Skip to main content

Surgical Treatment of Iatrogenic Patella Baja


Purpose of Review

Patella baja is characterized by a loss of patellar height and can develop as either an acute or chronic complication following a knee injury or surgical procedure. The purpose of this review is to describe the diagnosis and management of patella baja and highlight the senior author’s surgical technique.

Recent Findings

The pathogenesis of patella baja involves a complex interaction between quadriceps dysfunction, immobilization, and inflammation leading to infrapatellar scarring and adhesions. It is associated with fractures about the knee and can result as a complication of surgical procedures such as anterior cruciate ligament (ACL) reconstruction, particularly bone-patellar tedon-bone autografts, high tibial osteotomies (HTOs), tibial tubercle osteotomies (TTOs), and total knee arthroplasties (TKAs). Patients with patella baja can have limited knee range of motion, anterior knee pain, significant weakness with active knee extension, and an extensor lag. Surgical intervention is indicated in cases of symptomatic patella baja. Treatment strategies include tibial tubercle proximalization, patellar tendon lengthening, and patellar tendon reconstruction. Allografts and autografts can be utilized to augment tendon lengthening or reconstructive procedures. Various small case series have reported favorable outcomes for these procedures.


The treatment of patella baja is challenging and little consensus exists on optimal management, as much of the literature is limited to small case series. The preferred surgical technique of the senior author involves an end-to-end patellar tendon lengthening with hamstring autograft augmentation.

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

Fig. 1
Fig. 2
Fig. 3
Fig. 4


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Flören M, Davis J, Peterson MGE, Laskin RS. A mini-midvastus capsular approach with patellar displacement decreases the prevalence of patella Baja. J Arthroplast. 2007;22:51–7.

    Article  Google Scholar 

  2. Patella Baja in Total Knee Arthroplasty - PubMed [Internet]. [cited 2022 Jan 25]. Available from:

  3. Fox AJS, Wanivenhaus F, Rodeo SA. The basic science of the patella: structure, composition, and function. J Knee Surg. 2012;25:127–41.

    Article  Google Scholar 

  4. Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101:101–4.

    Article  CAS  Google Scholar 

  5. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. Patellar Instability. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Jan 25]. Available from:

  6. Phillips CL, Silver DAT, Schranz PJ, Mandalia V. The measurement of patellar height: a review of the methods of imaging. J Bone Joint Surg Br. 2010;92:1045–53.

    Article  CAS  Google Scholar 

  7. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot. 1982;68:317–25.

    CAS  Google Scholar 

  8. Noyes FR, Wojtys EM, Marshall MT. The early diagnosis and treatment of developmental patella infera syndrome. Clin Orthop Relat Res. 1991:241–52.

  9. Paul RW, Brutico JM, Wright ML, Erickson BJ, Tjoumakaris FP, Freedman KBet al. Strong agreement between magnetic resonance imaging and radiographs for Caton-Deschamps index in patients with patellofemoral instability. Arthrosc Sports Med Rehabil 2021;3:e1621–e1628.

  10. Thévenin-Lemoine C, Ferrand M, Courvoisier A, Damsin J-P. Ducou le pointe H, Vialle R. is the Caton-Deschamps index a valuable ratio to investigate patellar height in children? J Bone Joint Surg Am. 2011;93:e35.

    Article  Google Scholar 

  11. Berg EE, Mason SL, Lucas MJ. Patellar height ratios. A comparison of four measurement methods. Am J Sports Med. 1996;24:218–21.

    Article  CAS  Google Scholar 

  12. Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup. Am J Sports Med. 1994;22:440–9.

    Article  CAS  Google Scholar 

  13. Biedert RM, Albrecht S. The patellotrochlear index: a new index for assessing patellar height. Knee Surg Sports Traumatol Arthrosc. 2006;14:707–12.

    Article  Google Scholar 

  14. Middleton S, Bajada S, Powell R, Nelson A, Mandalia V. Patellotrochlea index in Normal healthy knees. J Knee Surg. 2020.

  15. Grelsamer RP, Meadows S. The modified Insall-Salvati ratio for assessment of patellar height. Clin Orthop Relat Res. 1992:170–6.

  16. Caton JH, Prudhon JL, Aslanian T, Verdier R. Patellar height assessment in total knee arthroplasty: a new method. Int Orthop. 2016;40:2527–31.

    Article  Google Scholar 

  17. Konrads C, Grosse LC, Ahmad SS, Springer F, Schreiner AJ, Schmidutz F, Erne F. Reliability of a Caton-Deschamps-derived patella height index for knee arthroplasty. Int Orthop. 2021;45:2001–5.

    Article  Google Scholar 

  18. Early development of patella infera after knee fractures - PubMed [Internet]. [cited 2022 Jan 25]. Available from:

  19. Chonko DJ, Lombardi AV, Berend KR. Patella Baja and total knee arthroplasty (TKA): etiology, diagnosis, and management. Surg Technol Int. 2004;12:231–8.

    Google Scholar 

  20. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med. 1987;15:331–41.

    Article  CAS  Google Scholar 

  21. Ahmad CS, Kwak SD, Ateshian GA, Warden WH, Steadman JR, Mow VC. Effects of patellar tendon adhesion to the anterior tibia on knee mechanics. Am J Sports Med. 1998;26:715–24.

    Article  CAS  Google Scholar 

  22. Krieg JC, Mirza A. Case report: Patella Baja after retrograde femoral nail insertion. Clin Orthop Relat Res. 2009;467:566–71.

    Article  Google Scholar 

  23. Sebastian P, Michael Z, Frederik G, Michael M, Marcus W, Moritz C, et al. Influence of patella height after patella fracture on clinical outcome: a 13-year period. Arch Orthop Trauma Surg. 2021.

  24. Tria AJ, Alicea JA, Cody RP. Patella Baja in anterior cruciate ligament reconstruction of the knee. Clin Orthop Relat Res. 1994:229–34.

  25. Chase JM, Hennrikus WL, Cullison TR. Patella infera following arthroscopic anterior cruciate ligament reconstruction. Contemp Orthop. 1994;28:487–93.

    CAS  Google Scholar 

  26. Adam F, Pape D, Kohn D, Seil R. Length of the patellar tendon after anterior cruciate ligament reconstruction with patellar tendon autograft: a prospective clinical study using roentgen stereometric analysis. Arthroscopy. 2002;18:859–64.

    Article  Google Scholar 

  27. Hantes ME, Zachos VC, Bargiotas KA, Basdekis GK, Karantanas AH, Malizos KN. Patellar tendon length after anterior cruciate ligament reconstruction: a comparative magnetic resonance imaging study between patellar and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2007;15:712–9.

    Article  Google Scholar 

  28. Otsuki S, Murakami T, Okamoto Y, Nakagawa K, Okuno N, Wakama H, et al. Risk of patella baja after opening-wedge high tibial osteotomy. J Orthop Surg (Hong Kong). 2018;26:2309499018802484.

    Article  Google Scholar 

  29. Ozkaya U, Kabukçuoğlu Y, Parmaksizoğlu AS, Yeniocak S, Ozkazanli G. Changes in patellar height and tibia inclination angle following open-wedge high tibial osteotomy. Acta Orthop Traumatol Turc. 2008;42:265–71.

    Article  Google Scholar 

  30. Scuderi GR, Windsor RE, Insall JN. Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am. 1989;71:245–8.

    Article  CAS  Google Scholar 

  31. Gooi SG, Chan CXY, Tan MKL, Lim AKS, Satkunanantham K, Hui JHP. Patella height changes post high Tibial osteotomy. Indian J Orthop. 2017;51:545–51.

    Article  Google Scholar 

  32. Sakai N, Koshino T, Okamoto R. Patella Baja after displacement of tibial tuberosity for patellofemoral disorders. Bull Hosp Jt Dis. 1993;53:25–8.

    CAS  Google Scholar 

  33. Weale AE, Murray DW, Newman JH, Ackroyd CE. The length of the patellar tendon after unicompartmental and total knee replacement. J Bone Joint Surg Br. 1999;81:790–5.

    Article  CAS  Google Scholar 

  34. Davies GS, van Duren B, Shorthose M, Roberts PG, Morley JR, Monk AP, Murray DW, Pandit HG. Changes in patella tendon length over 5 years after different types of knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016;24:3029–35.

    Article  Google Scholar 

  35. Bugelli G, Ascione F, Cazzella N, Franceschetti E, Franceschi F, Dell’Osso G, Svantesson E, Samuelsson K, Giannotti S. Pseudo-patella Baja: a minor yet frequent complication of total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2018;26:1831–7.

    Article  Google Scholar 

  36. Perelli S, Ibañez M, Morales-Marin C, Acuña-Avila G, Espinoza-von Bischhoffshausen R, Masferrer-Pino A, Monllau JC. Patellar tendon lengthening: rescue procedure for patella Baja. Arthrosc Tech. 2020;9:e1–8.

    Article  Google Scholar 

  37. Drexler M, Dwyer T, Marmor M, Sternheim A, Cameron HU, Cameron JC. The treatment of acquired patella Baja with proximalize the tibial tuberosity. Knee Surg Sports Traumatol Arthrosc. 2013;21:2578–83.

    Article  Google Scholar 

  38. • Vandeputte F-J, Vandenneucker H. Proximalisation of the tibial tubercle gives a good outcome in patients undergoing revision total knee arthroplasty who have pseudo patella baja. Bone Joint J. 2017;99-B:912–6 Discusses outcomes of proximalization procedure in TKA.

    Article  Google Scholar 

  39. • Schmidt S, Mengis N, Rippke JN, Zimmermann F, Milinkovic DD, Balcarek P. Treatment of acquired patella baja by proximalization tibial tubercle osteotomy significantly improved knee joint function but overall patient-reported outcome measures remain diminished after 2 to 4 years of follow-up. Arch Orthop Trauma Surg. 2021; Longer term outcomes of proximalization on native knee joints.

  40. Hockings M, Cameron JC. Patella Baja following chronic quadriceps tendon rupture. Knee. 2004;11:95–7.

    Article  Google Scholar 

  41. Cameron HU, Jung YB. Patella Baja complicating total knee arthroplasty. A report of two cases. J Arthroplast. 1988;3:177–80.

    Article  CAS  Google Scholar 

  42. Dejour D, Levigne C, Dejour H. Postoperative low patella. Treatment by lengthening of the patellar tendon. Rev Chir Orthop Reparatrice Appar Mot. 1995;81:286–95.

    CAS  Google Scholar 

  43. • Guido W, Christian H, Elmar H, Elisabeth A, Christian F. Treatment of patella baja by a modified Z-plasty. Knee Surg Sports Traumatol Arthrosc. 2016;24:2943–7 Provides a description Z-plasty technique and reports outcomes.

    Article  Google Scholar 

  44. In Y, Kim S-J, Kwon Y-J. Patellar tendon lengthening for patella infera using the Ilizarov technique. J Bone Joint Surg Br. 2007;89:398–400.

    Article  CAS  Google Scholar 

  45. Jeong JS, Wang JH. Treatment of patella infera by patellar tendon lengthening and augmentation with tibialis anterior tendon allograft. Knee. 2014;21:605–8.

    Article  Google Scholar 

  46. Yoo J-H, Chang J-D, Seo Y-J, Baek S-W. Reconstruction of a patellar tendon with Achilles tendon allograft for severe patellar infera--a case report. Knee. 2011;18:350–3.

    Article  Google Scholar 

  47. Takai S, Shimazaki N, Yoshino N, Watanabe N, Nakachi N, Kobayashi M, Matsusita T. New technique for knee flexion contracture with patella infera using patellar tendon reconstruction combined with anterior capsular shift: a case report. Arch Orthop Trauma Surg. 2009;129:1383–6.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Sabrina M. Strickland.

Ethics declarations

Conflict of Interest

Kathryn Barth and Sabrina Strickland declare that they have no relevant conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.

Additional information

Publisher’s note

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

This article is part of the Topical Collection on Advances in Patellofemoral Surgery

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Barth, K.A., Strickland, S.M. Surgical Treatment of Iatrogenic Patella Baja. Curr Rev Musculoskelet Med 15, 673–679 (2022).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Patella baja
  • Patella infera
  • Patellar tendon lengthening
  • Hamstring autograft