PLAIN PATELLOFEMORAL RADIOGRAPHS

ROBERT A. TEITGE, MD

Plain radiographs of the patellofemoral joint can show patellar location, bone shape, trabecular pattern, and
articular space thickness. With stress application, stability can be measured. Radiographs may be obtained in the
lateral, anterior-posterior, oblique or axial projections, with or without weight-bearing, with or without muscle
contraction, with or without stress application to the ligaments, and with the knee in varying degrees of flexion. In
addition to trabecular pattern, the lateral radiograph can reveal patellar subluxation, height, or trochlear dysplasia.
The axial view is rarely useful until 30° of knee flexion and then may show joint space loss, patellar shift or tilt,
and trochlear geometry. Stress radiographs may be required to show how far the patella can be displaced from
the trochlea with a given force, and thus, it may be the most accurate method of determining patellar instability.
Weight-bearing films may be necessary to show loss of joint space.
KEY WORDS: patella, radiography, x-ray, stress, instability
Copyright © 2001 by W.B. Saunders Company

Limb alignment, bone geometry, articular cartilage, lig- are minimal in the evaluation of malalignment in patellar
aments, muscles, and tendons are independent variables dysfunction:
that affect the operation of the patellofemoral joint and its
Coronal plane
dysfunction. Plain radiographs have been used for years
Q angle
to explain dysfunction, but not all inferences from plain
Patellar rotation (clockwise or counter-clockwise)
radiographs are complete or can reflect accurately on other
Varus or valgus of the knee
variables. 1 Basically, all that can be determined with static
Sagittal Plane
films is patellar location, bone shape, trabecular pattern,
Height, alta or baja
and articular space thickness. With stress application, sta-
Flexion or extension of the patella
bility can be measured. Patellofemoral diagnoses remain
Radius of the curvature of the patellofemoral joint
imprecise, and classification systems are often incomplete
Flexion or extension of the condyles on the femoral
or illogical. In each patellofemoral evaluation independent
shaft
variables should be analyzed separately and then later
Trochlear groove location relative to the anterior cortex
interdependent relationships integrated.
Soft-tissue contracture
Limb alignment is a reflection of the 3-dimensional ge-
Horizontal Plane
ometry of the entire skeleton. Forces transmitted through
Torsion of the acetabulum, femur, knee, tibia, ankle,
the patellofemoral joint are dependent on limb alignment
subtalar, and foot complex
(ie, varus and valgus, flexion and extension, rotation, off-
set from the body's center of mass); limb length; body Thomee et aP has argued that the definitions used for
weight; etc. Differentiation must be made between limb malalignment should be re-evaluated, because the scien-
alignment and patellar alignment, both of which affect
patellofemoral load transmission. Both the clinical estima-
tion and instrumented measurement of patellofemoral
alignment have been shown to be unreliable. 2
The author considers malalignment to be any limb devi-
ation from normal that affects patellofemoral mechanics,
including both limb alignment and an abnormal position-
ing of the' patella relative to the trochlea, which some
investigators call patellar malalignment. Limb alignment
must analyze the patella in a relationship to the body
center of mass in all 3 planes, not just the position of the
patella on the femur. The following skeletal considerations

From the Division of Sports Medicine, Wayne State University School of

Medicine, Warren, MI.
Address reprint requests to Robert A. Teitge, MD, 4050 E 12 Mile Rd,
Suite 110, Warren, MI 48092. !J!Ji!i%ii!<!L
Copyright © 2001 by W.B. Saunders Company
1060-1872/01/0903-0002535.00/0 Fig 1. Radiograph showing increased subchondral sclerosis
doi:l 0.1053/otsm.2001.25158 because of mechanical overload in this location.

134 Operative Techniques in Sports Medicine, Vol 9, No 3 (July), 2001: pp 134-151

Fig 2. Radiograph showing (A) a normal patella without risk factors and (B) the same patella dislocated indicating that no
conclusion about laxity may be drawn from a static film.
tific support is very weak for determining when alignment
is normal and when there is malalignmento
Articular cartilage reduces friction. Its surface cannot be
seen on plain radiographs, but its relative thickness may
be inferred by interpretation of the radiographic joint
space opening. Subchondral sclerosis may be an important
indicator of joint loading location and amount (Fig 1).
Ligaments prevent abnormal bone displacement, so the
surgeon can infer that if the bones are separated an abnor-
mal amount (dislocation or subluxation) the ligament in-
tegrity has been overcome. If the bones are not dislocated
or subtuxed on plain radiographs, the surgeon can make
no conclusion regarding ligament competence (Fig 2). Lit-
tle can be concluded regarding muscles from plain radio-
graphs, although with contraction of muscles when radio-
graphs are taken a subsequent shift of the patella may
sometimes be noted (Fig 3).
Patellofemoral pain may be the result of abnormal stress
from too much body weight; or from an abnormal limb
alignment, which causes unusual stress on ligaments or
tendons; or from lax ligaments that allow subluxation or
dislocation with a loss of normal surface area contact.
Fig 3. Radiograph showing how a patella may be displaced with muscle contraction (A) with quadriceps relaxed (B) with
quadriceps contracted.
PLAIN PATELLOFEMORAL RADIOGRAPHS
Arthrosis may be the result of any of these 3, and plain
radiographs may fail to reveal any of them. Plain radio-
graphs of the patellofemoral joint may be obtained from
the lateral, anteroposterior, oblique, or axial projections
with or without weight-bearing, with or without muscle
contraction, with or without ligament stress, and with the
knee in varying degrees of flexion.
ANTEROPOSTERIOR
The anteroposterior (AP) projection of the knee has been
used to estimate the limb varus and valgus, Q angle,
patellar height, patellar fragmentation, and patellar shift.
However, its usefulness is limited (Fig 4).
Varus-Valgus
The tibiofemoral angle can be measured, but it is an ap-
proximation of the varus or valgus as determined by a
more accurate weight-bearing mechanical axis run fully
from the center of femoral head to the center of the talus.
Small changes in the mechanical axis can affect patel-
lofemoral function.
135
 Fig 5. Radiograph showing Blumensaat's line for deter-
mination of patellar height.

Lateral
Fig 4. AP radiograph showing (A) bipartite fragment; (B)
height (ie, inferior pole at or above joint line); and (C) location The lateral radiograph has been used to define patellar
laterally (ie, central). height, patellar flexion, location of the patellar articular
surface, subchondral sclerosis (Haglund's excuvatum),
depth of the trochlea, proximal extent of the trochlear
surfaces, flexion or extension of the condyles relative to the
Q Angle femoral shaft, the relative size of the radius of curvature of
the condyles, patellar tilt, crossing sign, and the trochlear
Brattstrom 4 defined the Q angle as the supplement angle
boss or bump. Patellar height is usually measured on
to that angle formed b y the quadriceps' resultant and
the lateral roentgenogram. Various studies have corre-
patella and ligamentum patellae. If the surgeon could
place a radiographic marker at the quadriceps resultant
vector and the center of tendon attachment to the tibial
tubercle, then the Q angle might be measured on the AP
radiograph. But because the Q angle has been shown b y
Hvid and Anderson 5 to change with the femoral torsion
and b y Olerud and Berg 6 to change with foot position,
its use must be challenged.

Patellar height. Patellar height has been measured on the

AP radiograph as normally having the apex 2 to 3 cm
above the tibial plateau with the quadriceps contracted,
and at the level of the joint with the quadriceps relaxed
and the knee fully extended. 4 However, because the loca-
tion of the articular surface cannot be measured on the AP
projection, this is not as useful a measurement as that
obtained from the lateral projection. Patellar fragmenta-
tion such as a bipartite or multipartite patella is often best
seen on the AP radiograph. A shift medially or laterally
can be estimated if the knee joint axis is placed in the plane LT
- 1.0
of the film. However, radiology technicians often place the LP
patella anteriorly to obtain this projection, and if the pa-
tella is shifted on the femur, then the resulting tibiofemo-
ral projection is an oblique projection and its medial- Fig 6. The InsalI-Salvati ratio length tendon (LT)/length pa-
lateral location cannot be estimated. tella (LP) should normally be within 20% of 1.0.

136 ROBERT A. TEITGE

 TA
- .93
PA

Fig 7. Lateral radiograph at 90 ° knee flexion. By the Labelle

and Laurin 9 criteria the top of the patella should be below the
anterior cortex of the femur at 90 ° of knee flexion.
Fig 9. The Caton et a111 index is normally 0.93 and the patella
alta is healthy when the index is over 1.2.

lated patellar alta w i t h patellar instability, pain, and

chondromalacia.
Various investigators have used different m e t h o d s to
measure patellar height, including Blumensaat, 7 Insall and
Salvati, 8 Labelle and Laurin, 9 Blackburne and Peel, 1° Caton
et al, 11 deCarvalho et al, la Burgess, ~3 Koshino and Sugi-
moto, 1~ Grelsamer and Meadows, ~5 Leung et al, 16 and
D u p o n t JY (personal communication, Switzerland, 1996).
Blumensaat 7 in 1938 noted that if a lateral radiograph of
the knee is obtained at 30 ° of flexion, then a line extended
along the roof of the intercondylar fossa will intersect the
apex of the patella. If the apex is above this line a condition
of patella alta exists. Anderson .7 noted that 72% of 286
patients with a recurrent dislocation of the patella h a d
patella alta. Brattstrom, 18 however, measured the angle
between Blumensat's line and the shaft of the femur and
found that the average was 45 ° and the variation was
between 27 ° and 60°; thus errors are potentially common.
The additional difficulty with this m e t h o d is the need to
ensure the knee is flexed to exactly 30 ° (F~g 5).
Insall and Salvati 8 in 1971 found the Blumensaat 7 mea-
surement to be in error and suggested the ratio of the
length of the posterior surface of the patellar tendon from
the inferior pole of the patella to the tibial tubercle as it
relates to the greatest diagonal length of the patella (LT/
<:~i¸i;i: ,, / '
::~!ii;iii~....
~ 7 / "

, , , I// ,,11/,I

\" °z7 Ca ~.<S'u~, ~') ,

~ o D j : UX¢ y ,\ I
•

!7~ ,, J

- .89

A
\,",, 7/~q
--=0.8
B

Fig 10. The deCarvalho ratio T/P (T is the distance from inferior
articular patellar surface to anterior tibial articular surface and P
is the patellar articular surface) is normally 0,89 whereas patella
Fig 8. The Blackburne and Peep o ratio is normally 0.8. alta is over 1.20 with a confidence of 99%.

PLAIN PATELLOFEMORAL RADIOGRAPHS 137

 A
- .61
B

___A= <1.2
B
Fig 11. Burgess 13 found smaller variance using the ratio A/B
with normal being 0,66 (SD = 0.05),

Fig 13, Grelsamer and Meadows 15 modified Insall and Sal-

LP). The average value was 1.02 (standard deviation vati 8 A/B ratio normal controls averaged 1.5 whereas a ratio
[n/SD] = 0.13) and the 2 lengths should not differ by more of 1.25 is the cutoff between normal and patella alta.
than 20% (Fig 6).
Labelle and Laurin9 in 1976 noted that in a healthy knee
at 90 ° of flexion on a lateral film the patella should lie
below a line of extension of the anterior cortex of the
femur (Fig 7). Blackburne and Peel 1° in 1977 noted diffi-
culty with both Blumensaat's and Insall and Salvati's
method s and suggested the ratio of A/B, where A is the
perpendicular distance from the extension of the tibial
plateau line to the inferior edge of the patellar articular
surface and B is the length of the tibial articular surface.

A / / S / /

A1 + A2
- - - 2
B

Infant Adolescent
A~ + A2
Fig 12. The Kushino and Sugimoto ratio of PT/FT for (A) Fig 14. Leung's patella alta index of ~ had a mean of
infants and (B) adolescents with normal range 0,9 to 1,3, 2,98 with the 95% cutoff being 3.37.

138 ROBERT A. TEITGE

Fig 15. Radiograph showing a separation of patellar and
trochlear articular surfaces of 11 mm; normal is less than 4
mm.
This ratio is normally 0.8 (SD = 0.14, range 0.54 to 1.06 in
95% of subjects measured) (Fig 8).
The Caton et al 1~ index measures the distance between
the most inferior point of the patellar and the most ante-
rior tibial articulating surface to the length of the articular
surface of the patella via knee flexed between 30 ° and 60 °
(Fig 9).
deCarvalho et aP ~ in 1985 also had difficulty with the
Insall and Salvati s method in determining the locations of
the posterior border of the patellar tendon or its attach-
ment to the tibial tubercle. Therefore, they suggested mea-
suring the T / P ratio, where T is the shortest distance from
the articular margin of the patella to the tibial plateau and
P is the distance between the upper and lower limits of the
A 'i
]i 'i
~!
,~t':., '. .... -~:,", \*
I \
1 c
Fig 16. The trochlear may be measured by using the contour
lines for "A" the floor of the sulcus, "B" the lateral femoral
condyle, and "C" the medial femoral condyle.
PLAIN PATELLOFEMORAL RADIOGRAPHS
Fig 17. Radiograph showing these 3 contour lines, from left
to right: sulcus, lateral condyle, medial condyle.
articular surface of the patella. Normally, this ratio is 0.89
(range, 0.47 to 1.28, SD = 0.13). The 5% and 1% upper
limits of normal are 1.11 and 1.20, respectively, and these
should be used as the measure of patella alta (Fig 10).
Egund ~9 found the method of Insall to be inadequate,
and the Blackburne and Peep and Norman methods to be
influenced by anatomic variations or joint laxity. Norman
compared the distance of the inferior articular surface of
the patella above the tibial plateau with the body height.
Burgess 13 in 1989 pointed out that measurement of the
Insall and Salvati 8 ratio was often difficult because the
attachment site of the patetlar tendon to the tubercle can-
not be located on radiograms, whereas the ratio of Black-
burne and PeeD ° changes if the patellar size changes, even
though the location does not change. He, therefore, pro-
posed using a ratio of the femoral condyle AP dimension
(B) to the distance from the center of the articular surface
of the patella along the perpendicular to the tangent of the
tibial articular surface (A). His ratio had the smallest vari-
ance when compared with the Insall and Salvati s and
\
j.. )
1 cm
A I, It!,(~ "~;.:o° ',>','~;:" '-i:,.5.</ ~,
\\~' .(:, ~, {v/ . ~ . . , ) 0 / J
M / IN --~:---£-_s>" <.< /
1
Fig 18. Maldague and Malghem 20 measured the trochlear
depth 1 cm inferior to the top edge of the trochlea. M, medial
condyle; L, lateral condyle; G, trochlear groove.
139
 I same midpoint of the tibial physis (P) to the midpoint of
the distal femoral physis (F). The range of the ratio PT/FT
in 36 healthy children was from 0.9 to 1.3. Using this range
II only 3.4% (2 knees) were defined as patella alta, whereas
with the Blumensaat 7 measurement, 46% were defined as
S high riding, and with the Insall and SalvatP ratio, 67% of
! Iris\ the knees were high riding, and children less than 9 years,
100% high would be considered high (Fig 12). Walker et
X al 2] in 1998 stated that the Insall and Salvati ratio is satis-
15ol r) ~ I <":'\ \ N
factory in children, but the patella is normally higher than
~-" , , - I.,~'..~, \~. \
in adults. They gave normal values of 1.03 for boys and
tt[,~'t~"O o",.'i, "",',-,,~. t\ 1.06 for girls.
',t. :.:',7,.,. ,". "i' ', ,, .".,(>J,:?,." :I Grelsamer and Meadows ~s in 1992 suggested measuring
from the patellar tendon insertion on the tibia to the infe-
'%, .... :----y I ,...y rior articular limit on the patella (A) divided by the length
of the patellar articular surface (B) with a normal ratio
being 1.75, and 97% of controls without patellar symptoms
had a ratio of less than 2.0. This measurement avoids the
error introduced in the Insall and Salvati ratio when the
Y patient has an elongated inferior patellar pole (Fig 13).
Leung et al ~6 in 1996 described the patella alta index,
Fig 19. A consistent location to measure the depth of the
which is a ratio of the sum of the patellar tendon length
sulcus is along the line set 15 ° inferior to a line perpendicular
to the posterior cortex of the diaphysis and tangent to the plus the patellar length (A~) divided by the patellar artic-
posterior articular surface. Distance is normally 7.8 mm with ular surface length (A2) with a mean of 2.98. They noted
a threshold of dysplasia of <4 mm. (A, femoral condyle; B, that asymptomatic controls of southern Chinese had a
sulcus floor.) higher mean patellar height than that reported in Western
populations (Fig 14).
Blackburne and Peel m methods (Insall and SalvatP, 0.96, Dupont JY (personal communication, Switzerland, 1996)
SD = 0.16, range 0.66 to 1.26; Blackburne and Peep ° 1.25, emphasized the importance of the Bernageau index, which
SD = 0.23, range 0.79 to 1.71; Burgess ~3 0.66, SD = 0.05, measures the distance between the inferior articular sur-
range 0.56 to 0.76). Thus the Burgess 13 method may be the face of the patella and the superior articular surface of the
most reliable (Fig 11). trochlea with the knee in maximum extension and the
Koshino and Sugimoto ~4 in 1989 believed that neither quadriceps contracted. A relaxed quadriceps gives a false
the Blumensaat 7 method nor the Insall and SalvatP ratio impression of the location of the patella not reflective of
were satisfactory in children and described a ratio com- the functioning quadriceps mechanism. A distance of
paring the distance from the midpoint of the tibial physis greater than 4 mm is excessive and indicates patella alta
(T) to the midpoint of the patella with a distance from the (Fig 15).

Type l Type II Type III

iL ~! •

J "'! \ Trochlear i/ ~i\

!i ,\ ! ,,', sulcus i ",i ,\
Trochlear ",!,,
\\\ , Trochlear ,.:.,\\\ \ J/ Med,al ,:.~
~~li/condyle t,...\\~~

I!~l~] ; '-, ,'...,:.... .'~ t> ;'/.' !I I

I ~41,~, ,:].:'% ~'~'<,,'~o' K,' //
"~=~-:._-.~:.'-" ./ /
%. /
Medial N>... _..../
condyle / ~ Medial
condyle / - - - - f Lateral
Lateral Lateral condyle
condyle condyle

Fig 20. Type I or minor dysplasia of the trochlea occurs when both femoral condyles intersect the sulcus together and
somewhat proximally with the floor crossing condylar-the crossing sign. Type II or moderate dysplasia occurs when the
medial femoral condyle and the lateral femoral drop posterior to the sulcus line at different levels. Type III or major dysplasia
occurs when both condyles symmetrically cross the sulcus line distally leaving the sulcus floor to extend proximal to both
condyles. This proximal extension of the trochlear floor often forms a beak.

140 ROBERTA. TEITGE

 contact. Height of the patella may have a considerable role
mechanically in altering these tensions and retropatellar
pressures. Grelsamer et a127pointed out different articular
to nonarticular patellar length ratios and their effect on
measuring length and possible relationship to pain.

FEMORAL GEOMETRY
(TROCHLEAR SHAPE)
Trochlear geometry directs patellar tracking, 28 w h e n ab-
normally shallow, probably contributes to instability or
w h e n abnormally deep may contribute to arthrosis. 29
The shape of the distal femur is complex, and Siu et al, 3°
in a s t u d y of 5 normal femurs, attempted to define this
complexity. The lateral condyle is shifted anteriorly
with respect to the medial condyle. The medial and
lateral condyles do not run parallel to each other but
Fig 21. Radiograph of type I or minor dysplasia.
converge or toe in toward the patellofemoral groove at
82 ° and 80 ° respectively, with respect to the horizontal
Z axis. The condyles showed a camber with the poste-
No complete comparative studies of these different
rior part of the medial condyle at an angle of 87 ° with
methods have been published and thus it is not valid to
respect to the Z axis and the anterior part at 76 °, while
recommend one over another. The mechanism by which
in the lateral condyle the camber angle was 84 ° posterior
height alteration influences patellofemoral biomechanics
and 85 ° anterior. The femoral groove is inclined 15 °
has not been adequately studied and the clinical signifi-
distal and lateral with respect to the mechanical axis or
cance of height is not defined except that a variety of
105 ° with respect to the Z axis, which m a y be respon-
studies have correlated alta with both increased instability
sible for the lateral translation of the patella during knee
and pain. Brattstrom 18 in 1970 described 8 patients in
flexion. It is commonly believed that the femoral groove
whom surgery was necessary to lower the patella because
deepens as the patient moves distally, but this was
of pronounced symptoms of ache, tiredness, exudate, feel-
found not to be the case when studied by Farahmand et
ings of instability, and in some patients, catching of the
al. 31 When the patella is out of contact with the trochlear
patella even though there is no history of dislocation.
groove at full knee extension, its stability then does
Ahlback and Mattsson22 noted patella alta was 6 times
depend more on the patellofemoral ligaments especially
more frequent in knees with patellar osteoarthrosis than in
medially. 32 Elias et a133 have suggested that the medial
those with a normal femoropatellar joint. Huberti et a123
has shown a variation in contact location and pressures
with changes in height. Huber et a124has shown using load
sensors a reduction in pressures with distalization of the
patella. Buff et a125 van Eijden et al,26 Huberti et al,23 and
others have pointed out that the patella functions as a
balance beam so the forces in the quadriceps and patellar
tendons differ and vary with different points of patellar

Fig 22. Radiograph of type II dysplasia. Fig 23. Radiograph of type III dysplasia.

PLAIN PATELLOFEMORAL RADIOGRAPHS 141

 A ciSB i! o Fig 24. A trochlear boss or bump exists when the floor of the
trochlear is anterior to the anterior cortex of the femur. This eleva-
tion has been seen to be common in instability but does not nor-
mally exist. To measure this Dejour et ap4, 3s extends a projection
distal to the last 10 cm of the anterior femoral cortex and measures
between this line and the sulcus. (A) Measure technique, negative is
normal: A, medial condyle; B, floor of trochea; C, lateral condyle; D,
intersection of line of extension of the posterior diaphyseal cortex
with the line tangent to the posterior femoral condyle articular
l\;;_ . ........ i surface, (B) over + 3 mm is associated with objective instability
(66%), (C) negative boss and (D) neutral boss.
X Y

Positive boss Negative boss Neutral boss

1 !

I I

and lateral patellar retinaculum be thought of as the 2
collateral ligaments for the patellofemoral joint.
Dejour et a134,35 have measured trochlear shape from
the lateral roentgenograph and have defined trochlear
dysplasia with 3 measurements. On a true lateral radio-
graph there is perfect superimposition of the medial and
lateral condyles posteriorly, and 3 contour lines m a y be
seen anteriorly (Figs 16 and 17). These represent the
anterior curves of the medial femoral condyle, the lat-
eral femoral condyle, and the floor of the sulcus. Dejour
has used these lines to note the trochlear depth, the
crossing sign, and the trochlear boss. The investigators
believe that measurement on the lateral radiograph is
more accurate than measurements on the axial radio-
graph because dysplasia m a y be located in the region of
the proximal trochlea, an area not visualized on the
axial radiograph.
Sulcus Depth
Malghem and Maldague 36 measured the depth of the
trochlear groove to be 6 m m at a point 1 cm distal to its
proximal beginning (Fig 18). To locate a constant posi-
tion for reproducible measurements, Dejour et a134,35
recommended a line be drawn perpendicular to the
posterior cortex of the femur from a point where the
posterior cortex intersects the articular surface of the
posterior condyles. A second line is d r a w n from this
point angled 15 ° distal and anterior to cross the anterior
femoral condyles (Fig 19). The distance between the
anterior condylar line and the sulcus represents the
sulcus depth. The greater this distance, which averaged
7.8 m m in normal controls and 2.3 m m in his instability
group, the greater the stability provided by the trochlear
depth. The investigators believe this measure is more
important than the sulcus angle from the axial view
which can not be obtained until about 30 ° of knee flex-
ion. They believe that a shallow sulcus may become
normal by 30 ° of knee flexion an observation supported
by Kujala et a137 who showed that in a group of 11
w o m e n with a documented m i n i m u m of 2 dislocations
of the patella the distance between the anterior points of
the condyles were closer than in control knees. There
was a marked difference at 10 ° flexion in sulcus angle,
lateral patellofemoral angle, lateral patellar displace-
ment, lateral patellar tilt, and congruence angle between
the controls and dislocators. The most marked measure-
ments for the dislocators were the sulcus angle at 10 °
which was at least 170 ° and next the lateral patellofemo-
ral angle at 0 ° flexion which was 13 ° in dislocators and
+4 ° in controls.

14,2 ROBERTA. TEITGE


Fig 25. Radiograph of prominent trochlear boss.
Intersection or Crossing Sign
In the normal knee the line of the trochlear floor (sulcus) is
always posterior to the line representing the femoral con-
dyles. A type I or minor dysplasia is present when the
condyles are symmetrical and cross posterior to the line of
the floor of the trochlea at one point in its proximal portion
(Figs 20 and 21). A type II or moderate dysplasia exists if
the sulcus floor first crosses 1 femoral condylar line and
then at a different level the other condylar line (Figs 20 and
22). If the trochlear floor line intersects both condyles
before reaching the anterior cortex then a type III or major
dysplasia exists and there is little resistance to lateral
displacement of the patella; the trochlea is flat. In patients
with severe trochlear dysplasia, a small prominence or
"beak," referred to as the recentering beak, is often present.
It is seen to mark the proximal end point of the trochlear
floor (Figs 20 and 23).
Fig 26. Radiograph of Haglund's excavation.
PLAINPATELLOFEMORAL
RADIOGRAPHS
Trochlear Boss
Trochlearbossor "bump," accordingto Dejouret al,34is a
projection of the sulcus floor anterior to the anterior fem-
oral shaft cortex. In healthy knees this is close to 0 mm or
negative (-0.8 mm), whereas in patients with recurrent
dislocation it averaged 3.2 mm higher than the anterior
femoral cortex. The more anterior this sulcus line, the
more common both instability and osteoarthrosis. This
suggests that it is not only the relative height of the con-
dyles above the floor of the sulcus, which is important for
stability, but also the relative height of the floor of the
sulcus relative to the anterior cortex of the femur (Figs 24
and 25).
Grelsamer and Tedder 27 stated that on the lateral radio-
graph the intersection of the trochlear subchondral bone
meeting the lateral femoral condylar bone is an abnormal
finding, and its presence is highly suggestive of severe
trochlear dysplasia. It should prompt the clinician to con-
sider the patellofemoral joint as a source of knee pain.
Perrild et al 3s examined radiographs of 71 patients oper-
ated on for chondromalacia patella and found a high
correlation with the excavation of Haglund and slightly
less of a correlation with patella alta, but no correlation
with the Blackburne and Peep 0 index, congruence angle,
sulcus angle, age, joint gap, subchondral sclerosis osteo-
phytes, lateralization of the trabeculae, or Wiberg patella
type (Fig 26). Maldague and Malghem 44 described patellar
tilt on the lateral radiograph by comparing the relation-
ship of the median ridge with the lateral facet and classi-
fied the amount of tilt by how much separation there was
between these 2 radiographic lines (Fig 27).
~l MR
MR
MR
LF
LF--
MR LF
r
LF--~ ~ MR
Fig 27. Patellar tilt can be seen on the lateral radiograph.
Normally the median ridge of the patella is posterior and the
lateral facet can be seen as a line. When the patella is tilting
laterally the lateral facet moves posteriorly and the median
ridge moves anteriorly.
143
 A
LJ
Fig 28. Various methods used to obtain axial roentgenograms of the patellofemoral joint. (A) SettgasP 9 (common sunrise),
(B) Jaroschy 4° (Hughston41), (C) Knutsson 42 is useful in surgery, (D) Merchant et al. 43
AXIAL PROJECTION
The sulcus angle, the position of the patella relative to the
sulcus (ie, tilt, shift, or combination); the thickness of the
articular clear space; the variations of the subchondral
sclerosis; pathologic conditions such as osteochondral
fracture fragments or defects; and the shape of the patella
may be seen on the axial projection. The position of the
femur and patella that is projected by an axial radiograph
depends on the angle of the knee flexion when the radio-
graph is taken. The least distortion is obtained when the
x-ray plate is perpendicular to the x-ray beam, and various
techniques are available to view different portions of the
patellofemoral joint while the knee is flexed and, when
possible, keeping the plate perpendicular to the beam (Fig
28). To avoid overlap of the patella with the trochlea, the
144
\
\
beam is angled to be tangential to the femoral condyles.
This angle may be determined by viewing the lateral
radiograph taken in the desired degree of knee flexion (Fig
29). This angle varies considerably from patient to patient.
Because instability and perhaps arthrosis are more com-
mon at lower knee flexion angles, these are preferred.
Lauren et a144have suggested a knee flexion of 20 ° but this
is seldom possible and even line drawings from their
publications show 40 ° of flexion.
According to W i b e r g y Settegast s9 was the first to sug-
gest an axial projection of the patella, a view used by
Jaroschy. 4° This view has been popularized by Hugh-
ston. 42 Wiberg, 41 in an attempt to ascertain the appearance
of the lateral femoral condyle in dislocation of the patella,
took radiographs with knee flexion of 20 °, 40 °, 60 °, 90 °,
ROBERT A. TEITGE
 FL
I

ilJJ

Fig 28. (cont'd) Various methods used to obtain axial roentgenograms of the patellofemoral joint. (E) Ficat (F) Weight-
bearing.

and 115 ° and concluded that there was very little change
in appearance of the femur from 20 ° to 50 ° . He noted, in
examining 25 knees, 3 patellar shapes: type I with the
medial ridge m i d w a y between the medial and lateral bor-
ders of the patella so the facets were of equal size, type II
with the ridge being slightly towards the medial border,
and type III with the ridge displaced medially to such a
degree that there was hardly any room left for the medial
facet so that it sloped steeply forward and medially. He
then examined 13 patients, in whom either a luxation or
subluxation had been clinically diagnosed, and noted that
in 2 there was a completely flat trochlea and the patella
were abnormal, in 9 there was a flattened trochlea and the
patella were abnormal, and in 2 the patella was a healthy
type I but the trochlea was flattened. Thus in 11 of 13 the
altered shape of the patella reflected an altered shape of
the trochlea and was abnormal, but in 2 the dislocation
occurred with a normal patellar shape but an altered
trochlear shape; therefore, further supporting evidence of
trochlea dysplasia as a contributing cause of instability. A
variety of other measurements have been made in an
attempt to correlate measurements of shape to pathologic
condition. These include the facet ratio (Fig 30) measured
by Brattstrom (1 to 1.75) and by Ficat-Bizou (1 to 3), the
depth index 45 (3.6 to 4.2), and the facet angle (130° + 10°).
Cross and Waldrop 46 created an index of the ratio of width
to thickness of the patella and measured this in both
healthy controls and in subluxing patella noting a ratio of
15 to 17 in the healthy and 10 to 12 in the subluxing patella
perhaps reflecting a smaller medial facet (Fig 30).
Knutsson,42 according to Brattstrom4 was the first to
emphasize femoropatellar dysplasia, which meant a char-
acteristic osseous profile seen on an axial radiograph
showing the lateral condyle smoothed down to approach Fig 29. Lateral radiograph used to determine the femur to
the medial in height, or in extreme cases both are reduced beam angle needed for an accurate tangential view of the
so the sulcus is so shallow as to be scarcely visible. patellofemoral joint.

PLAIN PATELLOFEMORAL RADIOGRAPHS 1 4.5


R angle in his group of instability patients and found the
Ci
Fig 30. Patella showing depth index and facet angle. Cross
and Waldrop 46 ratio of pateliar width to thickness normally 15
to 17, but 10 to 12 in subluxation of patella. Brattstrom's
drawing of the measurements he obtained during his study
on the shape of the trochlea, including the depth index and
theangle of inclination of the trochlea.
Brattstrom4 measured all the femoral variables in Figure
30 and concluded that the sulcus angle was normally 141 °
to 142 °, whereas in the recurrent dislocation of the patella
patients it was 151 ° to 156 °. This increase in sulcus angle
may be due to a lowering of the lateral femoral condyle,
the medial femoral condyle, both condyles, or by the rais-
ing of the floor of the sulcus. Other measurements at-
tempting to define sulcus geometry include the depth
index 47 (width/depth, 5.3 + 1.2) and the angle of inclina-
tion of the trochlea (change in females, 6.1 ° + 0.3°). This
angle cannot be determined on a plain radiograph because
A o
' /
I
,! /
'/
c 1/I
Fig 31. (A) Congruence angle of Merchant et a143 is the angle between the bisector of the sulcus angle and the line to the
posterior tip of the median ridge. Normally this is 60 ° (medial) while in dislocators it was +23 ° (lateral). (B) Lateral patellar
displacement.
146
there is no practical way to control or measure the orien-
tation of the femur in the horizontal plane.
Dejour et a134 used the axial projection to compare sul-
cus angle, lateral patellofemoral angle, and congruence
difference in sulcus angle (144° v 130 °) and lateral patel-
lofemoral angle (16.3 ° v 10°) to be considerable but the
difference in congruence angle was not (controls, -6.5 ° +
6.5°; recurrent dislocators, 1.4 ° + 160; asymptomatic con-
tralateral knees, 7.7 ° _+ 11°).
LOCATION OF PATELLA IN TROCHLEA
These above measurements are an attempt to describe the
geometry but say nothing regarding the juxtaposition of
the patella and trochlea. Where the patella sits in relation
to the trochlea was described by Merchant et a143 who
devised an angle termed the congruence angle, (Fig 31)
which measured the deviation of the posterior most point
of the median patellar ridge to a reference bisector of the
sulcus angle. In 25 knees with proven recurrent dislocation
the angle measured +23 ° whereas in 200 normal knees
(100 individuals) it measured - 6 ° (SD = 11°).
Laurin et a144,48also described from the axial radiograph
at 20 ° of knee flexion a measurement of displacement of
the patella from the trochlea, the lateral patellar displace-
ment, and 2 measurements of patellar tilt: the patello-
femoral angle and the lateral patellofemoral index. Lateral
patellar displacement (Fig 31) may be measured by a refer-
ence line drawn perpendicular to the tangent line drawn
across the anterior aspect of the medial and lateral con-
dyles on the axial roentgenogram. In Laurin's study 97%
of healthy controls had the medial edge of the patella
touching or medial to this reference line whereas in pa-
tients with the clinical diagnosis of subluxing patella, only
47% had a normal relationship to the reference line, and in
chondromalacia 70% had a normal relationship. Thus he
described 3 patterns of patellar position in subluxation
and chondromalacia: displacement without tilt, tilt with-
out displacement, and displacement with tilt. These 3 pat-
terns describe the position of the patella relative to the
B
cl
I
A ___A
ROBERT A. TEITGE
 B

# i J '~\ ",

Fig 32. (A) Lateral patellofemoral angle. (B) Patellofemoral index.

femoral groove in the relaxed knee. For measuring tilt he described a similar view, but the foot can be externally
described the lateral patellofemoraI angle (Fig 32A) as an rotated, creating unwittingly the Malghem and Malda-
angle drawn on the axial radiograph taken at 20 ° of knee gue 52 external rotation subluxation view. In a limited
flexion. This angle is formed by the lines drawn tangent to number of patients we had a difficult time getting the
the femoral condyles and drawn on the surface of the patient to balance adequately to move their torso out of
lateral facet of the patella. This angle opens laterally in the line of the x-ray beam, but the view is good for viewing
97% of 100 healthy controls and the lines were parallel joint space loss and subluxation.
(80%) or open medially (20%) in 30 patients with the
clinical diagnosis of subluxation of the patella. In chon- Isolated facet view. Maldague and Malghem 52 have de-
dromalacia patella the angle was healthy in 90% of pa- scribed a useful method of obtaining a tangential lateral
tients. He also described the patellofemoral index (Fig 32B) view of the individual medial or lateral facets of the pa-
as a comparison of the height of the clear space medially to tella (Fig 34).
the clear space laterally. This measures a minitilt or mi-
crotilt of the patella and the ratio was 1.6 or less in healthy Patellar spin. Hille et a154 noted that in a series of 119
patients but more than 1.6 in 93% of 100 patients with the patient's knees with patellar chondropathy there was an
clinical diagnosis of chondromalacia patella. This tilt may absence of normal medial rotation of the patella between
occur as a result of the loss of the lateral patellofemoral 45 ° and 60 °. The distal (D) and proximal (P) poles of the
joint space, or as a result of laxity of the medial patel- patellar ridge are noted and the changing distance be-
lofemorat ligament, or possibly as a result of contracture of tween these points measured at different knee flexion
the lateral patellofemoral ligament or a combination of angles indicates patellar spin in millimeters (Fig 35).
any.
Blunden, 49 Macnab, 5° and McDougall and Brown 51 have
STRESS RADIOGRAPHS
all described bone fragments or ossification of the medial
retinaculum in recurrent dislocation of the patella. Because The previous techniques and measurements only reflect
these fragments are usually located distally near the at- the bone anatomy at rest. Abnormal values in asymptom-
tachment of the medial meniscopatellar ligament and may atic individuals are common. If the patella is subluxed or
represent an avulsion at this location, they may be hidden dislocated when the film is taken, this is important to note,
on the axial radiograph by an overlap with the wider
midpatellar distance. The fragments can be seen when the
x-ray beam is angled obliquely toward the apex of the
patella or the patella is otherwise spun (Fig 33).
Malghem and Maldague 52 described an axial view in
which the thighs are strapped together while a techni-
cian laterally rotates the tibia thus potentially subluxing
an unstable patella as the radiograph is taken. None of
40 control knees showed marked lateral subluxation,
whereas in 13 patients who had been operated on for
patellar instability, 3 had subluxation in the nonoperative
knee on plain radiographs and 10 were seen when the
lateral tibial rotation view was added.

Patellar Weight-Bearing View

Turner et a153 described a technique for taking the axial
view in the standing position and if full weight bearing
can be obtained and balance maintained through the
quadriceps contraction then this would seem to be a useful
adjunct in uncovering occult joint loss. Ahlback et a122 Fig 33. Radiograph of avulsion fragment from medial patella,

PLAIN PATELLOFEMORAL RADIOGRAPHS 147

 A B C

............ :.:+:.:....,

iiiiiiiiii iiiiiiitiiii i i i ...........

.: . . . . . . . . . . . . :.:.:.:.:+:.:+:.:.

ii!i~i!i!ii|iiiiiiiiii ............ .....

iiiiiiiiiiiliiiiiiiiii iiiiiiiiiiliiiiiiiiiii
Fig 34. (A) Lateral facet; (B) medial facet, medial knee up; (C) medial facet, medial knee down views of Maldague and
Malghem. 20

but when the patella is located normally but is disl0catable usually more horizontal with patella alta and vertical with
these measurements are of little or no value. Subluxation patella infera. The examiner supports the thigh to prevent
or dislocation invariably occurs with activity which gen- rotation while pressure is applied to the side of the patella
erates a stress to which the patella is subjected. For this with a rubber-padded block attached to a load cell (MED-
reason the author has used radiographs taken with stress metric Patella Pusher, San Diego, CA), which allows an
being applied to the patella, which are known as stress equal stress to be applied to both knees during all testing
radiographs. 55-60 (Fig 36). Muscle relaxation is imperative and occasionally
The estimation of patellar displacement as the patella is pain or apprehension prevent an adequate examination.
pushed out of the groove by the examiner is a common This can be performed during an examination under an-
tool used to diagnosis instability (Fig 36). Beginning in esthesia. In those with instability only in extension ade-
1982, the author began the routine use of radiographs to quate axial views taken in knee extension are not possible.
document patellar dislocation. The distance the patella can When the right and left knees of the healthy controls
be displaced from a reference line (Fig 31) reflects stability were stressed there was very little difference in the dis-
(ie, the integrity of the patellofemoral ligaments and the placement distance between the 2 knees (1.5 m m differ-
support of the trochlea). ence in the lateral direction and 1.2 mm in the medial
The author examined a group of asymptomatic volun- direction). The author then identified 3 clinical groups,
teers with radiographs taken with the knee flexed 35 ° and those who had a history and examination consistent with
the patella being displaced in both the medial and the lateral patellar dislocation and who had not had surgery
lateral directions. This view is taken with the knees flexed but who had pain, apprehension, and increased patellar
35 ° and supported on a frame used for axial views with
the tube above the patient and the x-ray plate perpendic-
ular to the beam and located anterior to the tibia. The tube
angle can be adjusted so the beam is tangent to the femur
and patella at their contact point (Fig 29). This angle is

Fig 35. Patellar spin has been can be calculated by measur- -- ,,. ".

ing the distance between points a and b on radiographs

taken with different degrees of knee flexion. Fig 36. Drawing of stress x-ray application.

148 ROBERT A. TEITGE

 Fig 37, Radiograph of medial instability shown by stress application (A) without stress and (B) with stress,
excursion when the patella was stressed in the lateral
direction but not in the medial direction; those who had
undergone a lateral retinacular release for anterior knee
pain and who were worse after surgery with pain, appre-
hension, and increased excursion of the patella when it
was pushed in the medial direction but not in the lateral
PLAIN PATELLOFEMORAL RADIOGRAPHS
direction; and those who had undergone a lateral retinacu-
lar release for the treatment of lateral patellar instability
and who were worse after surgery with pain, apprehen-
sion, and an increased patellar excursion in both the me-
dial and lateral directions. Measurements of patellar
height, congruence angle, lateral patellofemoral angle,
Fig 38. Radiographs of multidirectional instability shown
by stress application (A) without stress, (B) with stress
laterally, (C) with stress medially.
149
 T A B L E 1. Average Stress Measurements in the 4 Groups
Lateral Stress R/L Medial Stress R/L
Groups Differences (mm) Differences (rnm)
Healthy 1,5 1.2
Lateral instability 7.5* 0.1
Medial instability 0.5 10.3"
Multidirectional instability 9.5* 10.8"
*P < .0001
s u l c u s a n g l e , a n d lateral a n d m e d i a l c o n d y l a r h e i g h t s
w e r e m e a s u r e d as w e l l as t h e c o m p a r i s o n of p a t e l l a r
e x c u r s i o n in b o t h the m e d i a l a n d l a t e r a l d i r e c t i o n s for
b o t h t h e i n v o l v e d k n e e a n d the o p p o s i t e a s y m p t o m a t i c
k n e e . M e a s u r e m e n t s in all 3 g r o u p s w e r e n o t e a b l y dif-
f e r e n t f r o m the h e a l t h y c o n t r o l s a n d w e r e u s e d to d e f i n e
t h e g r o u p s as l a t e r a l i n s t a b i l i t y , m e d i a l i n s t a b i l i t y , a n d
m u l t i d i r e c t i o n a l i n s t a b i l i t y ( F i g u r e s 2A, B, 37, 38). T a b l e
1 s u m m a r i z e s t h e d i s p l a c e m e n t d i f f e r e n c e s in all 4
g r o u p s . T h e c o n g r u e n c e a n g l e w a s s i g n i f i c a n t in t h e
l a t e r a l i n s t a b i l i t y g r o u p at P < .003, h o w e v e r o n l y 8 or
27 p a t i e n t s (30%) h a d t h e d i a g n o s i s c o n f i r m e d b y a n
a b n o r m a l c o n g r u e n c e angle. T h e lateral p a t e l l o f e m o r a l
a n g l e w a s s i g n i f i c a n t in t h e lateral i n s t a b i l i t y g r o u p at
P < .043, h o w e v e r o n l y 6 or 27 p a t i e n t s (22%) h a d t h e
d i a g n o s i s c o n f i r m e d b y a n a b n o r m a l lateral p a t e l -
l o f e m o r a l a n g l e . T h e s u l c u s a n g l e w a s s i g n i f i c a n t in t h e
lateral i n s t a b i l i t y g r o u p at P < .01, p a t e l l a r h e i g h t w a s
d i f f e r e n t in b o t h t h e lateral i n s t a b i l i t y g r o u p (P < .4)
a n d in the m u l t i d i r e c t i o n a l g r o u p (P < .01). N o o t h e r
m e a s u r e m e n t s w e r e s t a t i s t i c a l l y significant.
T h e stress r a d i o g r a p h i c test w a s m o r e a b n o r m a l t h a n
a n y o t h e r test. T h e d i a g n o s i s of m e d i a l p a t e l l a r instabil-
ity w a s o n l y c o n f i r m e d b y stress r a d i o g r a p h s ; n o o t h e r
m e a s u r e m e n t r e v e a l e d a n y a b n o r m a l i t y in this g r o u p . It
w a s c o n c l u d e d t h a t a p o s i t i v e p a t e l l a r stress r a d i o g r a m
w a s a m o r e a c c u r a t e test of p a t e l l a r i n s t a b i l i t y t h a n a n y
o t h e r r a d i o g r a p h i c m e a s u r e m e n t . T h e r e are s o m e p a -
tients w i t h u n s t a b l e p a t e l l a o n stress r a d i o g r a p h s w h o
are a s y m p t o m a t i c a n d t h e r e are s o m e p a t i e n t s w h o m a y
b e u n s t a b l e w h o h a v e n e g a t i v e stress r a d i o g r a p h s b u t
stress r a d i o g r a p h s r e m a i n a r e l i a b l e m e t h o d of q u a n t i -
t a t i n g a f o r c e - d i s p l a c e m e n t m e a s u r e m e n t of t h e p a t e l -
l o f e m o r a l joint.
CONCLUSION
After a h i s t o r y a n d p h y s i c a l e x a m i n a t i o n p l a i n radio-
g r a p h s f o r m a n e c e s s a r y baseline s t u d y to e v a l u a t e the
p a t e l l o f e m o r a l joint. Plain films m a y reveal the v a r u s a n d
v a l g u s of the knee, the h e i g h t of the patella, the s h a p e of
the t r o c h l e a a n d patella, the l o c a t i o n of the patella relative
to the t r o c h l e a at g r e a t e r t h a n 20 ° to 40 ° of k n e e flexion,
loss of joint space, a n d w i t h stress the side d i s p l a c e m e n t
p o t e n t i a l of the patella a n d its instability (dislocatability).
Plain films d o n o t reveal limb rotation, foot position, pre-
cise c o n d i t i o n of the articular cartilage, a n d c o n d i t i o n of
the m u s c l e s or t e n d o n s .
150
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