Lateral Retinacular Release

- See: Retinacular Release for TKR

- Discussion:
    - see lateral anatomy of the knee and blood supply to the knee
    - 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;
    - anatomy:
          - lateral retinaculum consists of two layers;
          - superficial oblique layer;
                - extends from the IT band to the lateral border of the patella and patellar tendon;
          - transverse retinaculum:
                - extends from the undersurface of the IT band to the lateral patellar border; 
    - indications for surgery:
                 - patellofemoral instability: (see subluxation)
                         - Lateral retinacular release in patellofemoral subluxation: Indications, results and comparison to open patellofemoral reconstruction. 
                         - The role of lateral retinacular release in the treatment of patellar instability. 
                         - Comparison of lateral release versus lateral release with medial soft-tissue realignment for the treatment of recurrent patellar instability: a systematic review. 
                         - Thermal medial retinaculum shrinkage and lateral release for the treatment of recurrent patellar instability. 
                         - Long-term results of lateral retinacular release. 
                         - Lateral retinacular release: a survey of the International Patellofemoral Study Group. 
                 - retinacular tightness and pain 
                          - 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;
                             - 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 magnetic resonance imaging of the patellofemoral joint
                                     - Arthroscopic lateral retinacular release: functional results in a series of 67 knees. Malek M. Orthop Rev. 1985;14:55. 
                                     - Lateral release of the patella: indications and contraindications.  
                                     - Lateral retinacular release for anterior knee pain: a systematic review of the literature. 
                                     - Long-term results of lateral retinacular release.
                                     - Lateral retinacular release: a survey of the International Patellofemoral Study Group.
                                     - Lateral release for patellofemoral arthritis. 

- Examination of the Patellofemoral Joint

- Radiographic evaluation
     - Computerized tomography of the patellofemoral joint before and after lateral release or realignment.

Arthroscopic Release:
    - note: arthroscopic 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;

- 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;
          - deep retinacular layer is then incised 2 cm lateral to and parallel to the superficial retinacular layer incision;
          - 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. A prospective, randomized outcome study.
          - Z-plasty lateral retinacular release for the treatment of patellar compression syndrome

- 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 retinacular release
    - An analysis of complications in lateral retinacular release procedures.  
    - Factors associated w/ poor results following arthroscopic subcutaneous lateral retinacular release
    - An analysis of complications in lateral retinacular release procedures.
    - Pitfalls of the lateral retinacular release.  

Anatomy of the junction of the vastus lateralis tendon and the patellae.  

Lateral release and proximal realignment for patellar subluxation and dislocation. A long-term follow-up.

What is the role of lateral retinacular release?

Open Lateral Retinacular Closure Surgery for Treatment of Anterolateral Knee Pain and Disability After Arthroscopic Lateral Retinacular Release

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 9, 2012 4:00 pm