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Isolated lateral retinacular release for patellar maltacking
The Knee 5 Ž1998. 187]190
Isolated lateral retinacular release for patellar maltacking Ravindra P. JoshiU , Frederick W. Heatley Orthopaedic Academic Unit, Rayne Institute, St. Thomas’ Hospital, London SE1 7EH, UK Accepted 10 September 1997
Abstract The outcome following an isolated lateral retinacular release for patellar maltracking was analysed. Thirty-nine knees were evaluated at an average follow up of 2.8 years. The assessment was performed by the modified Sandow and Goodfellow questionnaires and Crosby and Insall grading system. The results showed more than 80% of the patients had satisfactory outcome. This study has shown that if indications are observed rigidly a high level of patient satisfaction can be achieved following an isolated lateral retinacular release. Q 1998 Elsevier Science B.V. All rights reserved. Keywords: Lateral release; Maltracking
1. Introduction The results of an isolated lateral retinacular release in literature are difficult to compare due to differences in indication, selection criteria, surgical techniques and outcome assessment. The reported satisfactory results for patellar pain andror instability ranges from 14 to 99% w1]9x. The aim of this study was to analyse the results of the isolated retinacular release for patellar maltracking. The patients were selected for surgery by the strict criteria after defining, clinically and radiologically, the mechanical cause for the problem. The outcome was analysed to see whether high patient satisfaction can be obtained by this selective approach. 2. Material and methods Between 1983 and 1992, an isolated lateral retinacular release was performed for patellar maltracking on 39 knees Ž34 patients.. Five patients had bilateral U
Corresponding author. Tel.: q44 181 6330964; fax: q44 181 6330964. 0968-0160r98r$19.00 Q 1998 Elsevier Science B.V. All rights reserved. PII S0968-0160Ž97.10020-5
release. There were 28 femalesr33 knees and six malesrsix knees. The mean age at the time of operation was 23 Ž18]41. years in females and 28 Ž20]41. years in male patients. The average follow up was 2.8 Ž1.0]9.5. years. All the patients had patellar maltracking diagnosed on clinical grounds supplemented by skyline view. Clinically, patients had symptoms of giving way, painful clicking, swelling and locking. The apprehension test was positive. The skyline view showed either laterally subluxated w10x or tilted patella w11x. Those patients with generalized ligament laxity, high ‘Q’ angle Žmore than 208., evidence of patella alta or baja were not considered for the isolated lateral retinacular release. Only those patients with clinical and radiological evidence of patellar maltracking underwent lateral retinacular release. Those patients with undefined patellar pain were not considered suitable. Pre-operatively, all the patients had a course of physiotherapy. Average duration of symptoms before operation for 19 female patients Ž66%. was more than 3 years and minimum duration of symptoms before operation was 1 year. All the male patients had symptoms for more than 3 years before operation. Arthroscopic assessment was done prior to the lat-
188
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190
eral retinacular release to assess the condition of the articular surface of the patella and to rule out any associated pathology. In 10 female patients Ž30%., there was no evidence of chondromalacia patella ŽCMP. while in four Ž12%. lateral facet, in eight Ž24%. medial facet, in three Ž9%. central dome, in seven Ž21%. generalized and in one Ž3%. medial as well as central dome was involved with the changes of CMP. In two male patients Ž33%. there was no evidence of CMP while one each had medial, lateral, central and generalized changes of CMP. Two techniques were used depending on surgeon’s choice. For ‘open’ technique, the patient was re-prepared and re-draped after arthroscopic assessment. The lateral parapatellar incision was made from the level of tibial plateau to proximally up to the superior pole of the patella. The lateral retinaculum was divided and haemostasis was achieved by cauterizing the lateral geniculate artery or the branches of it. In ‘percutaneous’ technique, the scissors were introduced through the anterolateral portal of the arthroscopy and the lateral structures were divided blindly. Post-operatively the pressure dressing was applied in both the procedures with Velban and crepe bandage. Twenty-four patientsr25 knees were operated by percutaneous technique and 10 patientsr14 knees had surgery by open technique. Post-operatively patients were advised to do isometric exercise and straight leg raising from the first post-operative day. Patients were allowed weight bearing as tolerated with crutches and were discharged from the hospital when steady on feet. The pressure dressing was retained for 1 week and the patients were followed in the clinic at 2 weeks. At this follow up the wound was inspected and stitches were removed. The patients were then referred to physiotherapy to regain full range of movement and quadricepsrhamstring strengthening exercises with emphasis on vastus medialis strengthening exercises. Subsequently, the patients were followed in the out-patient clinic at 6 weeks for the first two visits and then 3-monthly. All were assessed clinically for any swelling, clicking, locking or giving way and advised to participate in sports gradually. Absence of these symptoms were considered as improvement in post-operative tracking. The patient was discharged from the out-patient clinic after improvement of these symptoms. For the functional assessment in this study, the Sandow and Goodfellow questionnaire w12x was modified by including the symptoms of giving way, swelling, locking and clicking. The Sandow and Goodfellow questionnaire assesses presence of pain, severity of pain, use of analgesia, frequency of pain, the extent to which sports were restricted and pain-associated activities. The patients were also classified by the Crosby and Insall grading system w13x. The outcome was
classified into four categories. Statistical analysis were performed by comparing the averages and responses and the level of significance was P- 0.05. 3. Results Functional assessment according to the modified Sandow and Goodfellow questionnaire ŽTable 1. showed that more than 80% of patients had relief of symptoms and had improved activities after surgery. None of the patients were made worse after the procedure. The results, as assessed by the Crosby and Insall grading system ŽTable 2., showed that there were 41% of the patients who were in excellent, 47% in good, 12% in fairrpoor and none in the worse category. In this series, 24 patients underwent percutaneous Table 1 Responses to questionnaires
Presence of pain Yes No Severity of pain Better Same Worse Use of analgesia Regularly Rarelyrnil Frequency of pain Continuous Daily WeeklyrRarely None Sports restricted activity Severely Occassionally Not at all No participation Pain associated activities Sports Stair climbling Walking Sitting Standing Cold weather Giving way Yes No Swelling Yes No Clicking Yes No Locking Yes No
Number
Percent
8 26
23.5 76.5
30 4 0
88.2 11.8 00.0
4 30
11.8 88.2
2 2 4 26
5.9 5.9 11.8 76.4
3 12 14 5
8.8 3.5 41.3 14.7
3 4 4 0 4 5
8.8 11.8 11.8 00.0 11.8 14.7
2 32
5.9 94.1
2 32
5.9 94.1
2 32
5.9 94.1
3 31
8.8 91.2
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190 Table 2 Post-operative assessment by Crosby]Insall grading system Grade
Excellent Good Fairrpoor Worse
Number of patients
Percent
14 16 4 0
41 47 12 0
release while 10 had open release. The results ŽTable 3. showed that there is no significant difference between the two techniques. However, following the open technique there were more ‘excellent’ results Ž50%. than those in the percutaneous technique Ž37.5%.. The results in male and female patients ŽTable 4. showed that female patients had less ‘excellent’ results as compared to male patients, however, the difference was not significant Ž P) 0.05.. There were two complications in the series. One patient had percutaneous lateral release done and developed haemarthrosis while the other patient developed severe stiffness following percutaneous release. There were no complications following the open procedure.
4. Discussion
There was a predominance of female patients Ž4.6:1.0. in this series. Earlier reports by Goldthwaite w5x, McNab w14x and Smillie w15x also showed predominance of female patients in their study. However, Hughston w16x reported a male to female ratio of 3:1 whilst Scuderi et al. w9x reported equal distribution. Scuderi et al. stated that the female patients in their series did not do as well as their male counterpart and speculated that factors such as wide pelvis, more femoral anteversion and genu valgum may result in residual forces in the knee that tend to pull patella laterally. In this series, 67.0% of male patients as compared with 36.5% of female patients fared ‘excellent’. On arthroscopic assessment, 30% of the patients had no evidence of CMP whilst others had a variable extent of involvement. There was no correlation between the extent of the changes of CMP and the symptoms as well as the outcome following lateral release. Goodfellow et al. w17x also stressed that the presence of CMP cannot be held responsible for the symptoms of patellofemoral pain in young patients. Leslie and Bentley w18x found only 50% of the patients with clinical symptoms of CMP had any microscopic changes when viewed arthroscopically. However, Jackson w19x supported the positive relationship
189
Table 3 Outcome in open and percutaneous techniques Žfigures representing percentages.
Percutaneous Open
Excellent
Good
FairrPoor
Worse
37.5 50.0
50.0 40.0
12.5 10.0
0 0
Table 4 Outcome in male and female patients Žfigures representing percentages.
Males Females
Excellent
Good
FairrPoor
Worse
67.0 36.5
16.5 53.5
16.5 10.0
0.00 0.00
between subluxation, dislocation and chondromalacia. Later, Bentley and Dowd w20x added further weight to the theory that patellofemoral subluxation could be associated with CMP. All the male patients and 66% of female patients had symptoms for more than 3 years. These patients remained symptomatic even after a course of physiotherapy. Sandow and Goodfellow w12x have shown that anterior knee pain tends to improve with time and is a serious disability for a few. In our series, all the operated patients had clinical and radiological evidence of patellar maltracking and therefore remained symptomatic even after a course of non-operative treatment. There was one case of haemarthrosis Ž3%. following percutaneous technique and none following open technique. Arthroscopic release has the cosmetic advantage over an open operation and it has a disadvantage that bleeding cannot be easily controlled. It may be that open lateral release through 2-cm incision which allows control of bleeding from superior lateral geniculate artery will eventually prove to be the procedure of choice w4x. In reviewing the literature, it is often difficult to separate the results in patients with recurrent dislocation or subluxation of the patella from those with patellofemoral pain caused by lateral patellar compression syndrome. In our series, as assessed by the Crosby and Insall grading system, 41% of the patients had excellent results and 47% had good results. The assessment by the modified Sandow and Goodfellow questionnaire also showed that more than 80% of the patients had improved symptoms. The overall rate of satisfaction was more than 80%. Merchant and Mercer w10x reported preliminary results of lateral retinacular release showing 85% good and excellent were observed. Surgery was performed in patients with
190
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190
activity related parapatellar pain and recurrent dislocations. Metcalf w7x presented the results of arthroscopic lateral release for patellar subluxation or dislocation in 79 patients at an average follow up of 48.7 months. They reported 86% excellent to good results. Bigos and McBride w2x reported the results in 76 patients Ž102 knees. with the symptoms of patellofemoral pain, subluxation or frank dislocation at an average follow up of 14.5 months. The outcome showed 54 knees were completely asymptomatic and 32 knees were painful only with activities. Chen and Ramanathan w3x reported the results of lateral release done percutaneously with help of smillie knife. They reported 44% excellent and 37.5% good results in recurrent dislocation group, 60% and 30% good in recurrent subluxation group and 74% excellent and 13% good in acute dislocation group. Schonholtz et al. w8x reported on 22 lateral retinacular releases performed through minimal lateral incision at 4 years of follow up. Sixty-seven percent of the patients Ždislocationrsubluxation group. improved after lateral retinacular release. Only one out of seven patients Žpatellar pain group. had a satisfactory result. Aglietti et al. w1x reported 45 patients with arthroscopic lateral release at an average follow up of 4 years. Of those with instability, 68.5% had satisfactory results. Dandy and Griffiths w4x reviewed 41 knees after arthroscopic lateral release for recurrent dislocation of patella at mean follow up of 4 years. There were 39% of patients with excellent and 51% with good results. Kolowich et al. w6x reported that surgery for patellar instability was not as predictable as for lateral compression syndrome. It is understood that this was a retrospective study of 39 knees operated over a 9-year period. However, to avoid heterogeneity, the same surgical technique was used on the group of patients with a defined pathology. The inclusion criteria were specific and the review and analysis were critical. In summary, this study has shown that, provided selection criteria are rigidly followed, isolated retinacular release can provide a high level of patient satisfaction, high success rate and low complication rate. It is mandatory to define the patellar pathology clearly and should eliminate those patients without any clinical andror radiological evidence of patellar maltracking from the option of the isolated lateral retinacular release.
References w1x Aglietti P, Pisaneschi A, Buzzi R, Gaudenzi A, Allegra M. Arthroscopic lateral release for patellar pain and instability. Arthroscopy 1989;5:176]183. w2x Bigos SJ, McBride GG. The isolated retinacular release in the treatment of patellofemoral disorders. Clin Orthop 1984;186:75]80. w3x Chen SC, Ramanathan EB. The treatment of the patellar instability by lateral release. J Bone Jt Surg wBrx 1984;66:344]348. w4x Dandy DJ, Griffiths D. Lateral release for recurrent dislocation of the patella. J Bone Jt Surg wBrx 1989;71:121]125. w5x Goldthwaite JE. Slipping or recurrent dislocation of the patella with the report of eleven cases. Boston Med Surg J 1904;150:169]174. w6x Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S. Lateral release of the patella: Indications and contraindications. Am J Sports Med 1990;18:359]365. w7x Metcalf RW. An arthroscopic method for lateral release of the subluxating or dislocating patella. Clin Orthop 1982;167:9]18. w8x Schondholtz GJ, Zhan MG, Magee CM. Lateral retinacular release of the patella. Arthroscopy 1988;3:269]271. w9x Scuderi G, Cuomo F, Scott N. Lateral release and proximal realignment for patellar subluxation and dislocation. J Bone Jt Surg wAmx 1988;70:856]861. w10x Merchant AC, Mercer RL. Lateral release or patella: A preliminary report. Clin Orthop 1974;103:40]45. w11x Ficat RP, Hungerford DS. Disorders of patellofemoral joint. Baltimore: Williams and Watkins, 1977. w12x Sandow MJ, Goodfellow JW. The natural history of anterior knee pain. J Bone Jt Surg ŽBr. 1985;67:36]38. w13x Crosby EB, Insall J. Recurrent dislocation of patella. Relation of treatment to osteoarthritis. J Bone Jt Surg wAmx 1976;56:9]13. w14x McNab I. Recurrent dislocation of the patellae. J Bone Jt Surg wAmx 1952;34:957]967. w15x Smillie IS. Diseases of the knee joint. New York: Churchill Livingstone, 1980. w16x Hughston JC. Subluxation of the patella. J Bone Jt Surg wAmx 1968;50:1003]1026. w17x Goodfellow J, Hungerford DS, Zindel M. Patellofemoral joint mechanics and pathology. J Bone Jt Surg wBrx 1976;58:287]290. w18x Leslie IJ, Bentley G. Arthroscopy in the diagnosis of chonrdomalacia patellae. Am Rheum Dis 1978;37:540]547. w19x Jackson RW. Etiology of chondromalacia patellae. In: American Academy of Orthopaedic Surgeons. Instructional course lectures. St. Louis: Mosby, 1976;25:26]40. w20x Bentley G, Dowd G. Current concepts of etiology and treatm ent of chondrom alacia patellae. C lin O rthop 1984;189:209]228.
Isolated lateral retinacular release for patellar maltacking Ravindra P. JoshiU , Frederick W. Heatley Orthopaedic Academic Unit, Rayne Institute, St. Thomas’ Hospital, London SE1 7EH, UK Accepted 10 September 1997
Abstract The outcome following an isolated lateral retinacular release for patellar maltracking was analysed. Thirty-nine knees were evaluated at an average follow up of 2.8 years. The assessment was performed by the modified Sandow and Goodfellow questionnaires and Crosby and Insall grading system. The results showed more than 80% of the patients had satisfactory outcome. This study has shown that if indications are observed rigidly a high level of patient satisfaction can be achieved following an isolated lateral retinacular release. Q 1998 Elsevier Science B.V. All rights reserved. Keywords: Lateral release; Maltracking
1. Introduction The results of an isolated lateral retinacular release in literature are difficult to compare due to differences in indication, selection criteria, surgical techniques and outcome assessment. The reported satisfactory results for patellar pain andror instability ranges from 14 to 99% w1]9x. The aim of this study was to analyse the results of the isolated retinacular release for patellar maltracking. The patients were selected for surgery by the strict criteria after defining, clinically and radiologically, the mechanical cause for the problem. The outcome was analysed to see whether high patient satisfaction can be obtained by this selective approach. 2. Material and methods Between 1983 and 1992, an isolated lateral retinacular release was performed for patellar maltracking on 39 knees Ž34 patients.. Five patients had bilateral U
Corresponding author. Tel.: q44 181 6330964; fax: q44 181 6330964. 0968-0160r98r$19.00 Q 1998 Elsevier Science B.V. All rights reserved. PII S0968-0160Ž97.10020-5
release. There were 28 femalesr33 knees and six malesrsix knees. The mean age at the time of operation was 23 Ž18]41. years in females and 28 Ž20]41. years in male patients. The average follow up was 2.8 Ž1.0]9.5. years. All the patients had patellar maltracking diagnosed on clinical grounds supplemented by skyline view. Clinically, patients had symptoms of giving way, painful clicking, swelling and locking. The apprehension test was positive. The skyline view showed either laterally subluxated w10x or tilted patella w11x. Those patients with generalized ligament laxity, high ‘Q’ angle Žmore than 208., evidence of patella alta or baja were not considered for the isolated lateral retinacular release. Only those patients with clinical and radiological evidence of patellar maltracking underwent lateral retinacular release. Those patients with undefined patellar pain were not considered suitable. Pre-operatively, all the patients had a course of physiotherapy. Average duration of symptoms before operation for 19 female patients Ž66%. was more than 3 years and minimum duration of symptoms before operation was 1 year. All the male patients had symptoms for more than 3 years before operation. Arthroscopic assessment was done prior to the lat-
188
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190
eral retinacular release to assess the condition of the articular surface of the patella and to rule out any associated pathology. In 10 female patients Ž30%., there was no evidence of chondromalacia patella ŽCMP. while in four Ž12%. lateral facet, in eight Ž24%. medial facet, in three Ž9%. central dome, in seven Ž21%. generalized and in one Ž3%. medial as well as central dome was involved with the changes of CMP. In two male patients Ž33%. there was no evidence of CMP while one each had medial, lateral, central and generalized changes of CMP. Two techniques were used depending on surgeon’s choice. For ‘open’ technique, the patient was re-prepared and re-draped after arthroscopic assessment. The lateral parapatellar incision was made from the level of tibial plateau to proximally up to the superior pole of the patella. The lateral retinaculum was divided and haemostasis was achieved by cauterizing the lateral geniculate artery or the branches of it. In ‘percutaneous’ technique, the scissors were introduced through the anterolateral portal of the arthroscopy and the lateral structures were divided blindly. Post-operatively the pressure dressing was applied in both the procedures with Velban and crepe bandage. Twenty-four patientsr25 knees were operated by percutaneous technique and 10 patientsr14 knees had surgery by open technique. Post-operatively patients were advised to do isometric exercise and straight leg raising from the first post-operative day. Patients were allowed weight bearing as tolerated with crutches and were discharged from the hospital when steady on feet. The pressure dressing was retained for 1 week and the patients were followed in the clinic at 2 weeks. At this follow up the wound was inspected and stitches were removed. The patients were then referred to physiotherapy to regain full range of movement and quadricepsrhamstring strengthening exercises with emphasis on vastus medialis strengthening exercises. Subsequently, the patients were followed in the out-patient clinic at 6 weeks for the first two visits and then 3-monthly. All were assessed clinically for any swelling, clicking, locking or giving way and advised to participate in sports gradually. Absence of these symptoms were considered as improvement in post-operative tracking. The patient was discharged from the out-patient clinic after improvement of these symptoms. For the functional assessment in this study, the Sandow and Goodfellow questionnaire w12x was modified by including the symptoms of giving way, swelling, locking and clicking. The Sandow and Goodfellow questionnaire assesses presence of pain, severity of pain, use of analgesia, frequency of pain, the extent to which sports were restricted and pain-associated activities. The patients were also classified by the Crosby and Insall grading system w13x. The outcome was
classified into four categories. Statistical analysis were performed by comparing the averages and responses and the level of significance was P- 0.05. 3. Results Functional assessment according to the modified Sandow and Goodfellow questionnaire ŽTable 1. showed that more than 80% of patients had relief of symptoms and had improved activities after surgery. None of the patients were made worse after the procedure. The results, as assessed by the Crosby and Insall grading system ŽTable 2., showed that there were 41% of the patients who were in excellent, 47% in good, 12% in fairrpoor and none in the worse category. In this series, 24 patients underwent percutaneous Table 1 Responses to questionnaires
Presence of pain Yes No Severity of pain Better Same Worse Use of analgesia Regularly Rarelyrnil Frequency of pain Continuous Daily WeeklyrRarely None Sports restricted activity Severely Occassionally Not at all No participation Pain associated activities Sports Stair climbling Walking Sitting Standing Cold weather Giving way Yes No Swelling Yes No Clicking Yes No Locking Yes No
Number
Percent
8 26
23.5 76.5
30 4 0
88.2 11.8 00.0
4 30
11.8 88.2
2 2 4 26
5.9 5.9 11.8 76.4
3 12 14 5
8.8 3.5 41.3 14.7
3 4 4 0 4 5
8.8 11.8 11.8 00.0 11.8 14.7
2 32
5.9 94.1
2 32
5.9 94.1
2 32
5.9 94.1
3 31
8.8 91.2
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190 Table 2 Post-operative assessment by Crosby]Insall grading system Grade
Excellent Good Fairrpoor Worse
Number of patients
Percent
14 16 4 0
41 47 12 0
release while 10 had open release. The results ŽTable 3. showed that there is no significant difference between the two techniques. However, following the open technique there were more ‘excellent’ results Ž50%. than those in the percutaneous technique Ž37.5%.. The results in male and female patients ŽTable 4. showed that female patients had less ‘excellent’ results as compared to male patients, however, the difference was not significant Ž P) 0.05.. There were two complications in the series. One patient had percutaneous lateral release done and developed haemarthrosis while the other patient developed severe stiffness following percutaneous release. There were no complications following the open procedure.
4. Discussion
There was a predominance of female patients Ž4.6:1.0. in this series. Earlier reports by Goldthwaite w5x, McNab w14x and Smillie w15x also showed predominance of female patients in their study. However, Hughston w16x reported a male to female ratio of 3:1 whilst Scuderi et al. w9x reported equal distribution. Scuderi et al. stated that the female patients in their series did not do as well as their male counterpart and speculated that factors such as wide pelvis, more femoral anteversion and genu valgum may result in residual forces in the knee that tend to pull patella laterally. In this series, 67.0% of male patients as compared with 36.5% of female patients fared ‘excellent’. On arthroscopic assessment, 30% of the patients had no evidence of CMP whilst others had a variable extent of involvement. There was no correlation between the extent of the changes of CMP and the symptoms as well as the outcome following lateral release. Goodfellow et al. w17x also stressed that the presence of CMP cannot be held responsible for the symptoms of patellofemoral pain in young patients. Leslie and Bentley w18x found only 50% of the patients with clinical symptoms of CMP had any microscopic changes when viewed arthroscopically. However, Jackson w19x supported the positive relationship
189
Table 3 Outcome in open and percutaneous techniques Žfigures representing percentages.
Percutaneous Open
Excellent
Good
FairrPoor
Worse
37.5 50.0
50.0 40.0
12.5 10.0
0 0
Table 4 Outcome in male and female patients Žfigures representing percentages.
Males Females
Excellent
Good
FairrPoor
Worse
67.0 36.5
16.5 53.5
16.5 10.0
0.00 0.00
between subluxation, dislocation and chondromalacia. Later, Bentley and Dowd w20x added further weight to the theory that patellofemoral subluxation could be associated with CMP. All the male patients and 66% of female patients had symptoms for more than 3 years. These patients remained symptomatic even after a course of physiotherapy. Sandow and Goodfellow w12x have shown that anterior knee pain tends to improve with time and is a serious disability for a few. In our series, all the operated patients had clinical and radiological evidence of patellar maltracking and therefore remained symptomatic even after a course of non-operative treatment. There was one case of haemarthrosis Ž3%. following percutaneous technique and none following open technique. Arthroscopic release has the cosmetic advantage over an open operation and it has a disadvantage that bleeding cannot be easily controlled. It may be that open lateral release through 2-cm incision which allows control of bleeding from superior lateral geniculate artery will eventually prove to be the procedure of choice w4x. In reviewing the literature, it is often difficult to separate the results in patients with recurrent dislocation or subluxation of the patella from those with patellofemoral pain caused by lateral patellar compression syndrome. In our series, as assessed by the Crosby and Insall grading system, 41% of the patients had excellent results and 47% had good results. The assessment by the modified Sandow and Goodfellow questionnaire also showed that more than 80% of the patients had improved symptoms. The overall rate of satisfaction was more than 80%. Merchant and Mercer w10x reported preliminary results of lateral retinacular release showing 85% good and excellent were observed. Surgery was performed in patients with
190
R.P. Joshi, F.W. Heatley r The Knee 5 (1998) 187]190
activity related parapatellar pain and recurrent dislocations. Metcalf w7x presented the results of arthroscopic lateral release for patellar subluxation or dislocation in 79 patients at an average follow up of 48.7 months. They reported 86% excellent to good results. Bigos and McBride w2x reported the results in 76 patients Ž102 knees. with the symptoms of patellofemoral pain, subluxation or frank dislocation at an average follow up of 14.5 months. The outcome showed 54 knees were completely asymptomatic and 32 knees were painful only with activities. Chen and Ramanathan w3x reported the results of lateral release done percutaneously with help of smillie knife. They reported 44% excellent and 37.5% good results in recurrent dislocation group, 60% and 30% good in recurrent subluxation group and 74% excellent and 13% good in acute dislocation group. Schonholtz et al. w8x reported on 22 lateral retinacular releases performed through minimal lateral incision at 4 years of follow up. Sixty-seven percent of the patients Ždislocationrsubluxation group. improved after lateral retinacular release. Only one out of seven patients Žpatellar pain group. had a satisfactory result. Aglietti et al. w1x reported 45 patients with arthroscopic lateral release at an average follow up of 4 years. Of those with instability, 68.5% had satisfactory results. Dandy and Griffiths w4x reviewed 41 knees after arthroscopic lateral release for recurrent dislocation of patella at mean follow up of 4 years. There were 39% of patients with excellent and 51% with good results. Kolowich et al. w6x reported that surgery for patellar instability was not as predictable as for lateral compression syndrome. It is understood that this was a retrospective study of 39 knees operated over a 9-year period. However, to avoid heterogeneity, the same surgical technique was used on the group of patients with a defined pathology. The inclusion criteria were specific and the review and analysis were critical. In summary, this study has shown that, provided selection criteria are rigidly followed, isolated retinacular release can provide a high level of patient satisfaction, high success rate and low complication rate. It is mandatory to define the patellar pathology clearly and should eliminate those patients without any clinical andror radiological evidence of patellar maltracking from the option of the isolated lateral retinacular release.
References w1x Aglietti P, Pisaneschi A, Buzzi R, Gaudenzi A, Allegra M. Arthroscopic lateral release for patellar pain and instability. Arthroscopy 1989;5:176]183. w2x Bigos SJ, McBride GG. The isolated retinacular release in the treatment of patellofemoral disorders. Clin Orthop 1984;186:75]80. w3x Chen SC, Ramanathan EB. The treatment of the patellar instability by lateral release. J Bone Jt Surg wBrx 1984;66:344]348. w4x Dandy DJ, Griffiths D. Lateral release for recurrent dislocation of the patella. J Bone Jt Surg wBrx 1989;71:121]125. w5x Goldthwaite JE. Slipping or recurrent dislocation of the patella with the report of eleven cases. Boston Med Surg J 1904;150:169]174. w6x Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S. Lateral release of the patella: Indications and contraindications. Am J Sports Med 1990;18:359]365. w7x Metcalf RW. An arthroscopic method for lateral release of the subluxating or dislocating patella. Clin Orthop 1982;167:9]18. w8x Schondholtz GJ, Zhan MG, Magee CM. Lateral retinacular release of the patella. Arthroscopy 1988;3:269]271. w9x Scuderi G, Cuomo F, Scott N. Lateral release and proximal realignment for patellar subluxation and dislocation. J Bone Jt Surg wAmx 1988;70:856]861. w10x Merchant AC, Mercer RL. Lateral release or patella: A preliminary report. Clin Orthop 1974;103:40]45. w11x Ficat RP, Hungerford DS. Disorders of patellofemoral joint. Baltimore: Williams and Watkins, 1977. w12x Sandow MJ, Goodfellow JW. The natural history of anterior knee pain. J Bone Jt Surg ŽBr. 1985;67:36]38. w13x Crosby EB, Insall J. Recurrent dislocation of patella. Relation of treatment to osteoarthritis. J Bone Jt Surg wAmx 1976;56:9]13. w14x McNab I. Recurrent dislocation of the patellae. J Bone Jt Surg wAmx 1952;34:957]967. w15x Smillie IS. Diseases of the knee joint. New York: Churchill Livingstone, 1980. w16x Hughston JC. Subluxation of the patella. J Bone Jt Surg wAmx 1968;50:1003]1026. w17x Goodfellow J, Hungerford DS, Zindel M. Patellofemoral joint mechanics and pathology. J Bone Jt Surg wBrx 1976;58:287]290. w18x Leslie IJ, Bentley G. Arthroscopy in the diagnosis of chonrdomalacia patellae. Am Rheum Dis 1978;37:540]547. w19x Jackson RW. Etiology of chondromalacia patellae. In: American Academy of Orthopaedic Surgeons. Instructional course lectures. St. Louis: Mosby, 1976;25:26]40. w20x Bentley G, Dowd G. Current concepts of etiology and treatm ent of chondrom alacia patellae. C lin O rthop 1984;189:209]228.