Original Research

Patella Alta: A Comprehensive Review of Current Knowledge

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We systematically reviewed patella alta with respect to type of measurements, reported cutoff values, cutoff values for surgical correction, and proposed surgical techniques. Using the term patella alta, we performed a systematic literature search on PubMed. Inclusion criteria were original study or review articles, publication in peer-reviewed English-language journals between 2000 and 2017, and narrative description or measurement of human patellar height on plain radiographs or magnetic resonance imaging (MRI). All evidence levels were included.

Of 211 articles identified, 92 met the inclusion criteria for original study, and 28 for review. The 92 original study articles defined patella alta mostly with imaging-based measurements (81.5%) and more rarely by description only (18.5%). Eighteen types of measurement methods with 27 different cutoff values were used to assess patella alta; these methods included lateral radiographs, sagittal MRI, radiographic ratios measured on MRI, and patellar tendon length. The Insall-Salvati index (ISI) was used more than the Caton-Deschamps index (CDI); cutoff values for patella alta varied from >1.2 to >1.5 for ISI and from >1.2 to >1.3 for CDI. Both indices were seldom used on MRI; cutoff values were similar to those for conventional radiographs. On sagittal MRI, the patellotrochlear index was used most; cutoff values ranged from <0.125 to  0.28. Eleven studies used patellar tendon length and found it was increased (>52 mm to >56 mm).

The 28 reviews described patella alta mostly with ISI (75%) or CDI (64%). However, 12 (57%) of the 21 review studies that used ISI and 7 (39%) of the 18 review studies that used CDI did not report cutoff values. Only 2 review studies suggested an ideal patellar height after surgery.

Different procedures were used to treat patella alta: tibial tubercle distalization with and without patellar tendon tenodesis, tibial tubercle distalization and medialization, and distal advancement of the patellar tendon. Only 11 original studies proposed a critical patellar height as an indication for surgery; however, these studies mainly used CDI, and only 4 mentioned a desired postoperative patellar height after correction. 

Our review revealed many variations in patella alta definitions and descriptions, measurement methods, cutoff values, and treatment options. Presence of patella alta depends on the measurement method used. Unfortunately, there is no generally accepted consensus on patella alta. Given its influence on patellofemoral loading/stress and patellar stability, however, we must strive to establish a consensus in the near future.


 

References

Take-Home Points

  • Patella alta has a reduced articular area of PF contact.
  • Presence of patella alta depends on the measurement method.
  • Patella alta is defined as ISI >1.2 and CDI >1.2 to >1.3.
  • On sagittal MRI, PTI is used most often with cutoff values of <0.125 to 0.28.
  • Tibial tubercle distalization is most often used to treat patella alta. The desired postoperative patellar height is a CDI of 1.0.

Patella alta is a patella that rides abnormally high in relation to the femur, the femoral trochlea, or the tibia, 1 with decreased bony stability requiring increased knee flexion angles to engage the trochlea. 2,3 An abnormally high patella may therefore insufficiently engage the proximal trochlea groove both in extension and in the early phase of knee flexion—making it one of the potential risk factors for patellar instability. 4-10 Accordingly, patella alta is present in 30% of patients with recurrent patellar dislocation. 11 It also occurs in other disorders, such as knee extensor apparatus disorders, in patients with patellofemoral (PF) pain, chondromalacia, Sinding-Larsen-Johansson disease, Osgood-Schlatter disease, patellar tendinopathy, and osteoarthritis. 1,7,8,12-18 As such, patella alta represents an important predisposing factor for patellar malalignment and PF-related complaints. On the other hand, patella alta may also be a normal variant of a person’s knee anatomy and may be well tolerated when not combined with other instability factors. 4

Despite the importance of patella alta, there is no consensus on a precise definition, the most reliable measurement method, or the factors thought to be important in clinical decisions regarding treatment. To address this issue, we systematically reviewed the patella alta literature for definitions, the most common measurement methods and their patella alta cutoff values, and cutoff values for surgical correction and proposed surgical techniques.

Methods

In February 2017, using the term patella alta, we performed a systematic literature search on PubMed. Inclusion criteria were original study or review articles, publication in peer-reviewed English-language journals between 2000 and 2017, and narrative description or measurement of human patellar height on plain radiographs or magnetic resonance imaging (MRI). Excluded were abstracts and articles in languages other than English; animal and computational/biomechanical studies; case reports; and knee arthroplasties, knee extensor ruptures, and hereditary and congenital diseases. All evidence levels were included.

We assessed measurement methods, reported cutoff values for patella alta, cutoff values for performing surgical correction, proposed surgical techniques, and postoperative target values. Original study articles and review articles were analyzed separately.

Results

Of 211 articles identified, 92 met the inclusion criteria for original study, and 28 for review. All their abstracts were reviewed, and 91 were excluded: 17 for language other than English, 11 for animal study, 12 for biomechanical/computational study, 20 for case report, 8 for arthroplasty, 13 for hereditary or congenital disease, 1 for extensor apparatus rupture, 3 for editorial letter, and 6 for other reasons. Full text copies of all included articles were obtained and reviewed.

Original Study Articles

Definition. Of the 92 original study articles, 17 (18.5%) defined patella alta by description alone, and 75 (81.5%) used imaging-based measurements. Patella alta was described as a patella that rides abnormally high in relation to the trochlear groove, with a reduced articular area of PF contact 1,15,19-21 or decreased patella–trochlea cartilage overlap. 22 With this reduced contact area, there is increased PF stress. 21

With radiographic measurements, patella alta is defined as a Caton-Deschamps index (CDI) of >1.2 to >1.3, an Insall-Salvati index (ISI) of >1.2, a Blackburne-Peel index (PBI) of >1.0, 4,15,18,23-25 and a patellotrochlear index (PTI) of <0.125 to 0.28. 6,26

Table 1.

Table 2.
Measurement Methods. Four different patella alta measurement methods were used: lateral radiographs with corresponding ratios (68 studies, 5 indices, Table 1 ), radiographic ratios measured on MRI (23 studies, 3 indices, Table 2 ), sagittal MRI (13 studies, 4 methods, Table 3 ), and patellar tendon length (PTL) measurements (11 studies, 5 methods, Table 4 ). In 26 studies, multiple measurement methods were used.

Table 3.
Table 4.

On lateral radiographs, ISI was the most common measurement (33 studies), with patella alta cutoff values ranging from >1.2 to >1.5. The second most common measurement was CDI (24 studies), with cutoff values of >1.2 to >1.3. Other indices, such as the modified ISI (6 studies), the BPI (1 study), and the Koshino index (2 studies), had their cutoff values used more consistently (>1.6 to >2.4, >1.0, and >1.2, respectively) but these indices were rarely reported in the literature (Table 1). 27,28,29 

Thirty-six studies defined patella alta with MRI

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