Skip to main content
SpringerLink
Log in

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability

Knee Surgery, Sports Traumatology, Arthroscopy volume 29, pages 546–552 (2021)Cite this article

Abstract

Purpose

The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors.

Methods

Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores.

Results

Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship.

Conclusion

This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research.

Level of evidence

IV.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. Anagnostakos K, Lorbach O, Reiter S, Kohn D (2011) Comparison of five patellar height measurement methods in 90 degrees knee flexion. Int Orthop 35:1791–1797

    Article  Google Scholar 

  2. Balcarek P, Jung K, Ammon J, Walde TA, Frosch S, Schuttrumpf JP et al (2010) Anatomy of lateral patellar instability: trochlear dysplasia and tibial tubercle–trochlear groove distance is more pronounced in women who dislocate the patella. Am J Sports Med 38:2320–2327

    Article  Google Scholar 

  3. Biedert RM, Tscholl PM (2017) Patella alta: a comprehensive review of current knowledge. Am J Orthop (Belle Mead NJ) 46:290–300

    Google Scholar 

  4. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H (1982) Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot 68:317–325

    CAS  PubMed  Google Scholar 

  5. Caton JH, Dejour D (2010) Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop 34:305–309

    Article  Google Scholar 

  6. Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    Article  CAS  Google Scholar 

  7. Erickson BJ, Nguyen J, Gasik K, Gruber S, Brady J, Shubin Stein BE (2019) Isolated medial patellofemoral ligament reconstruction for patellar instability regardless of tibial tubercle–trochlear groove distance and patellar height: outcomes at 1 and 2 years. Am J Sports Med 47:1331–1337

    Article  Google Scholar 

  8. Fabricant PD, Ladenhauf HN, Salvati EA, Green DW (2014) Medial patellofemoral ligament (MPFL) reconstruction improves radiographic measures of patella alta in children. Knee 21:1180–1184

    Article  Google Scholar 

  9. Fleiss JL (1999) The design and analysis of clinical experiments. Wiley, New York

    Book  Google Scholar 

  10. Hiemstra LA, Kerslake S, Lafave M (2016) Assessment of demographic and pathoanatomic risk factors in recurrent patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 25:3849–3855

    Article  Google Scholar 

  11. Hiemstra LA, Kerslake S, Lafave M, Heard SM, Buchko GM (2014) Introduction of a classification system for patients with patellofemoral instability (WARPS and STAID). Knee Surg Sports Traumatol Arthrosc 22:2776–2782

    Article  Google Scholar 

  12. Hiemstra LA, Kerslake S, Lafave MR, Heard SM, Buchko GM, Mohtadi NG (2013) Initial validity and reliability of the Banff patella instability instrument. Am J Sports Med 41:1629–1635

    Article  Google Scholar 

  13. Hiemstra LA, Kerslake S, Loewen M, Lafave M (2016) Effect of trochlear dysplasia on outcomes after isolated soft tissue stabilization for patellar instability. Am J Sports Med 44:1515–1523

    Article  Google Scholar 

  14. Hopper GP, Leach WJ, Rooney BP, Walker CR, Blyth MJ (2014) Does degree of trochlear dysplasia and position of femoral tunnel influence outcome after medial patellofemoral ligament reconstruction? Am J Sports Med 42:716–722

    Article  Google Scholar 

  15. Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD (2012) Medial patellofemoral ligament reconstruction: a prospective outcome assessment of a large single centre series. J Bone Jt Surg Br 94:1202–1208

    Article  CAS  Google Scholar 

  16. Jaquith BP, Parikh SN (2015) Predictors of recurrent patellar instability in children and adolescents after first-time dislocation. J Pediatr Orthop 37:484–490

    Article  Google Scholar 

  17. Lafave MR, Hiemstra L, Kerslake S (2016) Factor analysis and item reduction of the Banff patella instability instrument (BPII): introduction of BPII 2.0. Am J Sports Med 44:2081–2086

    Article  Google Scholar 

  18. Lafave MR, Hiemstra LA, Kerslake S (2018) Validity, reliability, and responsiveness of the Banff patellar instability instrument (BPII) in a adolescent population. J Pediatr Orthop 38:e629–e633

    Article  Google Scholar 

  19. LaPrade MD, Kennedy MI, Wijdicks CA, LaPrade RF (2015) Anatomy and biomechanics of the medial side of the knee and their surgical implications. Sports Med Arthrosc 23:63–70

    Article  Google Scholar 

  20. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L (2007) The anatomy of the medial part of the knee. J Bone Jt Surg Am 89:2000–2010

    Article  Google Scholar 

  21. Lippacher S, Dejour D, Elsharkawi M, Dornacher D, Ring C, Dreyhaupt J et al (2012) Observer agreement on the Dejour trochlear dysplasia classification: a comparison of true lateral radiographs and axial magnetic resonance images. Am J Sports Med 40:837–843

    Article  Google Scholar 

  22. Lykissas MG, Li T, Eismann EA, Parikh SN (2014) Does medial patellofemoral ligament reconstruction decrease patellar height? A preliminary report. J Pediatr Orthop 34:78–85

    Article  Google Scholar 

  23. Neyret P, Robinson AH, Le Coultre B, Lapra C, Chambat P (2002) Patellar tendon length—the factor in patellar instability? Knee 9:3–6

    Article  Google Scholar 

  24. Nomura E (1999) Classification of lesions of the medial patello-femoral ligament in patellar dislocation. Int Orthop 23:260–263

    Article  CAS  Google Scholar 

  25. Sanchis-Alfonso V (2014) Guidelines for medial patellofemoral ligament reconstruction in chronic lateral patellar instability. J Am Acad Orthop Surg 22:175–182

    Article  Google Scholar 

  26. Sappey-Marinier E, Sonnery-Cottet B, O'Loughlin P, Ouanezar H, Reina Fernandes L, Kouevidjin B et al (2019) Clinical outcomes and predictive factors for failure with isolated MPFL reconstruction for recurrent patellar instability: a series of 211 reconstructions with a minimum follow-up of 3 years. Am J Sports Med 47:1323–1330

    Article  Google Scholar 

  27. Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ et al (2016) Outcomes after isolated medial patellofemoral ligament reconstruction for the treatment of recurrent lateral patellar dislocations: a systematic review and meta-analysis. Am J Sports Med 4:2993–3005

    Article  Google Scholar 

  28. Steensen RN, Bentley JC, Trinh TQ, Backes JR, Wiltfong RE (2015) The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study. Am J Sports Med 43:921–927

    Article  Google Scholar 

  29. Stupay KL, Swart E, Shubin Stein BE (2015) Widespread implementation of medial patellofemoral ligament reconstruction for recurrent patellar instability maintains functional outcomes at midterm to long-term follow-up while decreasing complication rates: a systematic review. Arthroscopy 31:1372–1380

    Article  Google Scholar 

  30. van Duijvenbode D, Stavenuiter M, Burger B, van Dijke C, Spermon J, Hoozemans M (2015) The reliability of four widely used patellar height ratios. Int Orthop 40:493–497

    Article  Google Scholar 

  31. Wagner D, Pfalzer F, Hingelbaum S, Huth J, Mauch F, Bauer G (2013) The influence of risk factors on clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc 21:318–324

    Article  Google Scholar 

  32. Woodmass JM, Johnson NR, Cates RA, Krych AJ, Stuart MJ, Dahm DL (2018) Medial patellofemoral ligament reconstruction reduces radiographic measures of patella alta in adults. Orthop J Sports Med 6:2325967117751659

    Article  Google Scholar 

  33. Ziegler CG, Fulkerson JP, Edgar C (2016) Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med 44:133–142

    Article  Google Scholar 

Download references

Acknowledgements

The authors wish to extend their gratitude to their colleagues at Banff Sport Medicine for their support of this research undertaking.

Funding

This research did not receive any specific grants or funding from any public, commercial or not-for-profit agencies.

Author information

Authors and Affiliations

  1. Banff Sport Medicine, PO Box 1300, Banff, AB, T1L 1B3, Canada

    Laurie Anne Hiemstra & Sarah Kerslake

  2. Department of Surgery, University of Calgary, Calgary, Canada

    Laurie Anne Hiemstra

  3. Department of Health and Physical Education, Mount Royal University, Calgary, Canada

    Mark R. Lafave

  4. Nova Scotia Health Authority, Nova Scotia, Canada

    Allison Tucker

Authors
  1. Laurie Anne Hiemstra
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sarah Kerslake
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mark R. Lafave
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Allison Tucker
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LH participated in study design and coordination, literature review, data collection, and manuscript writing. SK participated in study design and coordination, literature review, data collection, statistical analysis, and manuscript writing. ML participated in study design, statistical analysis and manuscript writing. AT participated in study design, literature review, data collection and manuscript writing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Laurie Anne Hiemstra.

Ethics declarations

Conflict of interest

The authors have nothing to disclose and declare no conflicts of interest.

Ethical approval

This study received ethics approval from the University of Calgary Conjoint Health Research Ethics Board and Child Health Research Office (E-24393).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hiemstra, L.A., Kerslake, S., Lafave, M.R. et al. Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 29, 546–552 (2021). https://doi.org/10.1007/s00167-020-05977-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-05977-8

Keywords

search

Navigation