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Wheeless' Textbook of Orthopaedics

Wheeless' Textbook of Orthopaedics

C.R. Wheeless MD

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Wheeless' Textbook of Orthopaedics

Lateral Retinacular Release:

- Discussion: - lateral release detaches patella from lateral soft tissue structures, including lateral retinaculum, fibers from tensa fascia lata muscle, & joint capsule; - a successful release should release the lateral patellofemoral ligament and the lateral patellotibial ligament; - in some cases, a distal realignment procedure or repair of the medial patellofemoral ligament will be required along w/ the lateral release; - radiographic evaluation; - indications for release: - lateral release is indicated only in individuals demonstrating tightness of lateral retinaculum. - patella tilt test indicates tightness of lateral retinaculum; - inability to rotate the lateral border of the patella more than 5 mm; - patella alta, chondromalacia, an elevated Q angle, and an atrophic trochlear groove may be associated w/ a tight retinaculum but these alone are not indications for lateral release; - failure of 6 months of formal physical therapy which is designed to strengthen quads and hamstrings; - note: lateral retinacular release should always be delayed until the end of the arthroscopy procedure, since bleeding and fluid extravasation will force termination of the case; - references: - Clinical prognosticators for the efficacy of retinacular release surgery to treat patellofemoral pain. - Evaluation of patients with persistent symptoms after lateral retinacular release by kinematic MRI of the patellofemoral joint. FG Shellock et al. Arthroscopy Vol 6: 1990. p 226-234. - Lateral retinacular release in patellofemoral subluxation: Indications, results and comparison to open patellofemoral reconstruction. JH Henry et al. Am J. Sports Med. Vol 14. 1986. p 121-129. - Arthroscopic lateral retinacular release: functional results in a series of 67 knees. M Malek. Orthop Rev. Vol 14. 1985. p 55. - Lateral retinacular release of the patella: indications and contra-indications. P Kolowich et al. American J. Sports Medicine. Vol 18. 1990. p 359. - Examination of the Patellofemoral Joint: - Arthroscopic Release: - lateral release detaches patella from lateral soft tissue structures, including lateral retinaculum, fibers from tensa fascia lata muscle, & joint capsule; - a tourniquet should not be used during this procedure since it has been shown to increase the occurance of postoperative hemarthrosis; - prior to performing the release, a complete arthroscopic exam is performed, which includes the knee flexion angle at patellar engagement and the knee flexion angle at patellar centralization; - normally, patellar centralization should take place between 30-45 deg; - part of the surgical statedgy is to avoid the superior geniculate artery; - a needle can be placed adjacent to the superior pole of the patella (1 cm proximal and lateral to the superior edge of the patella) which serves as a intra-articular marker; - the arthroscope is switched from the anterolateral portal to the anteromedial portal; - scissor release: - metzenbaum scissors are inserted into the anterolateral portal and are used to bluntly spread over the retinaculum; - the tips of the scissors are then placed across the retinaculum and are pushed superiorly inorder to effect the release; - care is taken to keep the curved tips of siccors directed posteriorly and 1 cm from the patellar edge; - the release should be visualized thru the anteromedial portal; - cautery release: - turn the cautery on the lowest setting that allows tissue cutting (avoids iatrogenic damage); - perform the retinacular release in layers starting from the superolaterally placed needle, and moving distally to the anterolateral portal; - removing the fascia in layers allows a better opportunity to control bleeding; - the release procedes until the subcutaneous tissue is visualized; - care should be taken to avoid cutting the muscular fibers of the vastus lateralis; - judge the adequacy of release: - the patella should allow 45 deg of eversion following the release and/or should allow medial translation of 25% of the patellar width; - document the change in knee flexion angles for patellar engagement and centrallization; - following the release, hemstasis is achieved w/ cautery (note that bleeding often does not become manifest until several minutes following the release, esp if a tourniquet is used); - references: - Arthroscopic determination of patellofemoral malalignment. JO Sojbjerg et al. CORR. Vol 215. p 1987. p 243-247. - The percutaneous lateral retinacular release. R Betz et al. Orthopedics Vol 5. 1982. p 57. - The percutaneous lateral retinacular release. R Betz et al. Am J. Sports Medicine. Vol 15. p 477. 1987. - Arthroscopic lateral retinacular release and the lateral patellar compression syndrome. FH Fu and MG Maday. Orthop. Clin. North Am. Vol 23. 1992. 601-612. - Open Lateral Lengthening: - advantages: - avoids division of the vastus lateralis obliqus; - allows retinacular lengthening which allows adequate hemostasis and avoids hemarthrosis; - technique: - 6 cm longitudinal incision is made 1 cm off the lateral border of the patella; - incision extends from the superior pole of the patella to a point just above Gerdy's tubercle; - incision extends down to the lateral retinaculum, and then a lateral subcutaneous flap is created; - lateral retinaculum is incised in line with the skin incision from a point just distal to vastus lateralis muscle fibers to a point just proximal to Gerdy's tubercle; - it is important to preserve the deep fibers of the retinaculum and synovium; - check the mobility of the patella at this point, and determine whether further release is necessary; - some authors accept 45 deg of lateral patellar mobility where as other insist on 90 deg of mobility; - if patellar mobility is inadequate at this point, then further dissection is needed; - a lateral retinacular flap is dissected off of the deep fibers of the retinaculum (and synovium) for a distance of 2 cm; - the deep retinacular layer is then incised 2 cm lateral to and parallel to the superficial retinacular layer incision; - the medial edge of the deep layer is sutured to the lateral edge of the superficial retinaculum; - this closure should be water tight, which helps to prevent hemarthrosis; - reference: Open lateral retinacular lengthening compared with arthroscopic release. DB O'Neil MD. JBJS Vol 79-A. No 12. Dec 1997. p 1759. Z-plasty lateral retinacular release for the treatment of patellar compression syndrome. LC Ceder et al. CORR Vol 144. 1979. p 110-113. - Post Operative Care: - initially knee is kept in a well fitted compression dressing inorder to prevent hemarthrosis; - after the release, rapid mobilization of the joint is very important to prevent scarring and tightening along released lateral structures; - intense rehabilitation of the vastus medialis is required; - Complications: Medial subluxation of the patella as a complication of lateral release. JC Hughston and M Deese. Americal J. Sports Medicine. Vol 16: 1988. p 383-388. An analysis of complications in lateral retinacular release procedures. N Small. Arthroscopy. Vol 5. 1989. p 282. Factors associated w/ poor results following arthroscopic subcutaneous lateral retinacular release. L Simpson et al. CORR. Vol 186. 1984 p 165. An analysis of complications in lateral retinacular release procedures. Pitfalls of the lateral retinacular release. DeHaven KE: Clin Sports Med 1989;8:279-290. - Retinacular Release for TKR: - at completion of TKR, patellar tracking are critically evaluated to insure stability; - patellar tracking may be improved by removal of patellar osteophytes and lateral retinacular release; - if significant preoperative valgus deformity is corrected, it may be necessary to perform lateral retinacular release to allow proper patellar tracking & prevent patellar subluxation or dislocation; - an attempt should be made to preserve the lateral geniculate vessels during the retinacular release, however, there is no evidence to suggest interruption of the the superior geniculate artery leads to osteonecrosis of patella; - following the medial arthrotomy and the lateral retinacular release, the only certain blood supply left is anterior tibial recurrent artery; - lateral retinacular release is carried down all the way to the tibia distally and to the region approx 2 fingerbreadths proximal to patella proximally; - lateral geniculate arteries can be preserved by performing the retinacular from within, at least 12 mm from the patella; - references: - Surgical interruption of patellar blood supply by total knee arthroplasty. - The relationship of lateral releases to patella viability in total knee arthroplasty. - Clinical, roentgenographic, and scintigraphic results after interruption of the superior lateral genicular artery during total knee arthroplasty. - Scintigraphic determination of patellar viability after excision of infrapatellar fat pad and/or lateral retinacular release in total knee arthroplasty. - TKR following HTO: - in approx 50%, patellofemoral mechanics are altered producing patella infera, necessitating a lateral retinacular release; - lateral release is most successful in patients with isolated lateral retinacular tightness as seen by negative or neutral patellar tilt; - lateral release clearly is not indicated in patients with lateral retinacular laxity; Anatomy of the junction of the vastus lateralis tendon and the patellae. MJ Hallisey et al. JBJS Vol 69-A. Apr 1987. p 545-549.

Lateral Retinacular Release:

- Discussion: - lateral release detaches patella from lateral soft tissue structures, including lateral retinaculum, fibers from tensa fascia lata muscle, & joint capsule; - a successful release should release the lateral patellofemoral ligament and the lateral patellotibial ligament; - in some cases, a distal realignment procedure or repair of the medial patellofemoral ligament will be required along w/ the lateral release; - radiographic evaluation; - indications for release: - lateral release is indicated only in individuals demonstrating tightness of lateral retinaculum. - patella tilt test indicates tightness of lateral retinaculum; - inability to rotate the lateral border of the patella more than 5 mm; - patella alta, chondromalacia, an elevated Q angle, and an atrophic trochlear groove may be associated w/ a tight retinaculum but these alone are not indications for lateral release; - failure of 6 months of formal physical therapy which is designed to strengthen quads and hamstrings; - note: lateral retinacular release should always be delayed until the end of the arthroscopy procedure, since bleeding and fluid extravasation will force termination of the case; - references: - Clinical prognosticators for the efficacy of retinacular release surgery to treat patellofemoral pain. - Evaluation of patients with persistent symptoms after lateral retinacular release by kinematic MRI of the patellofemoral joint. FG Shellock et al. Arthroscopy Vol 6: 1990. p 226-234. - Lateral retinacular release in patellofemoral subluxation: Indications, results and comparison to open patellofemoral reconstruction. JH Henry et al. Am J. Sports Med. Vol 14. 1986. p 121-129. - Arthroscopic lateral retinacular release: functional results in a series of 67 knees. M Malek. Orthop Rev. Vol 14. 1985. p 55. - Lateral retinacular release of the patella: indications and contra-indications. P Kolowich et al. American J. Sports Medicine. Vol 18. 1990. p 359. - Examination of the Patellofemoral Joint: - Arthroscopic Release: - lateral release detaches patella from lateral soft tissue structures, including lateral retinaculum, fibers from tensa fascia lata muscle, & joint capsule; - a tourniquet should not be used during this procedure since it has been shown to increase the occurance of postoperative hemarthrosis; - prior to performing the release, a complete arthroscopic exam is performed, which includes the knee flexion angle at patellar engagement and the knee flexion angle at patellar centralization; - normally, patellar centralization should take place between 30-45 deg; - part of the surgical statedgy is to avoid the superior geniculate artery; - a needle can be placed adjacent to the superior pole of the patella (1 cm proximal and lateral to the superior edge of the patella) which serves as a intra-articular marker; - the arthroscope is switched from the anterolateral portal to the anteromedial portal; - scissor release: - metzenbaum scissors are inserted into the anterolateral portal and are used to bluntly spread over the retinaculum; - the tips of the scissors are then placed across the retinaculum and are pushed superiorly inorder to effect the release; - care is taken to keep the curved tips of siccors directed posteriorly and 1 cm from the patellar edge; - the release should be visualized thru the anteromedial portal; - cautery release: - turn the cautery on the lowest setting that allows tissue cutting (avoids iatrogenic damage); - perform the retinacular release in layers starting from the superolaterally placed needle, and moving distally to the anterolateral portal; - removing the fascia in layers allows a better opportunity to control bleeding; - the release procedes until the subcutaneous tissue is visualized; - care should be taken to avoid cutting the muscular fibers of the vastus lateralis; - judge the adequacy of release: - the patella should allow 45 deg of eversion following the release and/or should allow medial translation of 25% of the patellar width; - document the change in knee flexion angles for patellar engagement and centrallization; - following the release, hemstasis is achieved w/ cautery (note that bleeding often does not become manifest until several minutes following the release, esp if a tourniquet is used); - references: - Arthroscopic determination of patellofemoral malalignment. JO Sojbjerg et al. CORR. Vol 215. p 1987. p 243-247. - The percutaneous lateral retinacular release. R Betz et al. Orthopedics Vol 5. 1982. p 57. - The percutaneous lateral retinacular release. R Betz et al. Am J. Sports Medicine. Vol 15. p 477. 1987. - Arthroscopic lateral retinacular release and the lateral patellar compression syndrome. FH Fu and MG Maday. Orthop. Clin. North Am. Vol 23. 1992. 601-612. - Open Lateral Lengthening: - advantages: - avoids division of the vastus lateralis obliqus; - allows retinacular lengthening which allows adequate hemostasis and avoids hemarthrosis; - technique: - 6 cm longitudinal incision is made 1 cm off the lateral border of the patella; - incision extends from the superior pole of the patella to a point just above Gerdy's tubercle; - incision extends down to the lateral retinaculum, and then a lateral subcutaneous flap is created; - lateral retinaculum is incised in line with the skin incision from a point just distal to vastus lateralis muscle fibers to a point just proximal to Gerdy's tubercle; - it is important to preserve the deep fibers of the retinaculum and synovium; - check the mobility of the patella at this point, and determine whether further release is necessary; - some authors accept 45 deg of lateral patellar mobility where as other insist on 90 deg of mobility; - if patellar mobility is inadequate at this point, then further dissection is needed; - a lateral retinacular flap is dissected off of the deep fibers of the retinaculum (and synovium) for a distance of 2 cm; - the deep retinacular layer is then incised 2 cm lateral to and parallel to the superficial retinacular layer incision; - the medial edge of the deep layer is sutured to the lateral edge of the superficial retinaculum; - this closure should be water tight, which helps to prevent hemarthrosis; - reference: Open lateral retinacular lengthening compared with arthroscopic release. DB O'Neil MD. JBJS Vol 79-A. No 12. Dec 1997. p 1759. Z-plasty lateral retinacular release for the treatment of patellar compression syndrome. LC Ceder et al. CORR Vol 144. 1979. p 110-113. - Post Operative Care: - initially knee is kept in a well fitted compression dressing inorder to prevent hemarthrosis; - after the release, rapid mobilization of the joint is very important to prevent scarring and tightening along released lateral structures; - intense rehabilitation of the vastus medialis is required; - Complications: Medial subluxation of the patella as a complication of lateral release. JC Hughston and M Deese. Americal J. Sports Medicine. Vol 16: 1988. p 383-388. An analysis of complications in lateral retinacular release procedures. N Small. Arthroscopy. Vol 5. 1989. p 282. Factors associated w/ poor results following arthroscopic subcutaneous lateral retinacular release. L Simpson et al. CORR. Vol 186. 1984 p 165. An analysis of complications in lateral retinacular release procedures. Pitfalls of the lateral retinacular release. DeHaven KE: Clin Sports Med 1989;8:279-290. - Retinacular Release for TKR: - at completion of TKR, patellar tracking are critically evaluated to insure stability; - patellar tracking may be improved by removal of patellar osteophytes and lateral retinacular release; - if significant preoperative valgus deformity is corrected, it may be necessary to perform lateral retinacular release to allow proper patellar tracking & prevent patellar subluxation or dislocation; - an attempt should be made to preserve the lateral geniculate vessels during the retinacular release, however, there is no evidence to suggest interruption of the the superior geniculate artery leads to osteonecrosis of patella; - following the medial arthrotomy and the lateral retinacular release, the only certain blood supply left is anterior tibial recurrent artery; - lateral retinacular release is carried down all the way to the tibia distally and to the region approx 2 fingerbreadths proximal to patella proximally; - lateral geniculate arteries can be preserved by performing the retinacular from within, at least 12 mm from the patella; - references: - Surgical interruption of patellar blood supply by total knee arthroplasty. - The relationship of lateral releases to patella viability in total knee arthroplasty. - Clinical, roentgenographic, and scintigraphic results after interruption of the superior lateral genicular artery during total knee arthroplasty. - Scintigraphic determination of patellar viability after excision of infrapatellar fat pad and/or lateral retinacular release in total knee arthroplasty. - TKR following HTO: - in approx 50%, patellofemoral mechanics are altered producing patella infera, necessitating a lateral retinacular release; - lateral release is most successful in patients with isolated lateral retinacular tightness as seen by negative or neutral patellar tilt; - lateral release clearly is not indicated in patients with lateral retinacular laxity; Anatomy of the junction of the vastus lateralis tendon and the patellae. MJ Hallisey et al. JBJS Vol 69-A. Apr 1987. p 545-549.
 
 
 
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