Intra- & Inter- Observer Variation in the Measurement of Patellar Height After Total Knee Replacement Using Digital

Radiography
BA Rogers1, NJ Little2 Peters Hospital, Chertsey, England 2Waikato Hospital, Hamilton, New Zealand
1St

SICOT, Hong Kong, August 2008

Introduction
Patellar height crucial for extensor mechanism Patella alta (high) & baja (low) associated with pathology Difficult to define femoral condylar groove radiologically Several ratios relate patella to proximal tibia

Patellar Height Measurement

Insall-Salvati

Mod. Insall-Salvati

Blackburne-Peel

Caton-Deschamp

Introduction
Figgie et al. (J. Bone and Joint Surgery. 1986;68-A:1035-40)
N=101 Associated poor function & Ant knee pain with patella baja

Koshino et al. (J. Arthroplasty.1990;5:323-327.)

N=94, using Insall-Salvati 65% incidence of patella baja post TKA (Kinematic)

Introduction
Grelsamer et al. (J. Arthroplasty. 2002;17:66-9.)
Accounting for poly insert in TKA Proximal transfer of joint line aka Pseudo-baja Concluded
true patellar baja cannot be measured post-TKA using either Blackburne-Peel or Caton-Deschamp

Aim
This study compares reliability of all four patellar height ratios pre- and post- total knee arthroplasty 1. Using film and digital imaging 2. Measuring inter- and intra- observer correlation

Methods
48 patients TKA for OA or RA Kinemax (Howmedica) or PFC (DePuy) Revision or previous HTO - excluded 2 examiners
Identical conditions Sequential measurement

Methods
Digital & Plain imaging Lateral knee XR, 20 + flexion IS, mod IS, BP & CD ratios measured Pre- & Post- TKA Repeated at 3 months 3072 measurements per examiner Statistical analysis: intra-class correlation coefficient (ICC)

48 Knees : Osteoarthritis or Rheumatoid Arthritis

2 Independent Observers

Digital Imaging Pre-Op Patellar Height Measurement Plain XR films

1. Caton Deschamps 2. Blackburn Peel 3. Insall Salvati 4. Mod Insall - Salvati

Repeated at 3 months

PFC / Kinemax TKA

Digital Imaging Post-Op Patellar Height Measurement Plain XR films

1. Caton Deschamps 2. Blackburn Peel 3. Insall Salvati 4. Mod Insall - Salvati

Repeated at 3 months

Results
Digital imaging superior Blackburn-Peel & Caton- Deschamps higher ICC, especially with digital Greater improvement with digital seen with Insall-Salvati ratio Intra- & Inter observer results similar

Results
0.25 0.2 Change in ICC 0.15 0.1 0.05 0 IS mod IS BP CD

Pre-TKR Post TKR

Improvement in intra class correlation for inter-observer error using digital radiography both pre- and post- TKR

Discussion
Magnification & contrast adjustment More accurate identification of landmarks Especially tibial tuberosity (IS & mIS)

Multiple Anterior Tibial Notches

Articular surface of patella not visible Convex Anterior Tibial Surface

Assessment of films showing patellar tendon insertion separate from anterior tibial notch or flare
N=15 Range of patella tendon insertion * Pre-Op/mm Post-Op/mm

-3 to +10

-4 to +13

+ve = insertion proximal to notch, -ve = distal

Example of patella tendon inserting proximal to anterior tibial notch

Discussion
Poly insert makes BP & CD methods more reliable post TKR No improvement for IS & mIS methods post TKR since directly measure patella tendon

Conclusion
1. The theoretical advantages of the Insall-Salvati and modified Insall-Salvati ratios, measuring true patellar height following TKA, need to be balanced against their inferior correlation in comparison to other ratios

2.

Digital imaging affords a non-uniform improvement with the Caton-Deschamps and Blackburn ratios, when measured using digital radiography following TKR, exhibiting a very high correlation.

Thank you