Arthroscopy:
The Journal
of Arthroscopic
and Relared Surgery
Published by Raven Press, Ltd. 0 1992 Arthroscopy
Association
8(4):531-536
of North America
Role of Arthroscopic Lateral Release in the Treatment of Patellofemoral Disorders C. Fabbriciani,
M.D., A Schiavone
Panni, M.D., and A. Delcogliano,
M.D.
Summary: The results of 50 arthroscopic lateral releases are reported. The average follow-up period was 36 months with a range of 18-52 months. Satisfactory results were achieved in 71% of 21 patients with patellar pain alone and in 76% of those (Betz RR, Lonergan R, Patterson R. The percutaneous lateral retinacular release Orthopaedics 1982;5:57-62) with instability. Patients with patellofemoral osteoarthritis or patellar dislocation were excluded from the series. Postoperative hemarthrosis occurred in 10%. Unsatisfactory results could be related to incomplete release, severe chondromalacia, or insufficient rehabilitation. Lateral release is capable of producing high rates of success with a low incidence of complication when used to treat patellar pain with tight retinaculum, patellar instability, and subluxation. Key Words: Patella-Lateral release-Pain-Instability-Subluxation.
Patellofemoral pain is one of the most frequently encountered problems in clinical orthopedics. This pain, which may or may not be associated with malalignment of the extensor apparatus, is one of the most common complaints in young patients, especially females; furthermore, it may impose signif’icant limitations on their daily physical activities. Fortunately the majority of these patients respond well to conservative treatment. A physical therapy program consisting of progressive isometric quadriceps-strengthening exercises, restriction of activities that require >90% flexion of the knee, periodic administration of antiinflammatory agents, and a program aimed at maintaining improved muscle trophism produced positive results in 82% of the patients studied by De Haven et al. (1) and in 93% of the cases observed by Micheli and Stanitsky (2). Surgical treatment may be necessary for patients who are still experiencing pain after at least 6 months of physical therapy. Approximately 180 sur-
gical procedures have been described thus far in the literature. In 1959 Cotta (3) found 137. The earliest case, which was described by Heller, dates back to 1850. The objective should be to reduce the dominant lateral forces that tend to lateralize the patella. A number of approaches can be used to achieve this end: (a) direct reduction in the lateral forces on the patellofemoral joint (lateral retinacular release), (b) indirect reduction of these lateral forces (distal realignment of the extensor apparatus), (c) increase in medial stability (capsular reefing or vastus medialis myoplasty), and (d) various combinations of the above techniques. Most of these techniques require lengthy periods of immobilization and a vigorous course of rehabilitation. In addition, the patient is left with a large scar. However, isolated release of the lateral retinaculum can be accomplished in an open procedure or with arthroscopy, which considerably reduces the amount of surgery. Merchant and Mercer (4) were the first to describe lateral retinacular release as an isolated surgical technique in 1974. Since then numerous variants of this procedure using both open (5-S) and arthroscopic (9-13) techniques have been reported.
From the Departmentof Orthopaedics,CatholicUniversityof the Sacred Heart, Rome, Italy. Address correspondence and reprint requests to Carlo Fabbriciani,M.D., Department of Orthopaedics, Catholic University, Largo A. Gemelli 8-00168 Rome, Italy.
531
532
C. FABBRICIANIETAL.
However, the indications for use of the lateral retinacular release and the results it produces vary widely. Satisfactory results have been reported in percentages that range from 14 (4) to 99% (5). A review of the literature reveals that lateral release has been used to treat patients with various types of patellofemoral disorders such as pain, malalignment, recurrent patellar dislocation, patellar chondromalacia, and patellofemoral osteoarthritis. Studies that compare treatment results for such a wide range of disorders, however, are inconclusive. Therefore, we will report the results of our experiences with lateral retinacular release in two types of patients: those with patellofemoral pain alone and those with signs of patellar instability. MATERIALS AND METHODS Between 1985 and 1988, 55 lateral retinacular releases were performed in the Orthopedic Department of the Catholic University in Rome, Italy. The patients’ symptoms included patellofemoral pain, catching, “giving way,” and subluxation of the patella. The mean duration of symptoms before surgery was 10 months (range 6-15 months). Follow-up ranged from 18 to 52 months with a mean of 36 months. All of the patients had used patellar braces and had undergone appropriate physical therapy for at least 6 months before surgery without significant improvement. The patients were divided into two groups. The first group contained 23 patients with patellar pain and no signs of instability [type III of Schutzer, Fulkerson’s scale (16)]. The mean Q angle for this group was 15.2”. The remaining 32 patients, all of whom had clear signs of patellar instability, made up the second group, in which the mean Q angle was 14.5” [type I of Schutzer, Fulkerson (16)l. The Q angle was less (14.5“) in the group of patellar instability than in the patellar pain group (15.2X as pointed out by Aglietti et al. (17). The mean age of the 55 patients was 25 years (range 15-38 years). There was a prevalence of female (39 cases) over male patients (16 cases). Because we believe that lateral release alone is insufficient to guarantee good results, this series contains no patients with dislocation of the patella. Patients with patellofemoral osteoarthritis were also excluded because the significant differences between the clinical and radiographic features of this condition and those of excessive lateral pressure or patellar instability would have made comArthroscopy,
Vol. 8, No. 4, 1992
paring results difficult. None of the patients previously had femoropatellar joint surgery. In the patellar pain group, symptoms were described as swelling and peripatellar pain that was accentuated by running, jumping, going up and down stairs, and flexion of the knee that exceeded 90”. In the instability group, other symptoms included swelling and the sensation that the patella was “giving way” or popping. Transient “locking” was reported by some of the patients, but this sensation was actually a manifestation of patellar subluxation rather than true locking. The vastus medialis obliquus was evaluated for hypoplasia (16), and medial mobility of the patella was measured. Patients with medial mobility of ~0.5 cm during l&20” flexion were placed in the group with excessive lateral pressure, whereas those with greater medial mobility and extensive patellar mobility in general were assigned to the group with instability (18). Patients were also evaluated for an apprehension sign, patellofemoral crepitus, and generalized ligamentous laxity. Hypertrophy of the vastus lateralis and tenderness of the patellar facets or retinaculum were common findings. Standard and weight-bearing radiographs were performed in all patients. In addition, axial views of the knee in 30, 60, and 90” were obtained, and the more recent patients underwent computed tomographic studies as well. SURGICAL TECHNIQUE All procedures were performed with patients under general anesthesia with a pneumatic tourniquet to avoid bleeding. The arthroscopic examination was carried out through both superolateral and inferolateral portals to evaluate more completely the patellar tracking and possible chondral damage (Fig. 1). Patellar tracking was evaluated before the release. In our opinion, distension of the articular cavity with a liquid does not have significant effects on tracking the patella. Casscell’s (19) method was used to classify cases of maltracking as those in which the patella was centered within the patellar groove of the femur with the knee flexed 90” (grade III). Fifteen of the patients were thus classified as grade I, 22 as grade II, and 18 as grade III. After lateral release, 23 of these patients showed normal tracking, 28 were classified as grade I, and 4 were classified as grade II.
LATERAL RELEASE IN PATELLOFEMORAL
FIG. 1. Arthroscopic view of the patellofemoral joint shows lateral patellar overhang.
Chondral damage was classified according to Outerbridge’s criteria (20). In the patients with patellar instability there were three cases of stage I chondromalacia, five cases of stage 2, two cases of stage 3, and one case of stage 4. The group of patients with patellar instability contained seven cases of stage 1 chondromalacia, six of stage 2, and two of stage 3. Six selective meniscectomies (four medial and two lateral) were performed. Cartilage shaving
533
DISORDERS
was carried out in patients with stage II, III, and IV chondromalacia. Metcalf s technique (10) was scrupulously followed for release of the lateral retinaculum. A subcutaneous tunnel was bluntly dissected through the inferolateral portal and full-thickness, longitudinal dissection of the retinaculum, capsule, and synovial tissue was carried out to the distalmost fibers of the vastus lateralis, -2 cm above the superior pole of the patella. The incision must follow the lateral border of the patella as closely as possible to avoid damage to the anterior branch of the lateral geniculate artery. Extreme care also must be taken to assure that all three layers of the retinaculum (21,22), particularly the patellotibial ligament and any other tight elements, have been divided completely . At this point, the arthroscope was inserted through a superolateral portal to evaluate further patellar tracking and centering (Fig. 2). If the “turn up” sign was
The Journal
of Arthroscopic
and Relared Surgery
Published by Raven Press, Ltd. 0 1992 Arthroscopy
Association
8(4):531-536
of North America
Role of Arthroscopic Lateral Release in the Treatment of Patellofemoral Disorders C. Fabbriciani,
M.D., A Schiavone
Panni, M.D., and A. Delcogliano,
M.D.
Summary: The results of 50 arthroscopic lateral releases are reported. The average follow-up period was 36 months with a range of 18-52 months. Satisfactory results were achieved in 71% of 21 patients with patellar pain alone and in 76% of those (Betz RR, Lonergan R, Patterson R. The percutaneous lateral retinacular release Orthopaedics 1982;5:57-62) with instability. Patients with patellofemoral osteoarthritis or patellar dislocation were excluded from the series. Postoperative hemarthrosis occurred in 10%. Unsatisfactory results could be related to incomplete release, severe chondromalacia, or insufficient rehabilitation. Lateral release is capable of producing high rates of success with a low incidence of complication when used to treat patellar pain with tight retinaculum, patellar instability, and subluxation. Key Words: Patella-Lateral release-Pain-Instability-Subluxation.
Patellofemoral pain is one of the most frequently encountered problems in clinical orthopedics. This pain, which may or may not be associated with malalignment of the extensor apparatus, is one of the most common complaints in young patients, especially females; furthermore, it may impose signif’icant limitations on their daily physical activities. Fortunately the majority of these patients respond well to conservative treatment. A physical therapy program consisting of progressive isometric quadriceps-strengthening exercises, restriction of activities that require >90% flexion of the knee, periodic administration of antiinflammatory agents, and a program aimed at maintaining improved muscle trophism produced positive results in 82% of the patients studied by De Haven et al. (1) and in 93% of the cases observed by Micheli and Stanitsky (2). Surgical treatment may be necessary for patients who are still experiencing pain after at least 6 months of physical therapy. Approximately 180 sur-
gical procedures have been described thus far in the literature. In 1959 Cotta (3) found 137. The earliest case, which was described by Heller, dates back to 1850. The objective should be to reduce the dominant lateral forces that tend to lateralize the patella. A number of approaches can be used to achieve this end: (a) direct reduction in the lateral forces on the patellofemoral joint (lateral retinacular release), (b) indirect reduction of these lateral forces (distal realignment of the extensor apparatus), (c) increase in medial stability (capsular reefing or vastus medialis myoplasty), and (d) various combinations of the above techniques. Most of these techniques require lengthy periods of immobilization and a vigorous course of rehabilitation. In addition, the patient is left with a large scar. However, isolated release of the lateral retinaculum can be accomplished in an open procedure or with arthroscopy, which considerably reduces the amount of surgery. Merchant and Mercer (4) were the first to describe lateral retinacular release as an isolated surgical technique in 1974. Since then numerous variants of this procedure using both open (5-S) and arthroscopic (9-13) techniques have been reported.
From the Departmentof Orthopaedics,CatholicUniversityof the Sacred Heart, Rome, Italy. Address correspondence and reprint requests to Carlo Fabbriciani,M.D., Department of Orthopaedics, Catholic University, Largo A. Gemelli 8-00168 Rome, Italy.
531
532
C. FABBRICIANIETAL.
However, the indications for use of the lateral retinacular release and the results it produces vary widely. Satisfactory results have been reported in percentages that range from 14 (4) to 99% (5). A review of the literature reveals that lateral release has been used to treat patients with various types of patellofemoral disorders such as pain, malalignment, recurrent patellar dislocation, patellar chondromalacia, and patellofemoral osteoarthritis. Studies that compare treatment results for such a wide range of disorders, however, are inconclusive. Therefore, we will report the results of our experiences with lateral retinacular release in two types of patients: those with patellofemoral pain alone and those with signs of patellar instability. MATERIALS AND METHODS Between 1985 and 1988, 55 lateral retinacular releases were performed in the Orthopedic Department of the Catholic University in Rome, Italy. The patients’ symptoms included patellofemoral pain, catching, “giving way,” and subluxation of the patella. The mean duration of symptoms before surgery was 10 months (range 6-15 months). Follow-up ranged from 18 to 52 months with a mean of 36 months. All of the patients had used patellar braces and had undergone appropriate physical therapy for at least 6 months before surgery without significant improvement. The patients were divided into two groups. The first group contained 23 patients with patellar pain and no signs of instability [type III of Schutzer, Fulkerson’s scale (16)]. The mean Q angle for this group was 15.2”. The remaining 32 patients, all of whom had clear signs of patellar instability, made up the second group, in which the mean Q angle was 14.5” [type I of Schutzer, Fulkerson (16)l. The Q angle was less (14.5“) in the group of patellar instability than in the patellar pain group (15.2X as pointed out by Aglietti et al. (17). The mean age of the 55 patients was 25 years (range 15-38 years). There was a prevalence of female (39 cases) over male patients (16 cases). Because we believe that lateral release alone is insufficient to guarantee good results, this series contains no patients with dislocation of the patella. Patients with patellofemoral osteoarthritis were also excluded because the significant differences between the clinical and radiographic features of this condition and those of excessive lateral pressure or patellar instability would have made comArthroscopy,
Vol. 8, No. 4, 1992
paring results difficult. None of the patients previously had femoropatellar joint surgery. In the patellar pain group, symptoms were described as swelling and peripatellar pain that was accentuated by running, jumping, going up and down stairs, and flexion of the knee that exceeded 90”. In the instability group, other symptoms included swelling and the sensation that the patella was “giving way” or popping. Transient “locking” was reported by some of the patients, but this sensation was actually a manifestation of patellar subluxation rather than true locking. The vastus medialis obliquus was evaluated for hypoplasia (16), and medial mobility of the patella was measured. Patients with medial mobility of ~0.5 cm during l&20” flexion were placed in the group with excessive lateral pressure, whereas those with greater medial mobility and extensive patellar mobility in general were assigned to the group with instability (18). Patients were also evaluated for an apprehension sign, patellofemoral crepitus, and generalized ligamentous laxity. Hypertrophy of the vastus lateralis and tenderness of the patellar facets or retinaculum were common findings. Standard and weight-bearing radiographs were performed in all patients. In addition, axial views of the knee in 30, 60, and 90” were obtained, and the more recent patients underwent computed tomographic studies as well. SURGICAL TECHNIQUE All procedures were performed with patients under general anesthesia with a pneumatic tourniquet to avoid bleeding. The arthroscopic examination was carried out through both superolateral and inferolateral portals to evaluate more completely the patellar tracking and possible chondral damage (Fig. 1). Patellar tracking was evaluated before the release. In our opinion, distension of the articular cavity with a liquid does not have significant effects on tracking the patella. Casscell’s (19) method was used to classify cases of maltracking as those in which the patella was centered within the patellar groove of the femur with the knee flexed 90” (grade III). Fifteen of the patients were thus classified as grade I, 22 as grade II, and 18 as grade III. After lateral release, 23 of these patients showed normal tracking, 28 were classified as grade I, and 4 were classified as grade II.
LATERAL RELEASE IN PATELLOFEMORAL
FIG. 1. Arthroscopic view of the patellofemoral joint shows lateral patellar overhang.
Chondral damage was classified according to Outerbridge’s criteria (20). In the patients with patellar instability there were three cases of stage I chondromalacia, five cases of stage 2, two cases of stage 3, and one case of stage 4. The group of patients with patellar instability contained seven cases of stage 1 chondromalacia, six of stage 2, and two of stage 3. Six selective meniscectomies (four medial and two lateral) were performed. Cartilage shaving
533
DISORDERS
was carried out in patients with stage II, III, and IV chondromalacia. Metcalf s technique (10) was scrupulously followed for release of the lateral retinaculum. A subcutaneous tunnel was bluntly dissected through the inferolateral portal and full-thickness, longitudinal dissection of the retinaculum, capsule, and synovial tissue was carried out to the distalmost fibers of the vastus lateralis, -2 cm above the superior pole of the patella. The incision must follow the lateral border of the patella as closely as possible to avoid damage to the anterior branch of the lateral geniculate artery. Extreme care also must be taken to assure that all three layers of the retinaculum (21,22), particularly the patellotibial ligament and any other tight elements, have been divided completely . At this point, the arthroscope was inserted through a superolateral portal to evaluate further patellar tracking and centering (Fig. 2). If the “turn up” sign was
