index, and means of each were
compared pre- and post-operatively to determine if patellar height
changed after MPFL reconstruction in the absence of a distal

Please cite this article as: Fabricant PD, et al, Medial patellofemoral ligament (MPFL) reconstruction improves radiographic measures of patella
alta in children, Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.07.023
 P.D. Fabricant et al. / The Knee xxx (2014) xxxxxx 3

Fig. 2. Measurement of patellar height indices. Measurement of the three patellar height indices used in the study: InsallSalvati Ratio (A) is measured as the ratio of patellar tendon length
(b) divided by patellar length (a); Modied InsallSalvati Ratio (B) is measured as the ratio of patellar tendon length (d) divided by patellar articular surface length (c); CatonDeschamps
Index (C) is measured as the ratio of the length from the tibial plateau to the inferior pole of the patella (f) divided by patellar articular surface length (e).

realignment procedure. Average pre- and post-operative values were
compared to normally accepted childhood ranges.
3.3. Statistical methods
Statistical analyses were performed by a member of the research
team with advanced training in biostatistics using SAS Software version
9.3 (SAS Institute, Inc., Cary, North Carolina, USA). Descriptive statistics
were used to evaluate the distribution of continuous data. After estab-
lishing data normality, paired Student's t-tests were used to evaluate
for postoperative changes in each of the continuous measures of patellar
height. McNemar's test for paired categorical data was used to compare
categories of normal vs. abnormal ranges of patellar height preopera-
tively and postoperatively. Intraclass correlation coefcient (ICC 2,1)
4.2. Patellar height
Mean preoperative and postoperative measures of patellar height along with normal
values are displayed in (Table 1). All three indices of patellar height indicated that there
was patella alta present in this cohort. Furthermore, all three measures signicantly
improved postoperatively (paired t-test, P b 0.001 for all) by 11.3% to 15.8% on average.
All three radiographic measures of patellar height fell within normal childhood ranges
postoperatively.
When applying criteria of normal ranges of each radiographic index of patellar height
to each patient, the number of children who had abnormal values improved for each mea-
sure. For InsallSalvati Ratio, 19 patients (70%) were abnormal preoperatively compared
to 12 (44%) postoperatively (McNemar's test; P = 0.02). For Modied InsallSalvati
Ratio, 20 patients (74%) were abnormal preoperatively compared to 12 (44%) postopera-
tively (McNemar's test; P = 0.01). For InsallSalvati Ratio, 18 patients (67%) were abnor-
mal preoperatively compared to 8 (30%) postoperatively (McNemar's test; P = 0.004).
Subgroup analyses of skeletal maturity and gender noted no differences in improve-
ment in patellar height indices (P N 0.05 for all). There were no complications or episodes
of recurrent patellofemoral instability in this cohort.

was used to quantify interrater reliability and intrarater reliability for

each measure of patellar height. This investigation was a retrospective
review of all available patients who met inclusion criteria, and therefore
an ad-hoc power calculation was not possible [32]. All analyses that
generated P-values were two-tailed and used P = 0.05 as the threshold
for statistical signicance.
4. Results
4.1. Interrater reliability and intrarater reliability
Interrater reliability was excellent for both the InsallSalvati Ratio (ICC = 0.89) and
CatonDeschamps Index (ICC = 0.78), and adequate for the Modied InsallSalvati
Ratio (ICC = 0.57). Intrarater reliability was excellent for all three indices: InsallSalvati
Ratio (ICC = 0.91), CatonDeschamps Index (ICC = 0.82), and Modied InsallSalvati
Ratio (ICC = 0.80).
5. Discussion
The current study conrmed the hypothesis that MPFL reconstruction
was associated with improved patellar height in the setting of patellar
instability, indicating that MPFL reconstruction may work by both
restoring the main dynamic medial patella stabilizer as well as restoring
static stabilization by directing the patella medially and distally into the
trochlear groove. The etiology of this nding is likely multifactorial: by
performing ligament reconstruction, the medial check reign inhibits the
patella from escaping the trochlea superolaterally, a slightly distally-
oriented graft may also decrease patellar height, and medializing the
resting state of the patella geometrically lowers the patella even in the
absence of distal realignment procedures. These results are useful to
surgeons performing MPFL reconstruction, as the improvement of patella

Table 1
Improvements in three indices of patellar height after MPFL reconstruction in children.

Patella height measurement Normal Mean SD preoperative Mean SD postoperative Mean absolute Mean % P-
range value value improvement improvement value

InsallSalvati Ratio b1.25a 1.41 0.27 1.25 0.22 0.16 11.3% b0.001
Modied InsallSalvati b2.00a 2.24 0.30 1.97 0.19 0.27 12.1% b0.001
Ratio
CatonDeschamps Index b1.27b 1.39 0.25 1.17 0.19 0.22 15.8% b0.001
a
Reported values in literature [29,30].
b
Mean normal value reported in literature plus 1 standard deviation [31].

Please cite this article as: Fabricant PD, et al, Medial patellofemoral ligament (MPFL) reconstruction improves radiographic measures of patella
alta in children, Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.07.023
4 P.D. Fabricant et al. / The Knee xxx (2014) xxxxxx

alta in the absence of a tibial tubercle distalization may allow for the
avoidance of an unnecessary additional surgical procedure. What
remains uncertain, however, is whether the preoperative patella alta
predated the initial injury, or if it was a result of traumatic patellofemoral
instability and an MPFL tear itself.
The topic of patella alta as an independent risk factor or result of
patellofemoral instability remains unclear. While many authors have
previously reported that patients with patellofemoral instability have
greater rates of patella alta [416], we speculate that this may be due
in part to the MPFL rupture itself. It is known that the MPFL is an
obliquely-oriented structure with an origin on the patella more
proximal than the distal insertion on the femur [33]. Therefore,
disruption of this important structure may itself contribute to the patel-
la alta that is measured on injury radiographs, but has previously been
reported as a risk factor despite the lack of longitudinal radiographic
data. While we have shown that restoring the distally-orientated
MPFL was associated with improved patellar height indices to within
normally accepted ranges for these measurements, the chronicity of
this phenomenon remains uncertain. These conclusions are corroborated
by similar ndings by Lykissas et al. in the pediatric orthopedic literature
[34]. In order to determine chronicity, otherwise healthy children would
need to be exposed to ionizing X-ray radiation for baseline patellar height
measurements in order to truly determine if patella alta is a risk factor or a
consequence of patellofemoral instability; a study such as this is unlikely
to be performed due to ethical concerns.
Previous studies have shown that there is an association between
patella alta and patellofemoral instability, however attempting to
causatively link the two is problematic for several reasons: 1) comparison
groups with different pathologies have a high risk of noncomparability as
described above, 2) using the contralateral knee for comparison is prob-
lematic as there may be signicant natural side-to-side differences in
Fig. 3. Mathematical theory revealing the possible inuence of patellar medialization on
patellar height [35], and 3) longitudinal study of radiographs of adoles- improving patella alta. Assuming a constant length of the patellar tendon, the
cent knees with patellofemoral instability may be problematic as patellar medialization of the patella during MPFL reconstruction may produce a rotation about
height changes with development. Lykissas et al. [34] did, however, show the tibial tubercle insertion. This rotation (angle ) would cause the vertical component
an improvement in patellar height to within normal ranges postopera- of the distance from the inferior pole of the patella to the tibial tubercle to decrease
from its initial length (b) to its nal length (a), by a factor of cos(), based on the formula:
tively using slightly different reconstruction techniques (gracilis
b cos() = a.
autograft with one patellar limb, tensioning in 45 of exion) than the
one employed in this study which conrms our results.
While the actual patellar tendon length does not change after MPFL procedures in patients with patellofemoral instability, indices that uti-
reconstruction, the measurement of patella alta on a two-dimensional lize the relative height of the patella to the tibial plateau are preferred.
lateral radiograph does improve. The MPFL acts as a check reign and These methods are advantageous in that they are calculated indepen-
creates a more medial resting position of the patella; this new dent of the length of the patellar tendon and tibial tubercle location.
medialized resting state in and of itself may also lower the patella on They therefore can change postoperatively in a clinically signicant
the lateral radiograph despite a constant patellar tendon length fashion with or without distal realignment, whereas with concomitant
(Fig. 3). This is noted geometrically: the new resting state of the patella distal realignment procedures those that rely on measurement to the
produces a rotation about the tibial tubercle insertion which can be tibial tubercle may not change. The current study supports the use of
measured in degrees (). This rotation would cause the vertical compo- the InsallSalvati Ratio and CatonDeschamps Index as reliable mea-
nent of the distance from the inferior pole of the patella to the tibial sures in the evaluation of children and adolescents with patellofemoral
tubercle to decrease on a two-dimensional lateral projection by a factor instability.
of cos(), thus contributing to lower patellar height. In addition to this There are limitations inherent to this study. First, generalizability of
indirect distalization of the patella, the medial check reign inhibits the these results may be limited as they represent the outcomes of one
patella from escaping the connes of the trochlea superolaterally, and technique as performed by a single surgeon. Second, while patella alta
the patella engages the trochlea in a greater range of knee exion. existed on preoperative lateral radiographs, chronicity may not be
While this may be partially responsible for conferring a modest inferred from this study design, as discussed above. Without
improvement in the measured indices of patellar height (11.3% to pre-injury radiographs it is impossible to know whether the patella
15.8% in the current study), it did however improve all three indices alta was present prior to the initial injury (and represented a risk factor
to within normal age-appropriate ranges for these measurements for initial patellofemoral dislocation), or if it was a result of the MPFL
postoperatively. disruption itself and noted on injury radiographs. Furthermore, this
The current study improves upon previous work by calculating the would not be ascertained even with a prospective study design, as
interrater reliability and intrarater reliability for each of three patellar pre-injury radiographs would not have been performed. Likewise,
height indices in adolescents. Interrater reliability was excellent for chronicity of the noted improvements in patellar height cannot be
both the InsallSalvati Ratio and CatonDeschamps Index, and adequate guaranteed beyond the study follow-up of three months' time, and
for the Modied InsallSalvati Ratio, while intrarater reliability was whether or not these improvements persist is an area of future research.
excellent for all three. This provides useful information toward the Finally, the retrospective design of this study, as with any study,
evaluation of patella alta in patients with patellofemoral instability. increases the risk of bias in both patient selection as well as variable
Due to the occasional need for concomitant distal realignment measurement. These potential biases were minimized in this study by

Please cite this article as: Fabricant PD, et al, Medial patellofemoral ligament (MPFL) reconstruction improves radiographic measures of patella
alta in children, Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.07.023
 P.D. Fabricant et al. / The Knee xxx (2014) xxxxxx
using all available cases that met inclusion criteria, and having the three
independent reviewers measure patella alta on blinded radiographs in
random order.
In conclusion, surgical reconstruction of the medial patellofemoral
ligament (MPFL) in children using hamstring autograft was consistently
associated with lower radiographic measurements of patellar height at
three months postoperatively for all three indices to within normal
childhood ranges for these measurements. This associated improvement
of patellar height could subsequently restore additional static osseous
congruity by drawing the patella deeper into the trochlear groove over
a greater range of exion angles, possibly eliminating the need for a
concurrent distalization procedure.
Conict of interest statement
The authors have no relevant conicts of interest to disclose.
Acknowledgments
The authors wish to thank Cyndi Conklin for her assistance with
Fig. 1. The authors wish to thank Joseph Lipman, PhD for his assistance
with Fig. 3.
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