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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