The Journal of Arthroplasty Vol. 16 No.

6 2001

Kinematics of the Patellofemoral Joint in

Total Knee Arthroplasty

James B. Stiehl, MD,* Richard D. Komistek, MD,† Douglas A. Dennis, MD,†

and Peter A. Keblish, MD‡

Abstract: Sagittal plane patellofemoral kinematics was determined for 81 subjects

while performing a weight-bearing deep knee bend under fluoroscopic surveillance.
Fourteen normal knees, 12 anterior cruciate ligment (ACL)– deficient knees, and 55
total knee arthroplasties (TKAs) were assessed. Of TKAs, 39 had resurfacing with a
dome-shaped patella, 8 had resurfacing with an anatomic mobile-bearing patella,
and 8 were unresurfaced. TKA patellae experienced more superior patellofemoral
contact and higher patellar tilt angles compared with the normal knees and ACL-
deficient knees (P ⬍ .05). Patellofemoral separation at 5° (⫾3°) extension was seen
in 86% cruciate-retaining and 44% cruciate-stabilized TKAs and 8% ACL-deficient
knees but not in the normal knees or mobile-bearing TKAs (P ⬍ .05). The patellar
kinematic patterns for subjects having a TKA were more variable than subjects
having either a normal knee or an ACL-deficient knee. Kinematic abnormalities of
the prosthetic patellofemoral joint may reduce the effective extensor moment after
TKA. Key words: total knee arthroplasty, patella, kinematics, biomechanics.

Complications resulting from patellofemoral resur-
facing are an important cause of revision in total
knee arthroplasties (TKAs) [1–12]. In many cases,
poor TKA kinematics and abnormal forces exerted
on the prosthetic components may play a key role
in wear, malalignment, or accelerated failure from
associated design flaws [13–22]. Such complications
have induced many surgeons to avoid patellar re-
surfacing in patients with osteoarthritis and good
remaining articular cartilage [23–27]. Studies indi-
cate, however, an increased incidence of revision
From the *Midwest Orthopaedic Biomechanical Laboratory, Colum-
bia Hospital, Milwaukee, Wisconsin; †Rose Musculoskeletal Research
Laboratory, Denver, Colorado, and ‡Lehigh Valley Hospital, Allentown,
Pennsylvania.
Submitted December 30, 1999; accepted January 18, 2001.
Funds were received in partial or total support of the research
material described in this article from DePuy, Johnson & John-
son Orthopaedics, Inc.
Reprint requests: James B. Stiehl, MD, 575 W. Deluxe Park-
way, #204, Milwaukee, WI 53212. E-mail: jbstiehl@aol.com
Copyright © 2001 by Churchill Livingstone威
0883-5403/01/1606-0004$35.00/0
doi:10.1054/arth.2001.24443
without resurfacing, and secondary resurfacing
may prove inferior to resurfacing at the time of
TKA [28 –32].
Mechanical analysis of the extensor mechanism
of the knee indicates that the levering action of the
patella is as important as its function as a spacer.
Models have predicted substantial changes in force
transmission through knee flexion by altering pa-
tellar ligament length and rotation in relation to the
tibial axis. The effective moment arm of the exten-
sor mechanism reflects not only the magnitude of
forces in the quadriceps and patellar ligaments, but
also their orientation[33–37].
Most previous experimental studies of the patella
have involved in vitro analyses or have not tested
the knee in the weight-bearing mode. The present
study investigates in vivo weight-bearing patel-
lofemoral kinematics in normal knees and in knees
after TKA with and without patellar resurfacing by
determining patellofemoral contact positions and
angular patellar tilt in relation to the sagittal axis of
the proximal tibia.

706
 Patellofemoral Joint Kinematics • Stiehl et al. 707

Methods

Using dynamic in vivo fluoroscopy with a 2-di-

mensional computer digitization technique, patel-
lofemoral contact position, patellar tilt angle, and
patellofemoral separation were determined for 81
patients [38,39]. Fourteen subjects had normal
knees, 12 had anterior cruciate ligament– deficient
(ACLD) knees, and 55 patients had TKAs. Of the
TKA group, 14 had been implanted with a posterior
cruciate–retaining (PCR) TKA, 25 had a posterior
cruciate–substituting (PS) TKA, and 16 had a mo-
bile-bearing posterior cruciate–sacrificing (MB)
TKA. All PCR TKAs and PS TKAs had patellar re-
surfacing, whereas 8 MB TKAs were resurfaced,
and 8 were unresurfaced. The prosthetic designs
chosen for the study were the Press Fit Condylar
PCR and PS designs (Johnson & Johnson, Inc,
Raynham, MA) and the Low Contact Stress (LCS)
rotating platform prosthesis (Depuy, Inc, Warsaw,
IN). Great care was taken to make symmetric cuts of
the patella to a hockey puck shape with an average
thickness of 14 to 15 mm. The final patellar thick-
ness after resurfacing was within 2 mm of the
presection distance.
All surgical implantations were performed by 2 Fig. 1. A schematic detailing the points digitized on each
surgeons (P.A.K., D.A.D.) using standardized surgi- fluoroscopic image. See text for details.
cal techniques. All patients with TKA were con-
sidered clinically successful with excellent clinical
rating scores and without significant pain or mea-
surable instability. Fluoroscopic analysis was done
by asking patients to stand with the knee in full The contact point between the patella and the
extension and perform 3 weight-bearing deep knee femur was determined by initially magnifying the
bends. Sagittal plane fluoroscopy was done as the fluoroscopic image by a factor of 3.5. The closest
radiology technician carefully centered the knee on distance between the most anterior portion of the
the screen. femoral component and the most posterior osse-
ous portion of the patella was denoted as the
contact point, point PF. The fluoroscopic image
Patellofemoral Contact Position was reduced back to normal size, and the distance
The contact position between the femur and pa- between the patellar mass center and the patel-
tella was determined in the sagittal plane using lofemoral contact point was measured. This mea-
2-dimensional computer digitization. Designated sured distance was scaled by a 1-inch metal ball
points on the femoral, tibial, and patellar compo- attached to the patient’s leg. This calibrated dis-
nents were digitized with respect to the newtonian tance was denoted as Q, the actual distance of the
reference frame (Fig. 1). Initially, points P1, P2, P3, contact point from the patellar mass center. A
and P4 were digitized on the patella at 0°, 30°, 60°, patellofemoral contact point superior to the pa-
and 90° of knee flexion. Two lines were con- tellar mass center was denoted as positive, and
structed, the first line connecting points P1 and P2 contact inferior to the patellar mass center was
and the second line connecting points P3 and P4. denoted as a negative distance. Although there
The midpoints of the lines P1–P2 and P3–P4 were are 2 contact regions observed on the lateral
found and denoted as points P5 and P6. After a line and medial condyles as knee flexion proceeds,
was constructed between points P5 and P6, the the patellofemoral contact, point PF, represented
midpoint of this line was determined and denoted the estimated midpoint of the contact regions
as the patellar mass center, point Pmass. in the sagittal plane.
708 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
Patellar Tilt Angle
At 0°, 30°, 60°, and 90° of flexion, points T1 and
T2 were digitized at the anterior margin of the tibial
plateau and the anterior cortex of the tibial shaft. A
line connecting points T1 and T2 was denoted as the
longitudinal axis of the tibia. The angle between the
longitudinal axes of the patella and tibia was mea-
sured and denoted as the patellar tilt angle. If the
longitudinal axis was anterior to the longitudinal
axis of the tibia, the patellar tilt angle was denoted
as positive and referred to as patellar extension. If the
longitudinal axis of the patella was posterior to the
longitudinal axis of the tibia, the patellar tilt angle
was denoted as negative and referred to as patellar
flexion.
Patellofemoral Separation
Patellar components were fixed in the trochlear
groove of femoral components. The distance be-
tween the most anterior portion of the femoral
condyle and the dorsal portion of the flat-surfaced
patellar component was measured and denoted as
distance D (Fig. 2). Fluoroscopy images at full ex-
tension only were analyzed by measuring the dis-
tance (⌬) between the most posterior portion of the
patellar component and the most anterior portion
of the femoral component. The amount of patel-
lofemoral separation was determined from the
equation, ⌬ ⫺ D, then multiplied by the magnifica-
tion conversion factor of 3.5. Patellar prosthetic
thickness was known in all cases but was not fig-
ured into this calculation. When patellofemoral
separation was observed in a subject, subsequent
fluoroscopy images were viewed to determine the
angle of knee flexion when the patella comes into
contact with the femur.
Fig. 2. Implant compo-
nents (left) and a fluoro-
scopic image (right) show-
ing the technique used to
determine patellofemoral
separation.
Error Analysis
An error analysis was conducted using an appa-
ratus that allowed for angles and distances to be
changed in increments of 0.01° and 0.01 mm. Five
implanted cadaver patellae were oriented into 18
different combinations of patellar tilt, separation,
and patellofemoral contact points (Fig. 3). Although
the analysis determined 2-dimensional patellar ki-
nematics, the cadaver patellar and femoral compo-
nents were abducted, adducted, internally rotated,
and externally rotated relative to each other to
simulate the out-of-plane rotations of the in vivo
knee. The determined errors were 0.52° for patellar
tilt, 0.71 mm for patellofemoral contact, and 0.38
mm for patellar separation.
Results
Patellofemoral Contact Position
The patellofemoral contact patterns were similar
for all knee types (Fig. 4, Table 1). At full extension,
the patellofemoral contact position was inferior to
the mass center of the patella for all knees except
for the resurfaced MB TKA (P ⬍ .05). For the
normal and ACLD knees, the average distance from
the contact position to the patellar mass center was
⫺8 mm, whereas subjects having a PCR and PS
fixed bearing and MB resurfaced TKAs were more
superior at ⫺1, ⫺2 and 2 mm (P ⬍ .05; PCR fixed
bearing and MB unresurfaced compared with nor-
mal). During knee flexion, the average contact po-
sition for all groups translated in the superior direc-
tion. There was greater variability in patellofemoral
contact patterns for the implanted knees and the
ACLD knees than normal knees, but the ACLD

Fig. 3. Error analysis of the
components (left) and flu-
oroscopic images (right).
contact positions were most similar to normal. For
the dome-shaped devices of the PCR and PS TKAs,
the average contact positions were more superior,
at 90° flexion, compared with the normal, ACL-
deficient and MB knees, but these results were not
statistically different (P ⬎ .05). The MB resurfaced
and unresurfaced TKAs experienced a significantly
different patellofemoral contact position at 30° of
knee flexion compared with the normal patella
(P ⬍ .05). On average, from 30° to 90° of knee
flexion, subjects having PCR and PS TKAs experi-
enced similar contact positions, whereas subjects
having either an unresurfaced or resurfaced patella
experienced similar contact positions (Table 1).
Fig. 4. Average patellofemoral contact positions versus
flexion angle. (ACLD, anterior cruciate ligament defi-
cient; PCR, posterior cruciate retaining; PS, posterior cru-
ciate substituting.)
Patellofemoral Joint Kinematics • Stiehl et al. 709
Patellar Tilt Angle
On average, the patellae for all knee types were
flexed in full extension and progressively extended
(most inferior portion of the patella extending from
the tibia) with increased knee flexion (Fig. 5, Table
2). There was not a statistical-difference in the
patellar tilt angles for the 6 knee groups. At full
extension, the normal (⫺7°), ACLD (⫺6°), PCR
fixed bearing (⫺6°), and MB unresurfaced (⫺7°)
patellae experienced the most similar patellar tilt
angle. Although the PS fixed bearing and MB re-
surfaced patellae experienced a different average
patellar tilt angle, the results were not statistically
different (P ⬎ .05). The patellae of normal knees
experienced an increase in extension with increas-
ing knee flexion. The average patellar tilt angles for
the normal knee were 0°, 5°, and 7° at 30°, 60°, and
90° of knee flexion. The ACLD knees had slightly
greater patellar tilt angles than normal knees,
which were 2°, 7°, and 12° at 30°, 60°, and 90°
(P ⬎ .05). On average, subjects having an unresur-
faced MB TKA patella experienced similar patellar
tilt angles compared with the normal patella at 0°,
30°, and 60° but experienced a more extended
angle of 14° at 90° of knee flexion. The average
change in patellar tilt angle compared with the
normal patella was substantially greater for the
fixed bearing PCR and PS TKAs at 30°, 60°, and 90°
of knee flexion (P ⬍ .05), and at 90° of knee flexion
for subjects having a MB resurfaced patella (P ⬍
.05). The most significant difference in the patellar
tilt angles, compared with the normal patella, oc-
curred at 90° of flexion, where the angle for PCR
and PS total knees was 25° and 26°, whereas the tilt
angle for the resurfaced MB TKA was 20° (Fig. 6).
710 The Journal of Arthroplasty Vol. 16 No. 6 September 2001

Table 1. Patellofemoral Contact Average Measurements

Flexion 0° 30° 60° 90°

Normal ⫺8 mm ⫺2 mm 5 mm 6 mm
ACLD ⫺8 mm ⫺4 mm 4 mm 7 mm NS
PCR fixed ⴚ1 mm 3 mm 8 mm 9 mm P ⬍ .05
PS fixed ⫺3 mm 2 mm 6 mm 9 mm P ⬍ .05
MB unresurfaced ⫺6 mm 5 mm 5 mm 6 mm NS
MB resurfaced 2 mm 4 mm 4 mm 5 mm NS

NOTE. Statistically different values compared with normal are in bold and significance is shown in the last column.
ACLD, anterior cruciate ligament deficient; PCR, posterior cruciate retaining; PS, posterior cruciate substituting; MB, mobile bearing;
NS, not significant.

Patellofemoral Separation portant levering function as opposed to a simple

At full extension, there was no measurable sep-
aration distance between the patella and femur for
any normal knees or the MB TKAs, whether resur-
faced or unresurfaced. Separation was seen in 1 of
the ACLD knees, 86% of PCR TKAs (P ⬍ .05,
compared with normal), and 44% of PS TKAs (P ⬍
.05, compared with normal). The maximum mea-
sured separation was 12.2 mm and 6.2 mm for PCR
TKAs and PS TKAs (Fig. 7, Table 3). The average
amount of separation for knees experiencing patel-
lofemoral separation was 3.9 mm and 1.1 mm for
PCR TKAs and PS TKAs. In knees showing patel-
lofemoral separation, the patella contacted the
trochlear groove of the femoral component at a
mean of 5° (⫾3°) of knee flexion.
Discussion
Numerous biomechanical studies have analyzed
the patellofemoral joint and have suggested an im-
pully spacer [33–36]. Factors related to patellar
kinematics are the comparison of the femorotibial
and patellofemoral contact, the angular orientation
of the patella, and the patellar ligament. The effec-
tive extensor moment arm increases with early
flexion of the knee related to the posterior transla-
tion of femorotibial contact with rollback and the
relative inferior patellofemoral contact position.
With increasing flexion, the effective moment arm
decreases because the patellar ligament swings pos-
teriorly as the patella falls into the median femoral
groove, reducing the actual moment arm. The
patellofemoral contact migrates superiorly, decreas-
ing the mechanical force advantage of the patella
lever [34]. Increasing patellar thickness is important
at ⬍35° because most of the force is taken up by the
quadriceps tendon. Conversely a thick patella does
not affect the levering action of the patella at higher
degrees of flexion. Patellar tendon length is impor-
tant because increasing this length moves patel-
lofemoral contact inferiorly, causing a greater mo-
ment arm and enhancing the levering of the
quadriceps tendon. As a result, there is a higher
patellar force concentration and a greater transmis-

Table 2. Patellar Tilt With Statistical analysis

Compared with Normal

Flexion 0° 30° 60° 90°

Normal ⫺7° 0° 5° 9°
ACLD ⫺6° 2° 7° 12° NS
PCR fixed ⫺6° 8° 16° 25° P ⬍ .05
PS fixed ⫺2° 8° 16° 26° P ⬍ .05
MB unresurfaced ⫺7° 0° 5° 14° NS
MB resurfaced ⫺4° 2° 11° 20° NS

Fig. 5. Average patellar tilt angles versus knee flexion
angle. (ACLD, anterior cruciate ligament deficient: PCR,
posterior cruciate retaining; PS, posterior cruciate substi-
tuting.)
NOTE. Statistically different values compared with normal are
in bold, and significance is shown in the last column.
ACLD, anterior cruciate ligament deficient; PCR, posterior
cruciate retaining; PS, posterior cruciate substituting; MB-mobile
bearing; NS, not significant.
 Patellofemoral Joint Kinematics • Stiehl et al. 711

Fig. 6. Examples of patellar

tilt angles. (A) Normal
knee. (B) Anterior cruciate
ligament– deficient knee.
(C) Posterior cruciate–re-
taining knee. (D) Posterior
cruciate–substituting knee.

sion to the patellar ligament. At 82° of flexion in
normal knees, the quadriceps tendon wraps around
the distal femur, which rapidly reduces the amount
of force transmitted through the patella and patellar
tendon [37].
In TKA, in vitro studies evaluated sagittal plane
patellofemoral contact area in normal knees and
TKAs. Huberti and Hayes [40] evaluated 12 human
cadaver knees finding distal patellofemoral contact
at 20° flexion and proximal migration to the most

Fig. 7. Patellofemoral sep-

aration for an implanted
knee (A) compared with
patellofemoral contact for
a normal knee (B).
712 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
Table 3. Patellar Separation
% of Maximum
Separation NC Total Separation
Normal 0 14 0 0
ACLD 1 12 8 2
PCR fixed 12 14 86 12
PS fixed 11 25 44 6 angle and the tendency for the distal patella to gap
MB unresurfaced 0 9 0 0
MB resurfaced 0 9 0 0
ACLD, anterior cruciate ligament deficient; PCR, posterior
cruciate retaining; PS, posterior cruciate substituting; MB, mo-
bile bearing.
proximal portion of the patella at 120° flexion.
Takeuchi et al [41] studied patellofemoral contact
in cadavers with 6 TKA types, finding an inconsis-
tent superior or inferior shift of the contact area
with flexion.
Stiehl et al [42] used dynamic videofluoroscopy
under weight-bearing conditions to investigate sag-
ittal plane patellofemoral kinematics in TKA. Patel-
lar ligament rotation, which measures the angle
formed by the patellar tendon and the longitudinal
axis of the tibia, started at 16° extension in normal
knees and progressed to 0°. Prosthetic knees had a
decreased angle in extension, which also progressed
to 0° with flexion. Patellar axis rotation, which
compared the angle between the patellar tendon
and the sagittal axis of the patella, increased with
knee flexion in normal knees and TKAs but was
greater than normal in TKAs in full flexion. Two
abnormalities first identified in that study included
abnormal patellar separation in full extension and a
pie-shaped or wedge gap opening at the distal pole
of the patella as the patellar prosthesis articulated
on the more superior surface of the dome.
Stiehl et al [43] previously investigated the MB
anatomic patella used in the current study, compar-
ing the results with or without posterior cruciate
ligament sacrifice. Patellofemoral contacts of both
MB implants were similar to normal but tended to
be more inferior with higher degrees of flexion,
which contrasted with the superior position seen on
dome-shaped implants. Patellar ligament rotation
was lower than normal in the MB implants reflect-
ing the posterior femorotibial contact in extension
and anterior translation beyond 60° flexion. Patel-
lar axis rotation angles were similar for normal
knees and TKAs.
The analysis in the current study focused on the
abnormalities identified in TKA from prior in vivo
fluoroscopic weight-bearing studies (ie, altered
patellofemoral contact, patellar tilt angle, and patel-
lofemoral separation in early flexion). We chose to
measure patellar tilt angle, which determines patel-
lar axis rotation with respect to the longitudinal axis
of the tibia as opposed to the patellar ligament. Prior
studies showed little change in patellar axis rotation
but significant alterations in the patellar ligament
open from the distal femur, both of which could be
shown by the patellar tilt angle [42].
In our study, patellofemoral contact position
moved superiorly in normal and ACLD knees in
virtually identical fashion. This finding is not sur-
prising because the joint line is unchanged, the
patella is anatomic for both, and the patellar reti-
nacular ligaments remain normal. Abnormal ACLD
femorotibial kinematics with posterior contact po-
sitioning may explain the patellofemoral separation
seen in 1 case. Neither this posterior femorotibial
contact nor the anterior translation with flexion
seemed to affect patellofemoral contact position,
however.
All TKAs experienced a more superior contact
position at full extension through 30° of knee flex-
ion, and this pattern continued for subjects having
a fixed-bearing PCR or PS TKA at 60° and 90° of
knee flexion. We can speculate that with PS TKAs,
whether fixed or MB, that joint line elevation re-
sulting from posterior cruciate disruption could
cause a more superior contact, at least with early
flexion. The MB resurfaced and unresurfaced patel-
lae with the PS LCS implant had contact positions
similar to normal knees at 60° and 90° flexion.
On average, the most superior overall patel-
lofemoral contact pattern was determined for sub-
jects having a PCR TKA. This observation is puz-
zling but may reflect the spherical shape of the
dome prosthesis and concurrently certain nonana-
tomic features of the prosthetic femoral compo-
nent. Another factor may be the relative line con-
tact of domed implants that leads to a balancing of
this contact position relative to the length of the
patellar tendon and the joint line. Prior kinematic
studies of PCR TKAs have shown consistently pos-
terior femorotibial contact in extension and erratic
anterior translation of the femorotibial contact with
flexion, which may cause more superior patel-
lofemoral contact [43,44]. It is known that the
effective extensor moment arm is reduced in TKAs,
but the exact roll of diminished patellar levering
resulting from superior patellofemoral contact is
unknown [34,35,45].
The patellar tilt angles of the domed patellae were
similar with PCR or PS TKAs and were greater than
normal knees or ACLD knees. This finding may
reflect joint line elevation with posterior cruciate

sacrifice or abnormal posterior femorotibial contact
positioning seen with PCR knees. The patellar tilt
angles of unresurfaced MB TKAs were most similar
to normal knees. Subjects having a resurfaced MB
TKA experienced larger patellar tilt angles com-
pared with subjects having an unresurfaced MB
TKA, but the values were lower than those deter-
mined for fixed-bearing TKAs having dome-shaped
patellae. This difference may reflect the relative
anatomic shape of the MB patella. In general, it
could be stated that patellar tilt angles produced
trends comparable to patellofemoral contact analy-
sis with higher patellar tilt angles correlating with
more superior patellofemoral contact. We have not
accounted for alteration in patellar thickness or
patellar tendon length after TKA, and the amount
of joint line elevation was not determined.
Patellofemoral separation is a phenomenon that
may be explained in part by femorotibial contact,
which tends to be more posterior for TKAs and
some ACLD knees. The highest incidence and mag-
nitude of separation was seen in PCR TKAs, which
may reflect absence of the anterior cruciate liga-
ment and posterior femorotibial contact in exten-
sion. PS TKAs showed a substantial number with
this finding, but only half the number seen with
posterior cruciate retention. Dennis et al [44]
showed that femorotibial contact with PS TKA, on
average, is more anterior than PCR TKA, which
could explain this difference. None of the unresur-
faced or resurfaced anatomic MB TKAs showed
separation, comparable to normal knees. The clini-
cal implication of patellofemoral separation is un-
known but could explain certain clunks that some
patients experience.
Conclusion
This study compared patellofemoral contact pat-
terns and patellar tilt angles of patients with normal
knees, ACL-deficient knees, and TKAs using an in
vivo weight-bearing fluoroscopic analysis. Dome-
shaped patellar prostheses showed the most abnor-
mal results, with more superior patellofemoral con-
tact and greater patellar tilt angles. These findings
may be related to kinematic abnormalities and cer-
tain technical changes, such as joint line positioning
and precise placement of the patellar prosthesis.
Results of ACL-deficient knees and TKAs that re-
tained normal patella or resurfaced with an ana-
tomic shaped prosthesis were comparable to nor-
mal. This information is enlightening regarding the
in vivo performance of the patella in TKA and will
Patellofemoral Joint Kinematics • Stiehl et al. 713
guide future studies that investigate problems with
prosthetic patellar resurfacing.
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