Radiographic Landmark Measurements for the Femoral Footprint of the Medial Patellofemoral Complex May Be Affected by Visible Femoral Shaft Length on Lateral Knee Radiographs

Purpose: To assess the effect of visible femoral shaft length on the accuracy of radiographic landmarks of the medial patellofemoral complex (MPFC). Methods: In 9 cadaveric knees, the MPFC footprint was exposed on the medial femur, and its proximal and distal boundaries were marked. Lateral fluoroscopic images of the knee were assessed in 1-cm length increments, beginning 1 cm proximal to the medial condyle and continuing proximally to 8 cm. The MPFC midpoint was described on each image relative to the posterior cortical line of the femur and a line perpendicular to this line through the proximal margin of the medial condyle. In addition, the MPFC midpoint was assessed relative to a line from the proximal posterior cortex to the midpoint of Blumensaat line. Results: Using the posterior cortical line as a reference, the MPFC radiographic landmark moved anteriorly with decreasing visible femoral shaft on radiographs, particularly at 4 cm and less. However, no proximal–distal change was noted. Linear regression analysis demonstrated a relationship between visible femoral shaft and MPFC position on radiographs (R = 0.461, R² = 0.212, B = –0.636, P < .001). For every centimeter decrease in the visible femoral shaft, the radiographic MPFC footprint moved anteriorly by 0.636 mm. Receiver operating characteristic curve analysis revealed that a minimum of 4 cm of femoral shaft on lateral radiographs is required for accurate MPFC footprint localization (area under the curve = 0.80; sensitivity = 76.7%; specificity = 69.0%; P < .001). In contrast, no anterior–posterior change was seen when referencing a line from the proximal posterior cortex to the midpoint of Blumensaat line. Conclusions: When using the posterior cortical line to identify the midpoint of the MPFC, at least 4 cm of femoral shaft should be visible for accurate assessment. If less than 4 cm of shaft is visible, a line through the midpoint of Blumensaat line and the proximal posterior cortex can be used as an alternative method to estimate the position of the femoral footprint. Clinical Relevance: As fluoroscopy is frequently used intraoperatively for MPFC reconstruction, our findings may serve as a guide when assessing femoral tunnel placement on fluoroscopy.