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Fully Arthroscopic Stabilization of the Patella
Technical Note
Fully Arthroscopic Stabilization of the Patella Miroslav Hasˇpl, M.D., Ph.D., Nikola Cˇicˇak, M.D., Ph.D., Hrvoje Klobucˇar, M.D., and Marko Pec´ina, M.D., Ph.D.
Abstract: The authors present a new fully arthroscopic technique for the treatment of patellofemoral instability consisting of plication of the medial patellar retinaculum and release of the lateral patellar retinaculum. The indication for this procedure is not only acute patellar luxation, but also recurrent patellar luxation and subluxation. The procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years. The indication for surgical arthroscopic treatment was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. Postoperative results after follow-up of 12 to 26 months have been good with no recurrence of subluxation or luxation. This procedure is a valuable technique for treating patellar maltracking and instability and acute and recurrent patellar luxation, particularly in adolescents and young adults. Key Words: Patellofemoral instability—Arthroscopic realignment—Arthroscopic stabilization.
T
reatment of anterior knee pain caused by patellofemoral instability is a source of much controversy. Many different surgical techniques have been described. Despite the proliferation and obvious success of arthroscopic procedures in the knee joint, procedures to stabilize the unstable patellofemoral joint have evolved slowly. Sherman et al.1 proposed a lateral retinacular release to prevent recurrent episodes of instability. Brief 2 suggested a surgical approach combining open medial tethering of the patellar tendon with arthroscopic lateral release. Yamamoto3 and Ku¨ndinger 4 described an arthroscopic-assisted technique for repair of the medial retinaculum in the acutely unstable patellofemoral joint. Small et al.5 used arthroscopic lateral release and arthroscopically controlled plication of the medial retinaculum. We
From the Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia. Address correspondence and reprint requests to Miroslav Hasˇpl, M.D., Ph.D., Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Sˇalata 6, 10 000 Zagreb, Croatia. E-mail: [email protected] © 2002 by the Arthroscopy Association of North America 1526-3231/02/1801-2939$35.00/0 doi:10.1053/jars.2002.30023
describe here a new fully arthroscopic technique for surgical treatment of subluxation and acute and recurrent luxations of the patella in adolescents and young adults.
SURGICAL TECHNIQUE The procedure starts with arthroscopic assessment of patelollofemoral tracking. Through the superomedial portal, a working cannula is introduced extraarticularly. This superomedial or extra-articular portal is located 2 fingers medial from superomedial border of the patella. The cannula is pushed extra-articularly into the subcutaneous tissue in the space between skin and medial retinaculum. The needle enters the medial retinaculum posterior to the edge of the retinacular defect. When the tip of the needle is in the joint, PDS suture is pushed into the joint (Fig 1). The suture grasper catches the inside limb of the PDS suture and withdraws it through the superolateral portal, located just above lateral border of the patella. The Transporter Suture Retriever (Acufex, Mansfield, MA) is inserted through the extra-articular cannula and perforates the medial retinaculum just to the medial border of the patella. The Transporter Suture Retriever
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 1 (January), 2002: E2
1
2
M. HASˇPL ET AL.
FIGURE 1. Introduction of the working cannula extra-articularly: the needle with PDS suture enters the medial retinaculum posterior to the edge of the retinacular defect.
catches the PDS suture and it is withdrawn through the extra-articular cannula outside (Fig 2); 4 to 5 sutures are usually required. The lateral retinacular release is performed through the inferolateral portal (Fig 3). Medial retinacular release below the PDS sutures is then performed (Fig 4). This medial retinacular release can be performed before insertion of the needle through the extra-articular cannula. An arthroscopic knot6,7 is formed outside of the cannula and slides down through the extra-articular cannula with or without a knot pusher. Under arthroscopic control, sutures are tied individually and plicated so that they overlap the medial retinaculum (Fig 5). The patella is then checked for stability during flexion and extension (Fig 6). Postoperatively, the knee is placed in a brace in full
FIGURE 2. The Transporter Suture Retriever perforates the medial retinaculum just to the medial border of the patella. It catches the PDS suture, which is withdrawn through the extra-articular cannula.
FIGURE 3. The lateral retinacular release is performed through the inferolateral portal.
extension for 3 weeks. Progressive partial and then full weight bearing is allowed during the period of immobilization. Active range of motion begins after 3 weeks, and full sports activity after 12 weeks. RESULTS This procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years (average, 18.8 years). All patients had patellofemoral dysplasia; there was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. The follow-up has been short, 9 to 18 months (average, 13.3 months), but the first results are promising; the patients have good
FIGURE 4. The medial retinacular release below the PDS sutures is performed.
ARTHROSCOPIC STABILIZATION OF THE PATELLA
3
FIGURE 5. An arthroscopic knot is formed outside and slides down through the extra-articular cannula with a knot pusher. Under arthroscopic control, sutures are tied individually and plicated so that they overlap the medial retinaculum.
patellofemoral articulation and have had no recurrence of subluxation or luxation. CONCLUSION Traditional extensive open procedures for the treatment of patellofemoral instability often carry significant postoperative morbidity and disability. This new fully arthroscopic procedure significantly reduces postoperative pain and morbidity. It also reduces the postoperative rehabilitation period. Good patellofemoral stability is achieved and there is only minor scarring. This minimally invasive procedure is particularly recommended for the immature knee. We believe that this new procedure should be considered in the treatment of patella maltracking and instability.
FIGURE 6. Arthroscopic technique: (A) After placing the 5 sutures on the medial retinaculum, medial (below the sutures) and lateral retinacular release is performed. (B) There is good patellofemoral tracking after the procedure.
REFERENCES 1. Sherman OH, Fox JM, Sperling H, et al. Patellar instability: Treatment by arthroscopic electrosurgical lateral release. Arthroscopy 1987;3:152-160. 2. Brief LP. Lateral patellar instability: Treatment with a combined open-arthroscopic approach. Arthroscopy 1993;9:617-623. 3. Yamamoto RK. Arthroscopic repair of the medial retinaculum and capsule in acute patellar dislocation. Arthroscopy 1986;2: 125-131.
4. K¨undinger R. Technik zur Arthroscopischen Retinakulumnaht nach Patellaluxation. Arthroscopie 1996;9:41-43. 5. Small NC, Glegau AI, Berezina MA. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 1993;9:63-67. 6. Loutzenheiser TD, Haryman DT II, Young SW, France MP, Slides JA. Arthroscopic knots. Arthroscopy 1995;11:199-206. 7. Delimar D. A secure arthroscopic knot. Arthroscopy 1996;12: 345-347.
Fully Arthroscopic Stabilization of the Patella Miroslav Hasˇpl, M.D., Ph.D., Nikola Cˇicˇak, M.D., Ph.D., Hrvoje Klobucˇar, M.D., and Marko Pec´ina, M.D., Ph.D.
Abstract: The authors present a new fully arthroscopic technique for the treatment of patellofemoral instability consisting of plication of the medial patellar retinaculum and release of the lateral patellar retinaculum. The indication for this procedure is not only acute patellar luxation, but also recurrent patellar luxation and subluxation. The procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years. The indication for surgical arthroscopic treatment was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. Postoperative results after follow-up of 12 to 26 months have been good with no recurrence of subluxation or luxation. This procedure is a valuable technique for treating patellar maltracking and instability and acute and recurrent patellar luxation, particularly in adolescents and young adults. Key Words: Patellofemoral instability—Arthroscopic realignment—Arthroscopic stabilization.
T
reatment of anterior knee pain caused by patellofemoral instability is a source of much controversy. Many different surgical techniques have been described. Despite the proliferation and obvious success of arthroscopic procedures in the knee joint, procedures to stabilize the unstable patellofemoral joint have evolved slowly. Sherman et al.1 proposed a lateral retinacular release to prevent recurrent episodes of instability. Brief 2 suggested a surgical approach combining open medial tethering of the patellar tendon with arthroscopic lateral release. Yamamoto3 and Ku¨ndinger 4 described an arthroscopic-assisted technique for repair of the medial retinaculum in the acutely unstable patellofemoral joint. Small et al.5 used arthroscopic lateral release and arthroscopically controlled plication of the medial retinaculum. We
From the Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia. Address correspondence and reprint requests to Miroslav Hasˇpl, M.D., Ph.D., Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Sˇalata 6, 10 000 Zagreb, Croatia. E-mail: [email protected] © 2002 by the Arthroscopy Association of North America 1526-3231/02/1801-2939$35.00/0 doi:10.1053/jars.2002.30023
describe here a new fully arthroscopic technique for surgical treatment of subluxation and acute and recurrent luxations of the patella in adolescents and young adults.
SURGICAL TECHNIQUE The procedure starts with arthroscopic assessment of patelollofemoral tracking. Through the superomedial portal, a working cannula is introduced extraarticularly. This superomedial or extra-articular portal is located 2 fingers medial from superomedial border of the patella. The cannula is pushed extra-articularly into the subcutaneous tissue in the space between skin and medial retinaculum. The needle enters the medial retinaculum posterior to the edge of the retinacular defect. When the tip of the needle is in the joint, PDS suture is pushed into the joint (Fig 1). The suture grasper catches the inside limb of the PDS suture and withdraws it through the superolateral portal, located just above lateral border of the patella. The Transporter Suture Retriever (Acufex, Mansfield, MA) is inserted through the extra-articular cannula and perforates the medial retinaculum just to the medial border of the patella. The Transporter Suture Retriever
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 1 (January), 2002: E2
1
2
M. HASˇPL ET AL.
FIGURE 1. Introduction of the working cannula extra-articularly: the needle with PDS suture enters the medial retinaculum posterior to the edge of the retinacular defect.
catches the PDS suture and it is withdrawn through the extra-articular cannula outside (Fig 2); 4 to 5 sutures are usually required. The lateral retinacular release is performed through the inferolateral portal (Fig 3). Medial retinacular release below the PDS sutures is then performed (Fig 4). This medial retinacular release can be performed before insertion of the needle through the extra-articular cannula. An arthroscopic knot6,7 is formed outside of the cannula and slides down through the extra-articular cannula with or without a knot pusher. Under arthroscopic control, sutures are tied individually and plicated so that they overlap the medial retinaculum (Fig 5). The patella is then checked for stability during flexion and extension (Fig 6). Postoperatively, the knee is placed in a brace in full
FIGURE 2. The Transporter Suture Retriever perforates the medial retinaculum just to the medial border of the patella. It catches the PDS suture, which is withdrawn through the extra-articular cannula.
FIGURE 3. The lateral retinacular release is performed through the inferolateral portal.
extension for 3 weeks. Progressive partial and then full weight bearing is allowed during the period of immobilization. Active range of motion begins after 3 weeks, and full sports activity after 12 weeks. RESULTS This procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years (average, 18.8 years). All patients had patellofemoral dysplasia; there was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. The follow-up has been short, 9 to 18 months (average, 13.3 months), but the first results are promising; the patients have good
FIGURE 4. The medial retinacular release below the PDS sutures is performed.
ARTHROSCOPIC STABILIZATION OF THE PATELLA
3
FIGURE 5. An arthroscopic knot is formed outside and slides down through the extra-articular cannula with a knot pusher. Under arthroscopic control, sutures are tied individually and plicated so that they overlap the medial retinaculum.
patellofemoral articulation and have had no recurrence of subluxation or luxation. CONCLUSION Traditional extensive open procedures for the treatment of patellofemoral instability often carry significant postoperative morbidity and disability. This new fully arthroscopic procedure significantly reduces postoperative pain and morbidity. It also reduces the postoperative rehabilitation period. Good patellofemoral stability is achieved and there is only minor scarring. This minimally invasive procedure is particularly recommended for the immature knee. We believe that this new procedure should be considered in the treatment of patella maltracking and instability.
FIGURE 6. Arthroscopic technique: (A) After placing the 5 sutures on the medial retinaculum, medial (below the sutures) and lateral retinacular release is performed. (B) There is good patellofemoral tracking after the procedure.
REFERENCES 1. Sherman OH, Fox JM, Sperling H, et al. Patellar instability: Treatment by arthroscopic electrosurgical lateral release. Arthroscopy 1987;3:152-160. 2. Brief LP. Lateral patellar instability: Treatment with a combined open-arthroscopic approach. Arthroscopy 1993;9:617-623. 3. Yamamoto RK. Arthroscopic repair of the medial retinaculum and capsule in acute patellar dislocation. Arthroscopy 1986;2: 125-131.
4. K¨undinger R. Technik zur Arthroscopischen Retinakulumnaht nach Patellaluxation. Arthroscopie 1996;9:41-43. 5. Small NC, Glegau AI, Berezina MA. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 1993;9:63-67. 6. Loutzenheiser TD, Haryman DT II, Young SW, France MP, Slides JA. Arthroscopic knots. Arthroscopy 1995;11:199-206. 7. Delimar D. A secure arthroscopic knot. Arthroscopy 1996;12: 345-347.