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Lateral retinacular release reduces pain in the right patient
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When John D. Kelly IV, MD, was trained in the 1980s, a lateral retinacular release was scheduled if a patient’s knee pain did not improve.
“We no longer have this knee-jerk response to patella pain as we did in the 1980s and 1990s,” said Kelly, now an associate professor of orthopedic surgery at the University of Pennsylvania. “Today, you have to treat a release with reverence. Everything we do has morbidity. It’s all about indications.”
The lateral retinaculum is a significant stabilizer to the patella, according to Kelly.
“It helps prevent lateral translation of patella. Imagine the patella has to go up and out – up the hill and out – so that compression affords lateral stability, even though this is counterintuitive. Tightness leads to tilt, not lateral translation.”
A study by Stephen M. Desio, MD, and colleagues from 1998 found that by cutting the lateral retinaculum, “the patella actually goes laterally a little easier, conferring some stability,” Kelly said. Therefore, “don’t cut it needlessly.”
Lateral tilt and tightness
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Indications for lateral release include lateral tilt and tightness. Kelly also provides his patients 6 months of rehabilitation because the literature shows that 92% plus of patients improve with rehab. Lateral facet softening also may reflect some excessive pressure, for which a lateral release may help.
“But the lateral softening has to be greater than the medial facet,” Kelly told attendees at Orthopedics Today Hawaii 2011. “You don’t want to unload the lateral side and overload the medial side. It has to be asymmetric.”
A handful of papers indicate that lateral release can even benefit some patients with lateral facet patella arthritis (DJD), Kelly said.
“Predictably, lesser degrees of degeneration should respond more reliably to release. Regarding patella arthritis, again, the key is symmetry,” he said. “Maybe that person has long-standing excessive lateral pressure. But you must have better medial cartilage to transfer load to.”
In the right patient, lateral release is effective because it relieves excessive pressure on the lateral facet, and in some patients “it improves the kinematics, providing the patient is tight laterally,” Kelly said. “The procedure also works, I believe, because it denervates the retinaculum.”
Rich neural supply
Histology studies show that the retinaculum is endowed with an extremely rich neural supply and that neural degeneration occurs in excessive lateral pressure syndrome. “Perhaps the excessive pressure induces slight ischemic changes to the nerve fibers. These fibers then degenerate and cause pain,” Kelly said. “Probably the lateral release works because we are simply ‘nuking’ all those nerve fibers.”
A physical exam, rather than an MRI, is more reliable in demonstrating a tight lateral retinaculum. Arthroscopic inspection may confirm lateral tilt and excessive lateral pressure. The ‘medial glide’, or translation of the patella medially with applied pressure, also needs to be less than two quadrants to warrant release.
“X-ray and MRI are to be considered more confirmatory, rather than indicative of need for release,” Kelly told Orthopedics Today.
“The execution of endoscopic lateral release has to be treated with reverence and should extend no further from the superior pole of patella to the inferior lateral portal,” Kelly said. “If you encounter a lot of bleeding, you probably went higher than the superior pole where the superior geniculate resides,” he said.
Thermal damage
Kelly is careful to avoid both superior and inferior geniculates, and uses a thermal device with a sharp tip to execute the release. He said that with a fine tip, there is less potential ‘collateral’ tissue damage.
Kelly recommends no tourniquet, and he views from the inferior medial or the superomedial portal. After release, Kelly lowers inflow and obtains compulsive homeostasis. A compressive wrap is also applied.
Generally, female patients may benefit more from the procedure because some basic science studies suggest patella kinematics tend to respond less favorably with release in male patients. For patella arthritis, in some series up to 80% of patients with patella femoral degeneration have shown some improvement, he said.
Kelly concluded by stating patients with medial facet chondrosis should absolutely avoid lateral release. Patella symptoms also can worsen if release is performed without lateral tightness.
“This will potentially destabilize an already loose articulation,” he said. Similarly, if bleeding is not effectively addressed, “hemarthrosis will clearly compromise results.”
Lastly, “Remember, this is an operation for pain, not for instability,” Kelly said.
Reference:
- Kelly JD. What about an isolated lateral retinacular release? Presented at Orthopedics Today Hawaii 2011. Jan 16-19. Koloa, Hawaii.
- John D. Kelly IV, MD, can be reached at University of Pennsylvania Department of Orthopedic Surgery, 34th and Spruce St., Philadelphia, PA 19104; 215-615-4400; email: john.kelly@uphs.upenn.edu.
- Disclosure: Kelly has no relevant financial disclosures.
