Arthroscopic Lateral Retinacular Release and Lateral Retinacular Lengthening

Chapter 87


Arthroscopic Lateral Retinacular Release and Lateral Retinacular Lengthening







Clinical and Surgical Pearls



• Isolated lateral release is a rather rare surgical procedure if the indications are observed correctly.


• When the procedure is done arthroscopically, hemostasis is important. The progressive technique involves control of any bleeding first with increased inflow pressure, followed by release of the tourniquet (if used); then with minimal intra-articular water pressure, final hemostasis is ensured.


• The use of a hooked electrocautery device allows cutting and hemostasis simultaneously. The device should be inserted through the lateral arthroscopic portal with the arthroscope in the medial portal, with a direct view of at the lateral retinaculum.


• As an alternative to open lateral retinacular release, lateral lengthening has the advantage of maintaining the overall integrity of the lateral retinacular restraint to the patellofemoral joint.



Lateral retinacular release, when performed for the wrong indication or with poor attention to technical details, leads to poor clinical results and a high complication rate.1 The isolated use of retinacular release is best limited specifically to patients with lateral patellar hypercompression syndrome. Used for that indication, there are more consistently good results, although the exact diagnostic criteria for a “tight lateral retinaculum” remain elusive.


With regard to patellofemoral instability, lateral release must be used very carefully because it can easily lead to increased lateral patellofemoral instability as well as medial patellar dislocation. Contrary to intuition, the lateral retinaculum is not a ligamentous structure pulling the patella laterally but a checkrein preventing the patella from subluxing medially and/or laterally depending on the degree of flexion of the knee joint.2


Stringent patient selection with appropriate indications must be paramount, because failure to select patients appropriately may lead to devastating outcomes for them. The goal of this chapter is to describe the role of lateral retinacular release and lateral retinacular lengthening in treating patients with patellofemoral symptoms and illustrate the surgical approach for both of those procedures.



Preoperative Considerations



History




Patients may also report primarily instability (history of recurrent subluxation or dislocation) with or without associated pain. It is important to note this distinction and to probe regarding the true cause of pain and discern the nature and role of the instability versus giving way because of transient pain or weakness.



Physical Examination


Factors affecting surgical indication are as follows:



Factors affecting surgical exclusion are as follows:



It is essential to consider the complex nature of patellofemoral joint pain and critically assess signs of instability, taking into account the entirety of the core and lower extremity. Patients with underlying instability or malalignment issues may require additional corrective proximal and distal realignment procedures in conjunction with lateral release. Lateral hypercompression syndrome needs to be identified clinically, because this is the most common pathology that benefits from isolated lateral release. If patellofemoral instability is present, lateral retinacular release and lengthening are among several procedures that may need to be done in combination. The evaluation for patellofemoral instability includes the evaluation of femoral axial alignment, rotational alignment, patellar height, tibial tuberosity–trochlear groove (TT-TG) measurements, and trochlear dysplasia.




Indications and Contraindications


The indications for lateral release have become increasingly rigorous since it was first described. Ideally, this procedure is performed for patients with isolated anterior knee pain from lateral patellar compression syndrome in the presence of a tight lateral retinaculum and patellar tilt, in whom extensive conservative therapy has failed. Alternatively, lateral release may be used as an adjunct to proximal or distal realignment procedures. In these patients lateral retinacular lengthening may be preferable.


Contraindications for isolated lateral retinacular release are patellar instability, an elevated TT-TG distance, trochlear dysplasia, and lower extremity malalignment or torsion. Additional contraindications are the same as those associated with arthroscopy, including acute or chronic infections or gross anatomic abnormalities of the knee.



Arthroscopic Lateral Release



Surgical Technique


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Open Repair of Posterior Shoulder Instability Autologous Chondrocyte Implantation in the Knee Arthroscopic Rotator Cuff Repair: Double-Row Techniques Surgical Treatment of Posterolateral Instability of the Elbow Primary Repair of Osteochondritis Dissecans in the Knee Arthroscopic Meniscus Repair: All-Inside Technique

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Sep 11, 2016 | Posted by in SPORT MEDICINE | Comments Off on Arthroscopic Lateral Retinacular Release and Lateral Retinacular Lengthening

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