The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 1 suppl 2

Surgical Techniques | September 01, 2004

Mesh Expansion Release of the Lateral Patellar Retinaculum During Total Knee Arthroplasty

William L. Healy, MD¹; Richard Iorio, MD¹; Paul Warren, MD¹

¹ Department of Orthopaedic Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 85-A, pp. 1909-1913, October 2003

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart@haderermuller.com).

Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Sep 01;86(1 suppl 2):193-200

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Abstract

BACKGROUND:

Release of the lateral patellar retinaculum can be used to treat patellofemoral instability and to balance the extensor mechanism during knee replacement operations. However, conventional lateral release disrupts the integrity of the lateral knee capsule, may damage the blood supply to the patella, and is associated with several other potential complications. Mesh expansion release of the lateral patellar retinaculum was developed to achieve the goal of lateral release and to reduce the potential for postoperative morbidity.

METHODS:

Thirteen consecutive knees in eleven patients were treated with mesh expansion lateral release during a total knee arthroplastyand were evaluated after a minimum duration of follow-up of two years. The mesh release technique consisted of multiple, longitudinal, parallel 5 to 10-mm stab incisions to mesh and expand the lateral patellar retinaculum and thereby medialize the patella in the trochlear groove of the femoral implant.

RESULTS:

Mesh expansion lateral release balanced the extensor mechanism in each knee, maintained the mechanical integrity of the lateral capsule, and avoided disruption of the lateral genicular blood supply to the patella. After a minimum duration of follow-up of two years, no complications had been noted in association with mesh expansion lateral release.

CONCLUSIONS:

Mesh expansion release of the lateral patellar retinaculum effectively balanced the patellofemoral joint during total knee arthroplasty, maintained the integrity of the lateral capsule, and preserved the lateral genicular blood supply.

Figures in this Article

INTRODUCTION

INTRODUCTION | SURGICAL TECHNIQUE | CRITICAL CONCEPTS | References

During a total knee arthroplasty operation, it is important to balance the extensor mechanism (the quadriceps tendon, patella, and patellar ligament) in relation to the distal femoral trochlear groove throughout a full range of motion (Figs. 1-A and 1-B). One of the more common causes of lateral patellofemoral instability is a tight lateral patel-lar retinaculum (Figs. 2 and 3). Conventional release of the lateral patellar retinaculum (a lateral release) has been asso-ciated with several potential complications. Mesh expansion release of the lateral patellar retinaculum was developed to balance the extensor mecha-nism during total knee arthro-plasty, to maintain the integrity of the lateral capsule of the knee, to preserve the lateral genicular blood supply, and to reduce morbidity associated with lateral release.

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FIG. 1-A AND 1-B: Fig. 1-A A balanced patellofemoral joint. Fig. 1-B An unbalanced patellofemoral joint with lateral patellar tilt.

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FIG. 2: Lateral patellar tilt.

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FIG. 3: Lateral patellar dislocation.

SURGICAL TECHNIQUE

INTRODUCTION | SURGICAL TECHNIQUE | CRITICAL CONCEPTS | References

During total knee arthroplasty, the stability, tracking, and balance of the patellofemoral articulation are evaluated throughout a complete range of motion with the use of the "rule of no thumb" test^1,2, the "towel clip" test^3,4, and/or the "one stitch" test⁵. In the "rule of no thumb" test, the knee is flexed and extended throughout a range of motion with no force applied to the extensor mechanism. Specifically, the thumb is not used to hold the patella in the femoral trochlea throughout the range of motion. The knee is passively flexed through a complete range of motion, and the balance and stability of the patellofemoral joint is noted. The patella should not tilt or subluxate, and patellofemoral contact should be evenly distributed medially and laterally. In the "towel clip" test, a towel clip apposes the edges of the joint capsule at the superomedial aspect of the patella. The knee is put through a range of motion, and the balance between the patella and the femoral trochlea is noted. In the "one stitch" test, one suture is used to appose the edges of the joint capsule at the superomedial aspect of the patella. The knee is put through a range of motion, and note is taken of the balance between the patella and the femoral trochlea. Some authors have demonstrated that the tourniquet should be released for a true and valid assessment of patellofemoral tracking. We do not release the tourniquet to evaluate patellofemoral tracking in our practice.

During the test of patellar tracking, if patellar tilt or instability is detected (Fig. 4), the bone cuts, the soft-tissue balance, and the position, size, rotation, and alignment of the knee implants are checked for technical problems that may have occurred during the reconstruction. Major problems with the knee reconstruction, such as malalignment or component malrotation (Figs. 5-A and 5-B), should be corrected at this time. If the knee reconstruction is satisfactory, and if a tight lateral patellar retinaculum is responsible for lateral patellofemoral instability, a lateral patellar retinaculum release can be performed to balance the patellofemoral joint and the extensor mechanism. In this situation, we advocate an incremental step-by-step approach to balancing the patellofemoral joint.

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FIG. 4: Lateral patellar tilt noted during the "rule of no thumb" test.

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FIG. 5-A AND 5-B: Fig. 5-A Normal rotation of femoral and tibial implants with normal femoral tracking. Fig. 5-B Internal rotation of the femoral implant can lead to lateral patellar instability because of a tight lateral patellar retinaculum.

Before the lateral retinaculum is incised, an intra-articular release of the patellofemoral ligament is performed. This step may balance the patellofemoral joint, obviating the need for release of the lateral patellar retinaculum. Another technique that may eliminate subtle or minor patellar tilt is a peel of the attachment of the lateral patellar retinaculum at the lateral, vertical aspect of the osseous patella⁶ (Figs. 6-A and 6-B). The peel should not create a defect in the extensor mechanism or the lateral retinaculum. A small, laterally deforming force on the patella can be relieved with this technique and can prevent the need to do a lateral release.

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FIG. 6-A AND 6-B: Fig. 6-A The tight lateral patellar retinaculum (highlighted) causes lateral patellar tilt. Fig. 6-B The "lateral peel" cuts the ventral attachment of the lateral patellar retinaculum to the lateral aspect of the patella, which can balance the patellofemoral joint in some cases of mild lateral patellofemoral instability.

During the preparation for mesh expansion lateral release, a lateral skin flap is elevated in the interval between the lateral knee joint capsule and the superficial fascia. This dissection of the lateral skin flap may also balance the patellofemoral joint without requiring further release of the lateral patellar retinaculum (Fig. 7).

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FIG. 7: Elevation of a lateral skin flap during the mesh expansion lateral release.

CRITICAL CONCEPTS

INTRODUCTION | SURGICAL TECHNIQUE | CRITICAL CONCEPTS | References

INDICATIONS:

Lateral patellar tilt or instability secondary to a tight lateral patellar retinaculum during total knee arthroplasty

CONTRAINDICATIONS:

Lateral patellar instability secondary to malalignment, implant malposition, or implant malrotation during total knee arthroplasty

PITFALLS:

Care should be taken to avoid cutting the lateral genicular blood vessels.

Sufficient intervals (5 to 10 mm) should be left between mesh incisions to prevent the extension of one stab incision to another, which might cause a large rent in the retinaculum and convert the mesh release to a conventional lateral release.

AUTHOR UPDATE:

Currently, we perform the mesh expansion lateral release in the same manner as that described in the original article. The only addition to the surgical technique in this article is the lateral patellar peel⁵, which can be helpful in some patients with mild or subtle lateral patellar instability and which may prevent the release of the lateral patellofemoral retinaculum in some patients.

The mesh expansion lateral release is performed with the knee in extension. A Lahey triple hook traction forceps (Jarit Surgical Instruments, Hawthorne, New York) is attached to the medial aspect of the capsule at the medial border of the patella. The patella is rotated 90° (with the articular surface facing medially). Anterior traction is applied to the extensor mechanism to put tension on the lateral patellofemoral retinaculum. The surgeon palpates the tight bands or fibers of the lateral retinaculum (Fig. 8). The lateral retinaculum is meshed with multiple 5 to 10-mm longitudinal, parallel, outside-to-inside stab incisions with a number-10 scalpel blade (Fig. 9). The stab incisions are confined to an area distal to the superior lateral genicular artery and proximal to the inferior lateral genicular artery. The genicular vessels can be protected by direct visualization and by limiting the meshed area to that part of the retinaculum that lies between the superior and inferior poles of the patella. The mesh release technique is similar to meshing a split-thickness skin graft (the so-called pie-crusting technique) (Figs. 10 and 11).

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FIG. 8: Palpation of tight lateral patellar retinaculum fibers during mesh expansion lateral release.

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FIG. 9: Stab incisions of the lateral patellar retinaculum during mesh expansion lateral release.

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FIG. 10: Mesh expansion lateral release technique.

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FIG. 11: Expansion of the lateral patellar retinaculum following meshing.

Meshing of the lateral patellar retinaculum allows this tissue to expand, and the patella assumes a more medial position in the femoral trochlea. The lateral retinaculum should expand sufficiently to allow the lateral border of the patella (which is rotated 90° with the joint surface facing medially) to be moved to the center of the trochlear groove when the knee is in extension. In our experience, this degree of mobility of the lateral retinaculum has been associated with a balanced patellofemoral joint throughout a full range of motion.

After the mesh release is completed, a balanced patellofemoral joint is documented throughout a complete range of motion of the knee with the use of the "rule of no thumb" test^1,2, the "towel clip" test^3,4, or the "one stitch" test⁵. The expansion of the lateral retinaculum can be appreciated by observing the opening of the meshed multiple stab incisions (Fig. 12). The patella should be balanced and stable in the femoral trochlear groove (Figs. 13 and 14). If lateral patellofemoral instability persists, more extensive meshing can be performed or the mesh release can be converted to a conventional lateral patellar retinaculum release; however, we have not encountered this situation in our experience. The anteromedial arthrotomy of the knee is then closed anatomically, edge-to-edge without imbrication or superior or inferior redirection.

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FIG. 12: Expansion of the lateral patellar retinaculum with the knee in flexion following meshing.

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FIG. 13: A balanced patellofemoral joint following mesh expansion lateral release with use of the "rule of no thumb" test.

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FIG. 14: A balanced patellofemoral joint.

References

INTRODUCTION | SURGICAL TECHNIQUE | CRITICAL CONCEPTS | References

Scott RD. Prosthetic replacement of the patellofemoral joint. Orthop Clin North Am.1979;10: 129-37.10129 1979 [PubMed]

Brick GW, Scott RD. The patellofemoral component of total knee arthroplasty. Clin Orthop.1988;231: 163-78.231163 1988

Pagnano MW, Kelley MA. The intraoperative assessment of patella tracking. In: Scuderi GR, Tria AJ Jr, editors. Surgical techniques in total knee arthroplasty. New York: Springer; 2002. p 317-24.317 2002

Insall JN. Surgical techniques and instrumentation in total knee arthroplasty. In: Insall JN, Windsor RE, Scott WN, Kelley MA, Aglietti P, editors. Surgery of the knee. New York: Churchill Livingstone; 1993. p 739-804.739 1993

Rae PJ, Noble J, Hodgkinson JP. Patellar resurfacing in total condylar knee arthroplasty. Technique and results. J Arthroplasty.1990;5: 259-65.5259 1990 [PubMed][CrossRef]

Shaw JA. Patellar retinacular peel: an alternative to lateral retinacular release in total knee arthroplasty. Am J Orthop.2003;32: 189-92.32189 2003 [PubMed]

Topics

patella ; surgical mesh ; knee replacement arthroplasty ; patellofemoral joint

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William L. Healy, Richard Iorio, Paul Warren; Mesh Expansion Release of the Lateral Patellar Retinaculum During Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 2004 Sep;86(1_suppl_2):193-200.

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