ISSN: 2320-5407 Int. J. Adv. Res.

10(11), 1048-1057

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/15764
DOI URL: http://dx.doi.org/10.21474/IJAR01/15764

RESEARCH ARTICLE
A MORPHOMETRIC STUDY OF PATELLA IN LUCKNOW REGION

Kanchan Bisht, Baibhav Bhandari, Swati Saxena, Garima Sehgal, Rashmi Malhotra and Yashu Bhardwaj
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Patella is the largest sesamoid bone which develops in
Received: 28 September 2022 the tendon of Quadriceps femoris muscle and protects the front of knee
Final Accepted: 30 October 2022 joint. It has gained anatomical, clinical & forensic significance due to
Published: November 2022 its vital role in patellofemoral mechanics and its property of resistance
to post mortem changes.
Key words:-
Sesamoid, Prosthesis, Anthropometric, Aims and Objectives: Our study aims to measure the various
Facet, Vernier Calipers, Parameters dimensions of left and right human patella which can be useful for the
manufacture of patellar prosthesis, better suited to Indian population, in
contrast to already available prosthesis which are mostly based on the
western anthropometric measurements.
Methods: The study involves 100 dry human patellae, 50 each from
left and right sides. Total patellar height, maximum height of articular
surface, maximum width, maximum thickness, shape, width of medial
and lateral articular facets of patella were measured using digital
Vernier calipers. Mean and standard deviation were calculated for each
parameter for left and right sides and the data was analyzed using
SPSS.
Results: The mean of patellar width on left side came out to be 41.65±
2.78, while for right side, the mean of patellar width was observed to be
42.83± 3.02. A statistically significant difference was observed in
patellar width of left and right sides (p= 0.044).
Conclusion: Anthropometric study of patella in India can thus be
helpful in designing femoropatellar prosthesis for our population
leading to better post-operative outcome.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
The patella, also referred to as knee cap, is the largest sesamoid bone, embedded in the tendon of Quadriceps
femoris. It has three borders- superior, lateral & medial and two surfaces-anterior & posterior. The superior border
of patella is called base and is thicker compared to the medial & lateral borders, which converge at the apex distally.
The posterior surface comprises upper articular part and lower non-articular part. The articular part is divided by a
smooth vertical ridge, into medial and lateral facets; lateral usually being larger. Each facet can further be divided by
faint horizontal lines into equal thirds. [1] Another facet is separated by a narrow strip along the medial border of the
patella which comes in contact with the medial femoral condyle in complete flexion. [2]

Patella increases the angle at which quadriceps femoris muscle acts, thus enhancing its leverage and protecting the
front of the joint. Patella is involved in various postures like sitting and squatting. So depending on cultural &
ethnic practices, several modifications can be observed in this sesamoid bone. [3]

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On the basis of width and convexity of medial and lateral articular facets (MAF & LAF), Wiberg divided patella
into 3 categories. Type I patella is defined as a patella whose MAF and LAF widths are concave and equal. Type II
patella, which is the most common type, is one in which the width of the MAF is flat or slightly convex and smaller
than the width of the LAF. In Type III patella the width of the MAF is convex and considerably smaller than the
width of the LAF.Another classification was proposed by Koyunku et al. according to which, patella with equal
width of MAF & LAF belonged to Class A, patella with WMAF smaller than WLAF belonged to Class B and
patella with WMAF greater than WLAF belonged to Class C. [4]

Depending on the variation in their position, patella can be named as patella alta (if placed higher) or patella baja (if
placed lower). The former carries risk for dislocation or subluxation of patella while the latter is more susceptible for
tendon rupture or neuromuscular disorder. [5]

Patella has gained anatomical, clinical & forensic significance due to its vital role in patellofemoral mechanics and
its resistance towards post mortem changes.For accurate sex determination from skeleton, ideally complete skeleton
should be available. However, in most of the cases, it is not possible and in such cases, patella can be useful for sex
determination. [6] It has been observed that patella is resistant to post-mortem changes, due to which it can be used
for personal identification. Measuring the dimensions of patellae can be useful for the determination of the size of a
patellar implant. [1]The knowledge of patellar thickness for example could be a guide for surgeons in estimating the
extent of depth of resection in total knee replacement. [2]

The patellar prostheses used currently in India are based on the anthropometric measurements of Western
population, due to which they are not perfectly suitable for Indian people. Measuring the anthropometric dimensions
of patella of Indian population from different regions can enable us to manufacture patellar prosthesis with better
accuracy leading to better post-operative results. [7]Our present study, conducted in Lucknow region of Uttar
Pradesh, is an attempt to contribute to this endeavour.

Material and Methods:-

Our study included 100 dry human patella bones (Left patellae=50, Right patellae=50), obtained from Department
of Anatomy of the institute. The side determination of these bones were done by keeping each of them on a plane
surface, in its anatomical position and observing the side to which its lateral articular facet rests. Seven parameters
of each patella were measured using Digital Vernier calipers, namely Total patellar height (H1), Maximum height of
articular surface (H2), Patellar width (PW), Patellar thickness (PT), Width of medial articular facet (WMAF), Width
of lateral articular facet (WLAF) and Shape of patella. Description of these parameters has been provided in Table
1. Left and right sided patellae were measured separately for these seven parameters, followed by the calculation of
maximum, minimum, mean and standard deviation of patellae of each side.

We have applied Statistical Package for Social Science (SPSS) version 21.0 for statistical analysis of the data and to
find out if any significant difference exists between right & left sided patellae.

Observation & Result:-

Total 100 dry patellae were taken and the above mentioned seven parameters were measured using digital Vernier
calipers separately for right & left sides as shown in Fig. 1, 2 & 3. Table 2represents the comparative analysis of
maximum, minimum, mean and standard deviation of different parameters of right & left patellae. The mean of total
patellar height in left and right sided patella came out to be 40.02 ± 2.68 and 40.21± 2.93 respectively. The
calculated mean for maximum height of articular surface was 30.69± 1.65 in left sided & 31.26± 3.17 in right sided
patella. The mean for patellar width on left side was calculated as 41.65± 2.78 while 42.83± 3.02 on right side. This
difference in patellar width was found to be statistically significant (p= 0.044) by t-test. In left sided patella, mean
for patellar thickness was 20.14± 1.51 and in right sided patella it was 20.31± 1.49. For width of medial articular
facet, the mean on left & right sides were 21.88± 1.52& 22.38± 1.77 respectively. Similarly, for width of lateral
articular facet, the calculated mean on left & right sides were 25.78± 1.94& 25.87± 2.32 respectively.

Table 3 shows the left & right patellae divided into three types according to Koyunku’s classification. Out of 50 left
patellae, six (12%) belonged to type A, i.e. width of their MAF & LAF were almost equal, 43 (86%) belonged to
type B, i.e. their WMAF were observed to be smaller than WLAF and one (2%) belonged to type C, i.e. WMAF
greater than WLAF, as represented by a pie chart in Fig. 4.

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Out of 50 right patellae, five (10%) belonged to type A, 42 (84%) belonged to type B and three (6%) belonged to
type C according to Koyuncu’s classification, as represented by a pie chart in Fig. 5.

In Fig. 6(a), width of medial and lateral articular facets are almost equal in patella, hence represents type A patella.
In Fig. 6(b), first two patellae represent type B (WMAF<WLAF) while latter two patellae represent type C
(WMAF>WLAF).

In Table 4, we have classified the patellae based on their shape as triangular, rounded or irregular. Out of 50 right
sided patellae, 30 (60%) were triangular, 15 (30%) were rounded and five (10%) were found to be irregular. Out of
50 left sided patellae, 37 (74%) were triangular, 10 (20%) were rounded and three (6%) were irregular in shape. Fig.
7represents different shapes of patellae included in the study.

Discussion:-
In India, the patellar prostheses used are mostly based on the anthropometric measurements of Western population,
due to which they are not perfectly suitable for Indian people. Manufacturing patellar prosthesis based on Indian
anthropometric measurements can lead to better results. [7] In this study, we have attempted to understand the
morphometry of patella in Lucknow population of India by measuring its various dimensions and compare it with
similar studies done in different population.

Most of the studies conducted on various populations in India were in view that Indian population has smaller
patellar dimensions as compared to those of Western or African population. [7], [8] The present study is also in
agreement with this view as represented by the comparative analysis with different ethnic populations in Table 5.

In our study, the mean patellar width on left side was 41.65± 2.78 and 42.83± 3.02 on right side. The values were in
accordance with the studies conducted by Kayalvijhi et al. [9] (42.1± 3.1) and Jain et al. [10](43.35± 4.10) on North
Indian population. This was slightly less compared to the studies conducted by Shang Peng et al. [11](44.13± 3.96) in
2014 on Southern Chinese population, Olateju et al. [4](45.14mm) in 2013 on South African populationand
markedly lesser compared to the study conducted by Baldwin et al.[12](50.30±5.65) in 2005 on American population.

In the present study, the mean of WMAF on left & right sides were found to be 21.88± 1.52 and 22.38± 1.77
respectively which was slightly higher than the studies conducted on Chinese, Koreans & Western population
(19.03mm, 18.4mm and 18.8mm respectively). But it was in accordance with the study conducted by Chapparwal et
al. on the population of Madhya Pradesh, where WMAF was found to be 20.69 mm. However, the mean of WLAF
according to our study was 25.78± 1.94 and 25.87± 2.32 for left & right sides respectively, which was comparable
with previous studies: 25.1mm in Chinese, 23.3mm in Koreans and 25.3mm in Western population respectively. [1]

Chapparwal et al. in their study on population of Madhya Pradesh, observed 82% patella as triangular (R: 80% & L:
84%), 12% rounded (both R & L) and 6% irregular in shape (R: 8% & L: 4%). [3] A study done on Brazilian dry
patella by Borges et al.in 2016 found 67.6% patellae were triangular, 21.6% oblong and 10.81% were irregular.
[13]
These findings were almost similar to that of ours where among the right patellae, 60% were triangular, 30% were
rounded & 10% were irregular and among left patellae, 74% were triangular, 20% were rounded & 6% were
irregular in shape.

According to a study conducted by Koyuncu et al. in Turkey, 19.5% patellae belonged to Type A (WMAF=WLAF),
50% belonged to Type B (WMAF<WLAF) and 30.5% patellae belonged to Type 3 (WMAF>WLAF). [14]However
in our study, among the right sided patellae, 10% were of Type A, 84% were of Type B and 6% belonged to Type C
variety. Similarly, among the left sided patellae, 12% were of Type A, 86% belonged to Type B and 2% belonged to
Type C variant of patella.

In the present study, we have not classified the patellae as male or female but few previous studies have realised the
significance of this sesamoid bone in sexual dimorphism. Akhlagi et al. conducted a prospective study on 113
patellae (57 male & 56 female) collected from fresh cadavers of Iranian population and observed that all the
dimensions were larger in males than females, confirming the high accuracy of using patellar dimensions for sex
determination in case of unavailability of other useful skeletal sample, like in cases of mass disasters. [15]Similar
finding was reported by Kumar et al. in their MRI based study where males of North Indian population were found
to have larger patellae than their female counterparts. [19]

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On comparing the various parameters of left & right sided patellae in our study, no statistically significant difference
was seen except for patellar width which was found to be slightly greater on right side (mean= 42.83± 3.02) than on
left side (mean= 41.65± 2.78) (p=0.044). This might be due to predominant use of one limb leading to better muscle
tone on that side which can apparently alter the dimensions of patella. Other factors like postural & ethnic habits
could also be responsible for the same. [4] Further studies could be helpful in this regard for deriving any conclusion.

Conclusion: -
Anthropology, Comparative anatomy, Forensic Medicine and Orthopaedic surgery are among the disciplines of
Medicine which can be benefitted from our findings related to patella. Indian population exhibit smaller dimensions
of patella as compared to that of Western population. Due to this disparity, most of the available prosthesis, which
are based on the anthropometric measurements of Western population, may not be suitable for Indian population and
could rather lead to inconvenience like pain in knee with restricted movements. Thus, measuring anthropometric
patellar dimensions from different regions of India can enable us to design patellar prosthesis with better accuracy
and hence result in better surgical outcome for the patients who are operated for chronic knee pain or disorders of
patellofemoral joint. It can also prove to be useful for estimation of sex in forensic science when no other
osteological evidence is available.

Figure Legends:
Fig. 1 (a) & (b):- Measurement of total patellar height (H1).

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Fig. 2:- (a) Measurement of maximum height of articular surface (H2)

(b) Measurement of patellar width (PW)
(c) Measurement of patellar thickness (PT)

Fig. 3:- (a) Measurement of width of medial articular facet (WMAF).

(b) Measurement of width of lateral articular facet (WLAF).

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Fig. 4:- Distribution of left sided patella.

Fig. 5:- Distribution of right sided patella.

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Fig. 6: (a) Koyuncu’sType A patella

(b) (i) & (ii): Koyuncu’s Type B patellae
(iii) & (iv): Koyuncu’s Type C patellae

Fig. 7:- Classification according to shape of patella.

Table 1:- Description of parameters of patella.

PARAMETER ABBREVIATION DESCRIPTION
Total patellar height H1 Linear distance between superior border and
apex.
Max. height of articular surface of H2 Maximum height of articular surface on the
patella posterior surface of patella.
Patellar width PW Linear distance between medial & lateral
borders.
Patellar thickness PT Linear distance between anterior surface &
median ridge.
Width of medial articular facet WMAF Max. width from medial border to median

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ridge.
Width of lateral articular facet WLAF Max. width from lateral border to median
ridge.

Table 2:- Anthropometric measurements of right & left patellae.

Measurement Side Min. Max. Mean S.D. Significance of
difference (t-
test)
Total patellar Left 34.18 46.25 40.02 2.68 ‘t’=0.336;
height (H1) Right 34.31 47.17 40.21 2.93 p=0.738
Max. height of Left 27.33 34.14 30.69 1.65 ‘t’=1.119;
articular surface Right 22.85 43.20 31.26 3.17 p=0.266
(H2)
Patellar width Left 37.49 51.56 41.65 2.78 ‘t’=2.036;
(PW) Right 35.71 48.67 42.83 3.02 p=0.044
Patellar Left 16.69 23.81 20.14 1.51 ‘t’=0.547;
thickness(PT) Right 16.48 24.01 20.31 1.49 p=0.585
WMAF Left 18.91 25.01 21.88 1.52 ‘t’=1.490;
Right 18.16 26.15 22.38 1.77 p=0.140
WLAF Left 21.72 30.89 25.78 1.94 ‘t’=0.210;
Right 20.95 31.44 25.87 2.32 p=0.834

Table 3:- Koyuncu’s classification of patella.

Class Left Patella Right Patella
No. % No. %
A 6 12.0 5 10.0
B 43 86.0 42 84.0
C 1 2.0 3 6.0
²=1.103 (df=2); p=0.576

Table 4:- Classification according to shape of patella.

Shape Left Patella Right Patella
No. % No. %
Triangular 37 74.0 30 60.0
Rounded 10 20.0 15 30.0
Irregular 3 6.0 5 10.0
²=2.231 (df=2); p=0.328

Table 5:- Comparative analysis with similar studies on different populations.

STUDY SAMPLE & POPULATION PATELLAR PATELLAR PATELLAR
SUBJECTS HEIGHT THICKNESS WIDTH
Mean SD Mean SD Mean SD
Baldwin et al.[12] 35 Adult American 38.60 2.47 23.90 2.30 50.30 5.65
(2005) patellae (Total
Knee
Arthroplasty)
Yooet al.[16] MRI of 163 Japanese 44.6 3.7 22.3 1.9 45.8 1.9
(2007) adults
Iranpour et al[17] 3-D CT scan British 34.3 4.8 22.4 2.3 44.8 4.8
(2008) from 37 adults
Agnihotri G et Dry bones North Indian 35.8 - 16.95 - 37 -
al[8]
(2013)
Olateju et al[4] 46 Adult South African 43.7 3.6 23.9 2.1 45.1 3.9

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(2013) Cadaveric
patellae
Shang Peng et al. CT scan from 40 Southern Chinese 39.94 3.68 22.72 1.81 44.13 3.96
(2014)[11] Chinese
volunteers
Kayalvizhi I et al 62 Dry bones North Indian 42.9 4.8 19.7 1.1 42.1 3.1
[9]
(2015)
Muruganet al.[1] 65 adult dry Indian 38.07 3.7 18.29 1.73 38.58 3.81
(2017) patella (Pondicherry)
Jain R et al. [10] 200 Normal X North Indian 41.67 4.01 19.22 2.19 43.35 4.10
(2019) ray
Parameshet al.[7] 66 Dry bones Indian 40.00 - 21.3 - 40.2 -
(2020) (Maharshtra&Tamilnadu)
Katchyet al.[18] 60 cadaveric Nigeria 46.1 0.47 26.6 0.15 46.9 0.29
(2020) patellae
Baisakhet al.[20] 60 dry bones Indian 36.75 - 18.39 - 36.58 -
(2021) (Odisha)
Present study 100 dry bones Indian 40.11 2.81 20.23 1.5 42.24 2.9
(2021) (Lucknow)
Taj et al.[21] 50 dry bones Indian 40.7 - 20.3 - 41.2 -
(2022) (Chennai)

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