Morphometric

Chin Med J 2014;127 (1)96
DOI: 10.3760/cma.j.issn.0366-6999.20131948
Center for Translational Medicine Research and Development,
Shenzhen Institutes of Advanced Technology, Chinese Academy of
Sciences, Shenzhen, Guangdong 518055, China (Shang P, Zhang LN,
Hou ZT, Bai XL, Ye X, Xu ZB and Huang X)
Correspondence to: Zhang Linan, Centre for Translational Medicine
Research and Development, Institute of Biomedical and Health
Engineering, Shenzhen Institute of Advanced Technology, Chinese
Academy of Sciences, Shenzhen, Guangdong 518055, China (Tel:
86-755-86392238. Fax: 86-755-86392276. Email: zhanglinan.cathy@
gmail.com)
This study was supported by the International Cooperation and
Exchange of the National Natural Science Foundation of China
(No. 30810103908) and the Shenzhen Personalized Orthopedics
Technology and Manufacturing Platform Project.
Original article
Morphometric measurement of the patella on 3D model reconstructed
from CT scan images for the southern Chinese population
Shang Peng, Zhang Linan, Hou Zengtao, Bai Xueling, Ye Xin, Xu Zhaobin and Huang Xu
Keywords: morphometric measurement; patella; 3D model; computed tomography; southern Chinese population
Background Due to racial differences in the morphology of the knee joint and due to most prostheses available in the
market being designed using measurements from Caucasians, the objective of this study was to provide the morphometric
data of the patella for the southern Chinese population for total knee arthroplasty (TKA), patellar resurfacing, and
prostheses design.
Methods The CT slices of the knee joint were obtained from both knees of 40 Chinese volunteers (20 females, 20
males, and age from 20–25 years) by performing a computer tomographic scan. A 3D model was reconstructed by
Mimics software based on the computed tomography images. Six metrical characteristics were measured by digital ruler.
Statistical analysis was performed with the SPSS statistical program.
Results The mean, standard deviation and P values of measurements and ratios were calculated using SPSS. All
dimensions showed a significant gender difference with P<0.05, but the six variables of the left and right knees had no
statistical significance with P>0.05. In addition, we studied the relationship between six couples (H-W, H-T, H-HAF, W-T,
W-HAF, T-HAF) of the four variables (H: height, W: width, T: thickness and HAF: height of articulating facet) that were
measured, which showed a significant correlation.
Conclusions Examination of the southern Chinese population revealed that males have larger patellae than women. In
both genders, comparing data between left and right knees shows no statistically significant difference. Compared with
Westerners in previous studies, the patella in our study was thin and small. There was a good linear regression correlation
between measurements of the patella. The indirect measurement method on 3D models makes it easy to obtain
anatomical data, and the results can provide a region and gender specific database for morphometric measurements of
the patella, and can be helpful for designing implants suited for southern Chinese patients.
Chin Med J 2014;127 (1): 96-101
In 2006, the number of primary total knee arthroplasty
(TKA) procedures performed in patients in the US was
about 524 600; from NIS data.1
Projected by Kurtz et al,2
the demand for TKA is estimated to grow by 673% in the
US from 2005 to 2030 (3 480 000 procedures). With the
increasing number of TKA, patella and patellofemoral
related complications are a growing concern after surgery.3-7
Previous studies reported the anatomy of the patella
plays an important role during the design of patellar
prostheses and TKA surgery.8-12
In the patellar resurfacing,
a thin residual patellar thickness (<11 mm) can lead to
stress fracture of the patella.13
It is desirable for the final
thickness of the resurfaced patella following TKA to match
the original patellar thickness. While increasing patella
thickness can reduce the range of motion and predispose to
patellar subluxation, a thin patella can reduce the contact
force and potentially result in fracture and anteroposterior
instability.8,9
Either a thicker or a thinner patella would
risk poor clinical results. To avoid these problems, the
restoration of the patella to the original thickness is
desirable during TKA surgery. However, if the overall
thickness was kept in a reasonable range when resurfacing
the patella, there are no adverse clinical findings.14
Considering the long-term clinical results and quality of
TKA, many researchers recommend thick residual patella
and reconstitution of original patellar thickness in TKA
surgery.10,14
In addition, the restoration of the original height
and the position of median ridge are also critical to improve
patellar tracking and help to restore normal patellofemoral
kinematics after TKA.12,15
The width/thickness ratio can be
used as surgical guidelines to restore original size. Hence,
the accurate morphometric measurements of the patella
used for prostheses design are necessary.
There is a significant difference in the morphology of the
knee joint between Asian and Western patients.16
But most
of the prostheses currently available in the market are
designed based on the measurements from Caucasians,
which may not be suitable for Asian patients.17-20
As is

Chinese Medical Journal 2014;127 (1) 97
well-known, Caucasian knees are generally larger than
Asian knees.21
There is a lack of data about the Asian knee
joint to determine if the oversize component could cause
poor clinical results after TKA.22
It is necessary to design
regional and gender specific patellar implants. Recently, a
new measurement was recommended based on 3D models
reconstructed by computer software.23,24
The 3D model
was an accurate and convenient measurement method to
procure adequate data.
The objective of this study was to obtain the morphometric
data of the patella for the southern Chinese population,
which would be useful for the patellar component design
and implantation in TKA. To achieve this goal, we used
a noninvasive method to measure the normal patella
through 3D models reconstructed by computed tomography
(CT) images. Based on these data, we hypothesized that;
the measurements between men and women differed,
the measurements between right and left patella had no
statistically significant differences, reliable relationships
among the measured features could be found, and
morphometric measurements of patellae for the southern
Chinese population tended to be smaller than measurements
for Caucasians based on data from previous Western
studies.
METHODS
This institutional review board (IRB) approved study was
based on 80 normal patellae in 40 volunteers (20 females,
20 males) of southern Chinese population between 20
and 25 years old. All volunteers needed to satisfy two
conditions: to minimize the effect of migration, their family
must be Hakkas, Teochews, Cantonese or Hokkienese for at
least three generations; to ensure the normal patellar shape,
their lower limb and knee joint should not have had old
wounds or diseases, and patellar shape was not deformed
according to the CT scans. The patella measurements
were performed by using 3D model reconstructions of
the patella with Mimics 15.0 (Materialise n.v., Belgium)
based on CT scans. While the volunteers were supine with
the patella facing towards the ceiling in the extended knee
position (0 degree of flexion), CT slices were obtained with
the CT scanner (Siemens SOMATOM PLUS, Germany)
with DICOM format (resolution: 512×512 pixels, slice
thickness: 1 mm, number of slices: 600) from the hip joint
to the ankle joint.
As shown in Figure 1, a 3D visual model was reconstructed
from a set of CT images by Mimics 15.0. The Hounsfield
scale threshold was used to control and correct the
segmentation of CT images. The selection of the threshold
value was critical to the accuracy of the reconstructed
model, and the profile line was drawn over the patella
(Figure 2). A lower limit of 226 Hounsfield units (HU)
and upper limit of 1950 HU were defined in order to
select the bone from the surrounding tissues. Based on
these operations, the reconstructed model was assumed to
represent the anatomical morphology of the patella, and the
surface was meshed by triangles. Using the measurement
ruler in Mimics software, the distance was measured
from one point of a triangle to another point of another
triangle. To improve the quality of the triangular elements,
a remeshing function was used, and the maximum edge
length of a triangle was set as 0.1 mm, so accuracy of the
distances measured on 3D models was limited by the size
of the triangle.
Six metrical characteristics were measured by digital ruler
in Mimics 15.0 (as shown in Figure 3) as following:
The height of patella (H) was measured from the tip of the
apex to the base border.
The width of patella (W) was measured from the medial
border to the lateral border.
The thickness of patella (T) was measured from the anterior
articular facet to the posterior articular facet.
Figure 2. Profile line was drawn in the axial image over the
patella and a lower limit of 226 Hounsfield units (HU) and upper
limit of 1950 HU were defined in order to select the bone from
the surrounding tissues.
Figure 1. Reconstructed patella 3D model from CT images by
Mimics 15.0.

Chin Med J 2014;127 (1)98
The height of articulating facet (HAF) was measured from
the anterior articular facet to the posterior articular facet.
The width of the medial facet (WMF) was measured
from the most projecting point of the medial border
perpendicular to the median ridge of the articular facet.
The width of lateral facet (WLF) was measured from the
most projecting point of the lateral border of the patella
perpendicular to the median ridge of the articular facet.
To measure the WMF and WLF, a base plane was first fitted
by the selected points along both sides of the articular facet.
A series of the most projecting points in the articulating
facet was found and projected onto the base plane, and
then a line was fitting through these projected points in the
base plane, which was simplified as the median ridge line
projected to the plane (shown in Figure 3C). The projecting
lines which were tangent to the medial border and the
lateral border were also drawn in the plane. Finally, the
width, WMF and WLF were measured according to the
vertical dimensions.
Statistical analysis was performed with the statistical
program SPSS 18.0 (SPSS Inc., IL, USA), and the mean,
standard deviation (SD) and range are listed in the results.
The geometry of patella was compared between male and
female patella by paired t test. A paired t test was also
used to compare the left and right patella for each gender.
Significance was considered at a P value less than 0.05. The
statistical analysis of width/thickness (W/T) ratio, width/
height of articulating facet (W/HAF) ratio, and width of the
lateral facet/width of the medial facet (WLF/WMF) ratio
was carried out using one-sample K-S normal test with
significance at P <0.05. Bivariate correlation and linear
regression were used to ascertain the relationship between
six couples of variables (H-W, H-T, H-HAF, W-T, W-HAF,
T-HAF) of four variables measured, containing height (H),
width (W), thickness (T), and HAF.
RESULTS
Descriptive statistical analysis of both patella dimensions
are presented for all subjects in Tables 1–3. It was observed
that the male patellae had larger geometrical dimension
than female patellae. The differences between males and
females reached statistical significance at P<0.001, except
for the HAF (P=0.006 for left patella and P=0.004 for right
patella) and WMF (P=0.002 for left patella and P=0.010 for
right patella). Even so, the differences of HAF and WMF
were still statistically significant by gender with P<0.05.
The six variables of the left and right knees were not
significantly different, with a P>0.05. Our results indicate
that a difference in patella design by gender, and left or
right knees is of minor relevance.
To study the relationship among the variables, the statistical
Figure 3. The measurement based on the 3D model. A: Anterior
facet of the patella. B: Tangential view of the patella from
the top. C: Dorsal surface of the patella (the point fitting line
simplified as median ridge).
Table 1. Left patellar dimensions of 40 knees for the southern Chinese population
Parameters
All left patella (n=40) Male (n=20) Female (n=20)
P values
Mean Range SD 95% Confidence intervals Mean SD Mean SD
H (mm) 39.90 31.90–47.88 3.85 38.67–41.13 42.84 2.67 36.95 2.25 < 0.001
W (mm) 44.15 36.30–53.21 3.99 42.87–45.42 47.01 3.04 41.28 2.48 < 0.001
T (mm) 22.79 19.84–27.19 1.82 22.21–23.37 23.95 1.59 21.62 1.18 < 0.001
HAF (mm) 26.21 19.23–36.28 3.43 25.12–27.31 27.96 2.86 24.46 3.08 0.006
WMF (mm) 19.15 15.28–23.37 2.24 18.43–19.86 20.32 2.06 17.97 1.78 0.002
WLF (mm) 25.06 20.00–30.77 2.68 24.14–25.86 26.69 2.52 23.31 1.55 < 0.001
H: height of patella. W: width of patella. T: thickness of patella. HAF: height of the articulating facet. WMF: the width of medial facet. WLF: the width of lateral facet.
Table 2. Right patellar dimensions of 40 knees for the southern Chinese population
Parameters
All right patella (n=40) Male (n=20) Female (n=20)
P values
H (mm) 39.98 32.32–48.72 3.55 38.84–41.11 42.77 2.23 37.18 2.10 < 0.001
W (mm) 44.12 35.57–52.28 3.98 42.84–45.39 47.01 2.91 41.23 2.55 < 0.001
T (mm) 22.65 19.28–27.08 1.83 22.06–23.23 23.87 1.53 21.43 1.18 < 0.001
HAF (mm) 26.53 18.88–37.52 4.09 25.22–27.84 28.57 4.06 24.50 3.03 0.004
WMF (mm) 18.92 14.42–25.08 2.20 18.22–19.62 19.87 2.31 17.96 1.63 0.010
WLF (mm) 25.21 19.49–30.46 2.88 24.29–26.13 27.14 2.46 23.28 1.79 < 0.001
Table 3. All patellar dimensions of 80 knees for the southern Chinese population
Parameters
All patellae (n=80) Male (n=40) Female (n=40)
P values
H (mm) 39.94 31.90–48.72 3.68 39.12–40.76 42.81 2.43 37.07 2.15 < 0.001
W (mm) 44.13 35.57–53.21 3.96 43.25–45.01 47.01 2.94 41.25 2.48 < 0.001
T (mm) 22.72 19.28–27.19 1.81 22.31–23.12 23.91 1.54 21.52 1.17 < 0.001
HAF (mm) 26.37 18.88–37.52 3.76 25. 54–27.21 28.27 3.48 24.48 3.01 < 0.001
WMF (mm) 19.03 14.42–25.08 2.21 18.54–19.52 20.10 2.17 17.97 1.68 < 0.001
WLF (mm) 25.10 19.49–30.77 2.77 24.49–25.72 26.91 2.46 23.30 1.65 < 0.001

analysis of W/T ratio, W/H ratio and WLF/WMF ratio are
listed in Table 4. Analysis of the ratios of W/T and W/H
seemed to show linear relationships among the variables.
Hence, a series of linear regression correlations were
calculated for all subjects. As shown in Table 5, there was
a strong relation between the four patellar dimensions in
all subjects, and the regression lines between three couples
(W-H, W-HAF, W-T) of the four variables were plotted in
Figures 4-6 .
DISCUSSION
It was reported the patella of Asian population were
thinner and smaller than western subjects.3,19,25
This fact is
confirmed in this study for a southern Chinese population.
From Table 3, the mean height was 37.07 mm in females
and 42.81 mm in males, which was smaller than reported
for Koreans, 40.0 mm in females and 45.6 mm in males.26
The mean width showed the same trend in our study,
41.25 mm in female and 47.01 mm in male. But the width
reported by Baldwin et al27
was 43.5 mm in females and
50.3 mm in males for Westerns. The mean thickness was
21.52 mm in females and 23.91 mm in males for the left
patella in our study, which are very close to the data from
Koreans, 21.2 mm in females and 23.1 mm in males, but
smaller than reports for Western patients undergoing TKA,
21.8 mm in females and 23.9 mm in males, which was
measured from patients with the average age of 69 years
by Baldwin in 2004; 22.6 mm in females and 26.1 mm
in males, which was measured from patients with the age
range of 36–89 years in 1995.3,27,28
The dimensions of the articulating facet included the height
at 24.48 mm in females and 28.27 mm in males, which was
smaller than the height reported by Baldwin et al,27
33.9
mm in females and 38.6 mm in males. The distance from
central ridge to the medial border was 17.97 mm in females
and 20.10 mm in males. The WMF was slightly smaller
than measurements from other population; Korean, 18.4
mm in females and 20.2 mm in males and Westerners, 18.8
mm in females and 21.1 in males.26-27
Moreover, the WLF
was also smaller: 23.30 mm in females and 26.91 mm in
males, while the same dimensions measured in Westerns
was 25.3 mm in females and 29.7 mm in males.27
As shown in Table 4, the ratio of width to the thickness of
patella was 1.94 (SD 0.12, range 1.66–2.20), which was
less than that of the normal knees from UK with an average
value of 2.1.23
It shows that Asians have a narrow patella
compared with Westerners.
Table 4. Statistical analysis of W/T ratio, W/HAF ratio and WLF/
WMF ratio
Items
W/T ratio W/HAF ratio WLF/WMF ratio
Mean SD Mean SD Mean SD
Overall 1.94 (1.66–2.20) 0.12 1.69 (1.28–2.19) 0.20 1.33 (0.91–1.71) 0.18
P values 0.933 0.991 0.990
Table 5. Correlation coefficients of the patellar dimensions for the
southern Chinese population (n=80)
Dimensions H W T HAF
HAF 0.571*
0.522*
0.564*
1
T 0.675*
0.743*
1 –
W 0.777*
1 – –
H 1 – – –
*
At the 0.01 level (bilateral) significantly correlated.
Figure 4. The regression line shows the relationship of patellar
height and patellar width (r=0.777, P<0.001).
height of articulating facet and patellar width (r=0.522,
P<0.001).
thickness and patellar width (r = 0.743, P<0.001).

Chin Med J 2014;127 (1)100
The mean ratio of the width to the height of articulating
facet in this study was 1.69 (SD 0.20, range 1.28–2.19),
which was larger than the ratios of W/H reported by
Baldwin et al27
(1.30) and Aglietti et al (1.31).29
And it
was confirmed that the width of the articulating facet was
greater than the height. The mean of the lateral facet to
medial facet ratio was 1.33 (SD 0.18, range 0.91–1.71),
which was the same as reported by Iranpour et al.23
According to the linear regression correlation (Figures
4–6 and Table 5), the width of the patella can be used to
predict normal patellar dimensions for a southern Chinese
population. These relationships among patellar dimensions
can provide some anthropometric rules for surgeons to
select the implanted prosthesis for Asian patients, especially
for southern Chinese patients. Beyond that, the dimensions
of the patella can also be used for sex determination for
forensic anthropologist and the design of prostheses for
clinical purposes.30-35
The method of measurements can be divided into direct
and indirect measurements. One of the direct measurements
is with dried bone or skeletal remains.30,36
The other is
intraoperative measurement performed by the operating
surgeon using a caliper.3,6,27
It is difficult to procure a
sufficient quantity of dry bones or patients needing TKA for
detailed research analysis. But indirect measurements can
be done. One of the indirect measurements is to measure
radiographic images using a digital ruler.26,37
In this study,
we adopted the indirect method by reconstructing 3D
models using CT images, and all of measurements in this
study were collected noninvasively. This was a quick,
inexpensive, and noninvasive way to get morphometric
measurements.
Several limitations should be noted while interpreting our
findings. First, the volunteers in our study were healthy and
20–25 years old and morphometric data were measured
from normal patella, which may differ from severely
deformed and diseased knees. Second, the measurements of
patellae were performed on a 3D model with a digital ruler,
and accuracy of data was associated with the threshold
value and the quality of mesh generation. In order to get
reliable data, we suggest that the profile line function be
used for the region growing function and the meshing
of the model be as fine as possible. Third, the 3D model
of the patella did not include the patellar cartilage. The
measurements should take into account the thickness of
patella used in TKA surgery. The thickness of patellar
cartilage was approximately 3–4 mm and it became thinner
during aging.38
However, we believe this study provides
valuable information about the patella required for patellar
component design and TKA for a southern Chinese
population.
In conclusion, our study performed indirect morphometric
measurements for a southern Chinese population on 3D
models reconstructed from CT images of normal patella.
Statistical analysis results show that males have larger
patella than females. The mesurements between left and
right knees are not significantly different. The dimensions
of the patella for a southern Chinese population are thinner
and smaller than for Westerners. In addition, there is a good
linear regression correlation between measurements of
the patella. This study could be used as a guideline to the
development of patellar prosthesis, especially for southern
Chinese population.
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(Received July 25, 2013)
Edited by Wang De
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