Paper 04: Differences in the Severity and Location of Patellofemoral Cartilage Damage Between Instability Patients With and Without Patella Alta
Authors: Johnson Emma , Campbell Michael , Reddy Manoj , Paul Ryan , Erickson Brandon , Tjoumakaris Fotios , Freedman Kevin , Bishop Meghan 
Published: March 2023

Objectives: Patellar instability is estimated to affect approximately 150 out of 100,000 adolescents between the age of 14-18 years old, a rate which is expected to increase over time. Several risk factors have been associated with patellar instability such as younger age, trochlear dysplasia and patella alta. Patella alta is defined as a superiorly-positioned patella, commonly determined using the Caton-Deschamps Index (CDI), with a ratio of 1.3 or greater indicative of patella alta. Patients with patella alta are approximately 2.5-4.0 times more likely to suffer a recurrent patellar dislocation, which is thought to be due to the changes in biomechanics seen in patella alta. Differences in chondral injury in patients with patellar instability between patella alta and patella norma has not been evaluated. Our objective was to retrospectively analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta. Methods: Patients with patellar instability who underwent patellar realignment surgery at a single institution with a preoperative MRI within 3 months were included. After measurement of CDI on MRI, patients were divided into patella alta (CDI>1.3) and patella norma groups. To quantify cartilage defect severity, the Magnetic Resonance Imaging Score and Classification system (AMADEUS) was utilized by two sports medicine clinical fellows. The AMADEUS score characterizes cartilage defect size, defect depth, presence of subchondral bone defects, and bone marrow edema. The scale is scored 0-100 with 100 indicating no cartilage damage. In patients with multiple cartilage defects on MRI, each defect was characterized and analyzed independently. Continuous variable data were reported as means with standard deviations and categorical data reported as frequencies with percentages. The distribution of data was assessed with the Shapiro-Wilk test. Continuous data were assessed with the Student’s t test and Mann-Whitney U tests as appropriate. Categorical data were assessed with chi-squared analysis. The threshold for significance was set to p < 0.05. Multivariate analysis was conducted with defect depth, bone edema, and AMADEUS score as the dependent variable. All statistical analyses were performed with R Studio (Version 3.6.3, Vienna, Austria). Results: One hundred-twenty-one patients were divided into patella alta (n=50) and patella norma (n=71). The groups did not significantly differ in sex ratio, age at MRI, body mass index (BMI), mean reported number of prior dislocations, or mean interval between first reported dislocation and date of MRI. Thirty-four (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects ( P=0.625) with no statistically significant difference in the size of the chondral defects between the groups ( P=0.419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs. 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%)( P=0.859). The patella alta group had a smaller proportion of patients who had full thickness defects in comparison to the patella norma group (60% vs 82%; P=0.030). The overall AMADEUS score for the patella alta group was higher (68.9 vs. 62.1; P=0.023) compared to the patella norma group, indicating superior articular cartilage status. When looking at a multivariate regression using AMADEUS score as the dependent outcome, female sex shows an increase in AMADEUS score with a beta estimate of 11.96 ( P<0.001). Female sex also shows a higher probability of having no defect associated bone marrow edema (Odds ratio:6.7; P=0.010), and a higher probability of partial-thickness defect rather than full-thickness (Odds ratio:3.9; P=0.004). Age, BMI, interval between dislocation and MRI, and reported number of dislocations were not found to be associated with total AMADEUS score, probability of having defect-associated bone marrow edema, or defect depth. Conclusions: There is a high percentage of cartilage injury in patients with a history of patellar instability with over 60% of patients showing cartilage damage on MRI. Patients with normal patellar height have a higher frequency of full thickness cartilage defects and more severe injury compared to those with patella alta. The location of cartilage injury between alta and norma is similar, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency.