Arthroscopic Medial Retinacular Plication With a Needle-Hole Technique Niti Prasathaporn, M.D., Somsak Kuptniratsaikul, M.D., and Kitiphong Kongrukgreatiyos, M.D.
Abstract: Patellar instability is a common problem resulting in anterior knee pain. The medial patellofemoral ligament, which is part of the medial retinaculum, is often injured, and this damaged structure can affect normal patellar movement. Medial retinacular plication can correct this main pathology of patellar instability. Many studies have shown good to excellent results with medial retinacular plication with or without lateral retinacular release. This medial retinacular plication technique can also be performed arthroscopically. Arthroscopic medial reticular plication with a needle-hole technique is a treatment that uses the less invasive technique of arthroscopy, does not require tissue grafts, and has a greater cosmetic advantage than open procedures.
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atellar instability is a common problem resulting in anterior knee pain. However, there are many causes of patellar instability: those that involve softtissue pathology or bony pathology. Many surgical techniques have been published over the years. We can categorize the types of surgical treatment for patellar instability as lateral retinacular release, proximal realignment, distal realignment, and patellectomy. The medial patellofemoral ligament, which is part of the medial retinaculum, is the main injured structure especially regarding normal knee alignment. Therefore, medial retinacular plication, a proximal realignment correction technique, can directly address the main pathology of patellar instability. In recent years medial retinacular plication has been developed using an arthroscopic technique, which is cosmetically more acceptable.1-5 Many studies have shown good to excellent results of medial retinacular placation with or without lateral retinacular release. This article describes arthroscopic medial retinacular
From the Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 23, 2014; accepted May 8, 2014. Address correspondence to Niti Prasathaporn, M.D., Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14153/$36.00 http://dx.doi.org/10.1016/j.eats.2014.05.004
plication with soft suture material through only small stab wounds (Table 1).
Surgical Technique We position the patient supine on the operating table. The patellar gliding test is performed medially and laterally for both knees. We determine the distance of medial retinacular plication from the excessive distance Table 1. Indication, Contraindications, Advantages, Tips and Pearls, and Limitation of Arthroscopic Medial Retinacular Plication With Needle-Hole Technique Indication Patellar instability in normal knee alignment Contraindications Patella alta Excessive Q angle Femoral trochlear dysplasia Advantages Less invasive technique No need for tissue grafts Knots’ location in an articular space, which will not irritate subcutaneous layer and skin Good cosmetic outcome Tips and pearls To prevent a skin dimple, the first and second needle passes through the medial retinaculum need to use the same stab wound. The distance between the first and second passes of the medial retinaculum depends on the severity of lateral patellar gliding. The tension of the medial retinaculum should be set in slight knee flexion (10 to 20 ). Limitation In cases of patellar instability due to bony pathologies, arthroscopic medial retinacular plication is not recommended.
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e483-e486
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Fig 2. A superolateral portal is used as a viewing portal. An 18-gauge needle, which is loaded with No. 1 PDS thread, is passed through the stab skin incision and medial retinaculum at the medial rim of the patella.
Fig 1. The left knee are fully extended in the supine position. The standard anteromedial (AM), anterolateral (AL), and superolateral (SL) portals are defined. The stab incisions are located on the superomedial quadrant of the patellar rim (S).
of lateral patellar gliding while comparing it with the contralateral side. If lateral retinacular tightness is present, lateral retinacular release may be performed. A tourniquet is usually used if not clinically contraindicated. General arthroscopic examination is routinely carried out through the standard anterolateral portal and anteromedial portal. A superolateral portal is created and used as a viewing portal. A stab surgical wound is made on the upper medial quadrant of the patella (Fig 1). The camera is placed through the anterolateral portal. An 18-gauge needle is loaded with No. 1 PDS thread (Johnson & Johnson, New Brunswick, NJ) folded over the bevel end. The needle is passed through the stab wound; then the medial retinaculum is penetrated at the rim of the patella (Fig 2 and Video 1). The PDS is pulled to make the first loop using a retriever or hook. The needle is pulled out of the retinaculum while the suture is kept loaded. The needle is medially shifted on the retinaculum. The distance between both punctures depends on the lateral gliding distance of the patella. After the appropriate distance has been determined, the needle is passed through the retinaculum into the joint (Fig 3). The first loop is released; then the retriever is passed through this loop to grasp the PDS at the bevel end. This PDS at the end of the retriever is pulled through the first loop and out the anteromedial portal (Fig 4). The needle is pulled out the retinaculum. The 2 arms of the
first loop are defined and pulled simultaneously to draw the suture end from the anteromedial portal (Fig 5). Then both ends of the PDS are drawn outside the joint. The ends of No. 2 Ethibond (Johnson & Johnson) are tied to the ends of the PDS (Fig 6). The PDS is pulled out through the anteromedial portal to pass the ends of the Ethibond into the joint and also out through the anteromedial portal. The steps can be repeated according to the number of stitches required to plicate the medial retinaculum. Usually, the plication requires around 3 to 5 stitches at the upper medial quadrant of the patella. Each set of Ethibond threads can be kept at the anteromedial portal for suture management. Once all the stitches are placed, the viewing portal changes to the anterolateral portal, and the sutures are tied through the superolateral portal in a position of slight knee flexion (10 to 20 ) (Fig 7). After medial retinacular plication has been completed (Fig 8), a compression dressing is applied.
Fig 3. A hook or suture retriever, which passes through the anteromedial portal, is holding the first loop of suture. The needle is passed through the same skin incision; then slide the needle on the medial retinaculum medially before the needle is passed through the medial retinaculum.
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Fig 4. The suture end of the second loop is drawn through the first loop and out the anteromedial portal.
Postoperative Protocol A hinged knee brace is used and locked in full extension on the first postoperative day. Partial to full weight bearing is allowed immediately after the operation. Range-of-motion exercises are allowed to 30 , 45 , and 90 of knee flexion after the second, fourth, and sixth postoperative week, respectively. Quadriceps strengthening exercise is initiated 4 weeks after the operation. Light sporting activities are allowed at 3 months, whereas contact sports are allowed at 6 months.
Discussion Patellar instability is one common problem resulting in anterior knee pain. However, there are many causes for patellar instability. These causes can be grouped as soft-tissue pathologies or bony pathologies. The medial patellofemoral ligament, which is part of the medial retinaculum, is often the main structure involved in injuries, especially in normal knee alignment. Therefore medial retinacular plication corrects this main
Fig 5. The first suture loop is pulled out the skin incision; then the suture end from the anteromedial portal is drawn to the skin incision.
Fig 6. The No. 1 PDS thread is changed to the soft, malleable No. 2 Ethibond thread, which is then relayed through the retinaculum.
pathology of patellar instability. In recent years, an arthroscopic technique has been developed for medial retinacular plication. The results of arthroscopic medial reticular plication have been published in many studies. Two decades ago, arthroscopically assisted proximal extensor mechanism realignment showed good to excellent subjective results in 92.5% of cases.1 A more recent case series by Haspl et al.2 also showed good results of fully arthroscopic medial retinacular plication and lateral retinacular release for patellar instability. Postoperative results after a follow-up period of 12 to 26 months were good, with no recurrence of subluxation or dislocation. In a retrospective study, Ali and Bhatti3 demonstrated a technique for arthroscopic proximal realignment for recurrent patellar instability. The study included 38 knees in 37 patients, which were evaluated at a mean follow-up of 51 months. The results showed excellent stability in 88.8% of knees and good to excellent Lysholm functional knee scores in 77.7%. For 32 knees, the patients were satisfied with the operation.
Fig 7. The viewing portal changes to the anterolateral portal. The No. 2 Ethibond suture stitch is tied to plicate the medial retinaculum through the superolateral portal.
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Fig 8. Three to five suture stitches are required for medial retinacular plication.
One published case-series study showed a truly allarthroscopic patellar realignment.4 The results showed significant improvement in pain, swelling, stair climbing, Lysholm score, and ability to return to sports. The congruence angle, lateral patellofemoral angle, and lateral patellar displacement showed significant improvement postoperatively. The author used the same suture management as used with the needle-hole technique. His technique used a PDS thread as the final suture, which is not as secure as a malleable thread. Soft-tissue cut-through can occur when a PDS thread changes to a malleable thread through acute-angle passing. In a recent study, Zhao et al.5 compared the results between arthroscopic medial retinacular plication and medial patellofemoral ligament reconstruction for recurrent patellar instability. Medial patellofemoral ligament reconstruction resulted in better static patellar
position and functional outcome than arthroscopic medial retinacular plication. The authors set the tension of the medial retinaculum in 40 of knee flexion, in which the bony structure (e.g., trochlear groove) is a main factor of patellar stability. For our technique, the medial retinaculum is set in slight knee flexion (10 to 20 ), in which the patella is not engaged into the trochlear groove. Our suture management is applied using the technique of Laupattarakasem et al.6 Arthroscopic medial retinacular plication can be considered an optional technique to surgically plicate the retinaculum in patellar instability cases. It uses a less invasive technique, does not require tissue grafts, causes less skin irritation due to intra-articular suture stitches, and has a greater cosmetic advantage than its open counterparts.
References 1. Small NC, Glogau AI, Berezin MA. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 1993;9:63-67. 2. Haspl M, Cicak N, Klobucar H, Pecina M. Fully Arthroscopic stabilization of the patella. Arthroscopy 2002;18:1-3. 3. Ali S, Bhatti A. Arthroscopic proximal realignment of the patella for recurrent instability: Report of a new surgical technique with 1 to 7 years of follow-up. Arthroscopy 2007;23:305-311. 4. Halbrecht JL. Arthroscopic patella realignment: An allinside technique. Arthroscopy 2001;17:940-945. 5. Zhao J, Huangfu X, He Y. The role of medial retinaculum plication versus medial patellofemoral ligament reconstruction in combined procedures for recurrent patellar instability in adults. Am J Sports Med 2012;40:1355-1364. 6. Laupattarakasem W, Sumanont S, Kesprayura S, Kasemkijwattana C. Arthroscopic outside-in meniscal repair through a needle hole. Arthroscopy 2004;20:654-657.
Abstract: Patellar instability is a common problem resulting in anterior knee pain. The medial patellofemoral ligament, which is part of the medial retinaculum, is often injured, and this damaged structure can affect normal patellar movement. Medial retinacular plication can correct this main pathology of patellar instability. Many studies have shown good to excellent results with medial retinacular plication with or without lateral retinacular release. This medial retinacular plication technique can also be performed arthroscopically. Arthroscopic medial reticular plication with a needle-hole technique is a treatment that uses the less invasive technique of arthroscopy, does not require tissue grafts, and has a greater cosmetic advantage than open procedures.
P
atellar instability is a common problem resulting in anterior knee pain. However, there are many causes of patellar instability: those that involve softtissue pathology or bony pathology. Many surgical techniques have been published over the years. We can categorize the types of surgical treatment for patellar instability as lateral retinacular release, proximal realignment, distal realignment, and patellectomy. The medial patellofemoral ligament, which is part of the medial retinaculum, is the main injured structure especially regarding normal knee alignment. Therefore, medial retinacular plication, a proximal realignment correction technique, can directly address the main pathology of patellar instability. In recent years medial retinacular plication has been developed using an arthroscopic technique, which is cosmetically more acceptable.1-5 Many studies have shown good to excellent results of medial retinacular placation with or without lateral retinacular release. This article describes arthroscopic medial retinacular
From the Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 23, 2014; accepted May 8, 2014. Address correspondence to Niti Prasathaporn, M.D., Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14153/$36.00 http://dx.doi.org/10.1016/j.eats.2014.05.004
plication with soft suture material through only small stab wounds (Table 1).
Surgical Technique We position the patient supine on the operating table. The patellar gliding test is performed medially and laterally for both knees. We determine the distance of medial retinacular plication from the excessive distance Table 1. Indication, Contraindications, Advantages, Tips and Pearls, and Limitation of Arthroscopic Medial Retinacular Plication With Needle-Hole Technique Indication Patellar instability in normal knee alignment Contraindications Patella alta Excessive Q angle Femoral trochlear dysplasia Advantages Less invasive technique No need for tissue grafts Knots’ location in an articular space, which will not irritate subcutaneous layer and skin Good cosmetic outcome Tips and pearls To prevent a skin dimple, the first and second needle passes through the medial retinaculum need to use the same stab wound. The distance between the first and second passes of the medial retinaculum depends on the severity of lateral patellar gliding. The tension of the medial retinaculum should be set in slight knee flexion (10 to 20 ). Limitation In cases of patellar instability due to bony pathologies, arthroscopic medial retinacular plication is not recommended.
Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e483-e486
e483
e484
N. PRASATHAPORN ET AL.
Fig 2. A superolateral portal is used as a viewing portal. An 18-gauge needle, which is loaded with No. 1 PDS thread, is passed through the stab skin incision and medial retinaculum at the medial rim of the patella.
Fig 1. The left knee are fully extended in the supine position. The standard anteromedial (AM), anterolateral (AL), and superolateral (SL) portals are defined. The stab incisions are located on the superomedial quadrant of the patellar rim (S).
of lateral patellar gliding while comparing it with the contralateral side. If lateral retinacular tightness is present, lateral retinacular release may be performed. A tourniquet is usually used if not clinically contraindicated. General arthroscopic examination is routinely carried out through the standard anterolateral portal and anteromedial portal. A superolateral portal is created and used as a viewing portal. A stab surgical wound is made on the upper medial quadrant of the patella (Fig 1). The camera is placed through the anterolateral portal. An 18-gauge needle is loaded with No. 1 PDS thread (Johnson & Johnson, New Brunswick, NJ) folded over the bevel end. The needle is passed through the stab wound; then the medial retinaculum is penetrated at the rim of the patella (Fig 2 and Video 1). The PDS is pulled to make the first loop using a retriever or hook. The needle is pulled out of the retinaculum while the suture is kept loaded. The needle is medially shifted on the retinaculum. The distance between both punctures depends on the lateral gliding distance of the patella. After the appropriate distance has been determined, the needle is passed through the retinaculum into the joint (Fig 3). The first loop is released; then the retriever is passed through this loop to grasp the PDS at the bevel end. This PDS at the end of the retriever is pulled through the first loop and out the anteromedial portal (Fig 4). The needle is pulled out the retinaculum. The 2 arms of the
first loop are defined and pulled simultaneously to draw the suture end from the anteromedial portal (Fig 5). Then both ends of the PDS are drawn outside the joint. The ends of No. 2 Ethibond (Johnson & Johnson) are tied to the ends of the PDS (Fig 6). The PDS is pulled out through the anteromedial portal to pass the ends of the Ethibond into the joint and also out through the anteromedial portal. The steps can be repeated according to the number of stitches required to plicate the medial retinaculum. Usually, the plication requires around 3 to 5 stitches at the upper medial quadrant of the patella. Each set of Ethibond threads can be kept at the anteromedial portal for suture management. Once all the stitches are placed, the viewing portal changes to the anterolateral portal, and the sutures are tied through the superolateral portal in a position of slight knee flexion (10 to 20 ) (Fig 7). After medial retinacular plication has been completed (Fig 8), a compression dressing is applied.
Fig 3. A hook or suture retriever, which passes through the anteromedial portal, is holding the first loop of suture. The needle is passed through the same skin incision; then slide the needle on the medial retinaculum medially before the needle is passed through the medial retinaculum.
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Fig 4. The suture end of the second loop is drawn through the first loop and out the anteromedial portal.
Postoperative Protocol A hinged knee brace is used and locked in full extension on the first postoperative day. Partial to full weight bearing is allowed immediately after the operation. Range-of-motion exercises are allowed to 30 , 45 , and 90 of knee flexion after the second, fourth, and sixth postoperative week, respectively. Quadriceps strengthening exercise is initiated 4 weeks after the operation. Light sporting activities are allowed at 3 months, whereas contact sports are allowed at 6 months.
Discussion Patellar instability is one common problem resulting in anterior knee pain. However, there are many causes for patellar instability. These causes can be grouped as soft-tissue pathologies or bony pathologies. The medial patellofemoral ligament, which is part of the medial retinaculum, is often the main structure involved in injuries, especially in normal knee alignment. Therefore medial retinacular plication corrects this main
Fig 5. The first suture loop is pulled out the skin incision; then the suture end from the anteromedial portal is drawn to the skin incision.
Fig 6. The No. 1 PDS thread is changed to the soft, malleable No. 2 Ethibond thread, which is then relayed through the retinaculum.
pathology of patellar instability. In recent years, an arthroscopic technique has been developed for medial retinacular plication. The results of arthroscopic medial reticular plication have been published in many studies. Two decades ago, arthroscopically assisted proximal extensor mechanism realignment showed good to excellent subjective results in 92.5% of cases.1 A more recent case series by Haspl et al.2 also showed good results of fully arthroscopic medial retinacular plication and lateral retinacular release for patellar instability. Postoperative results after a follow-up period of 12 to 26 months were good, with no recurrence of subluxation or dislocation. In a retrospective study, Ali and Bhatti3 demonstrated a technique for arthroscopic proximal realignment for recurrent patellar instability. The study included 38 knees in 37 patients, which were evaluated at a mean follow-up of 51 months. The results showed excellent stability in 88.8% of knees and good to excellent Lysholm functional knee scores in 77.7%. For 32 knees, the patients were satisfied with the operation.
Fig 7. The viewing portal changes to the anterolateral portal. The No. 2 Ethibond suture stitch is tied to plicate the medial retinaculum through the superolateral portal.
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Fig 8. Three to five suture stitches are required for medial retinacular plication.
One published case-series study showed a truly allarthroscopic patellar realignment.4 The results showed significant improvement in pain, swelling, stair climbing, Lysholm score, and ability to return to sports. The congruence angle, lateral patellofemoral angle, and lateral patellar displacement showed significant improvement postoperatively. The author used the same suture management as used with the needle-hole technique. His technique used a PDS thread as the final suture, which is not as secure as a malleable thread. Soft-tissue cut-through can occur when a PDS thread changes to a malleable thread through acute-angle passing. In a recent study, Zhao et al.5 compared the results between arthroscopic medial retinacular plication and medial patellofemoral ligament reconstruction for recurrent patellar instability. Medial patellofemoral ligament reconstruction resulted in better static patellar
position and functional outcome than arthroscopic medial retinacular plication. The authors set the tension of the medial retinaculum in 40 of knee flexion, in which the bony structure (e.g., trochlear groove) is a main factor of patellar stability. For our technique, the medial retinaculum is set in slight knee flexion (10 to 20 ), in which the patella is not engaged into the trochlear groove. Our suture management is applied using the technique of Laupattarakasem et al.6 Arthroscopic medial retinacular plication can be considered an optional technique to surgically plicate the retinaculum in patellar instability cases. It uses a less invasive technique, does not require tissue grafts, causes less skin irritation due to intra-articular suture stitches, and has a greater cosmetic advantage than its open counterparts.
References 1. Small NC, Glogau AI, Berezin MA. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 1993;9:63-67. 2. Haspl M, Cicak N, Klobucar H, Pecina M. Fully Arthroscopic stabilization of the patella. Arthroscopy 2002;18:1-3. 3. Ali S, Bhatti A. Arthroscopic proximal realignment of the patella for recurrent instability: Report of a new surgical technique with 1 to 7 years of follow-up. Arthroscopy 2007;23:305-311. 4. Halbrecht JL. Arthroscopic patella realignment: An allinside technique. Arthroscopy 2001;17:940-945. 5. Zhao J, Huangfu X, He Y. The role of medial retinaculum plication versus medial patellofemoral ligament reconstruction in combined procedures for recurrent patellar instability in adults. Am J Sports Med 2012;40:1355-1364. 6. Laupattarakasem W, Sumanont S, Kesprayura S, Kasemkijwattana C. Arthroscopic outside-in meniscal repair through a needle hole. Arthroscopy 2004;20:654-657.
