Techniques in Orthopaedics:
Special Section: Tips & Pearls
From the Royal Orthopaedic Hospital, Birmingham, United Kingdom.
Address correspondence and reprint requests to Kirti Moholkar, The Royal Orthpaedic Hospital, Birmingham, United Kingdom. E-mail: firstname.lastname@example.org
The causes of anterior knee pain include patellofemoral malalignment, excessive patellar lateral pressure, chondromalacia patellae, and patellofemoral osteoarthritis.3
If conservative management fails and surgical intervention is necessary, arthroscopic lateral release is effective in reducing the pain of symptomatic patellofemoral osteoarthritis, excessive patellar lateral pressure, chondromalacia patellae, and patellofemoral malallignment.1–3
Arthroscopic lateral retinacular release should always be delayed until the end of the arthroscopy procedure, since bleeding and fluid extravasation will force termination of the case. Arthroscopic lateral retinacular release can be complicated by hemarthrosis in 10% to 18% of cases.9 Higher complication rates were noted with tourniquet use.7 Bleeding often does not become manifest until several minutes after the release, particularly if a tourniquet is used. Avoiding tourniquet while doing arthroscopic lateral release allows the visualization of bleeders that can be coagulated before they bleed hence preventing postoperative hemarthrosis and associated complications. The tourniquet also binds the quadriceps muscle to the femur making the assessment of patellar tracking inaccurate.4
Placement of accurate arthroscopic portals is crucial in arthroscopic knee surgery.5
To perform a lateral release the use of a superomedial operating portal is described.6,8 This portal can injure the sensitive vastus medialis obliqus muscle causing postoperative pain, hematoma at the portal site and decreased quadriceps function postoperatively.6
Lateral release using a new novel “Lateral Release Portal” helps the arthroscopic surgeon to place the portal under vision with accuracy, visualize the lateral retinaculum and perform a complete lateral release from superolateral aspect of the patella to lower limit of the lateral retinaculum without having to swap portals. The efficacy of adequate lateral release is confirmed if the patella can be everted by 45 degrees and translated medially around 25% of the patellar width.
Infiltrate the portal sites and the lateral retinaculum with 20 ml of Xylocaine with 1% adrenaline. This helps the visualization and the process of hunting the bleeders and coagulating them. The Arthroscopic procedure is started with the usual lateral visualization port. The lateral port is placed 0.5 cm inferior and 0.5 cm lateral to the inferior pole of the patella. This port is slightly higher than the most commonly described one in the center of the soft spot. The lateral visualization port placed as described helps the arthroscope insertion into the joint without scoring and scuffing the hyaline cartilage. It also helps navigate the arthroscope in the lateral gutter, intercondylar notch, and suprapatellar pouch with relative ease.
SUPEROLATERAL PORT (drainage port/Patellar tracking visualization port)
The superolateral drainage portal is placed 2.5-cm lateral and 2.5-cm superior to the superior pole of the patella. This portal can be made using the outside-in technique using the needle. This portal can be used to visualize the patellar tracking and hence correct positioning is vital. Complete the routine diagnostic and the necessary therapeutic procedures.
Assess the patellar tracking from the superolateral port at varying degrees of knee flexion (Fig. 1). Use a switching stick (thin blunt trocar) and introduce the arthroscope over it which helps introduction of the scope in the joint with ease. The use of a 30 deg scope is adequate. Avoid the use of tourniquet while doing a lateral release.
THE “LATERAL RELEASE PORTAL”
The Lateral release port is situated 5 cm inferior to the inferior pole of the patella and 3.5 cm lateral to the tibial tubercle, roughly lying just below the Gerdy‘s tubercle (Fig. 2). This port is used to introduce the Electrocautery to perform the lateral retinacular release. Mark the portal with a needle and confirm its placement accuracy with the arthroscope (Fig. 3).
Start the release at the superolateral corner (Fig. 4). Pay strict attention to the bleeders and coagulate them as they are encountered. After a couple of lateral releases the position of the superolateral geniculate vessel though not constant in every patient can be carefully located and coagulated before it bleeds avoiding a “red out” (joint full of blood).
Full thickness of the lateral retinacular tissues is released (Fig. 5). Care is taken to avoid cutting into the vastus lateralis superolaterally and the overlying skin!
The release is complete when the retinaculum has been released from the superolateral corner to the “Lateral Release Port” port that is the lower most limit of the lateral retinaculum. At the end of the lateral release the patellar mobility and balancing should have improved significantly (Fig. 6). Inject 20 ml of 5 mg Chirocaine into the knee joint and suture the portal wounds with 2 O prolene.
Achieve thorough hemostasis as it is a key to the success and outcome of this procedure. If tourniquet has been used it should be released before closure to coagulate the bleeders. Once the tourniquet is released the bleeders bleed profusely making visualization difficult and sometimes impossible. In such a case use a suction drain comes highly recommended.
The “Lateral Release Portal” has been successfully used for quite some time and all patients are discharged home the same day. No postoperative hemarthrosis was noted. Majority of the patients have no pain and are back to the activities of daily living within a week and back to work by 3 weeks. The outcome certainly depends on the underlying condition and its severity. Aggressive postoperative physiotherapy concentrating on the vastus medialis obliqus is imperative.
The success of lateral release depends on the initial pain relief and aggressive rehabilitation. Postoperative hemathrosis affects the outcome because of pain with an effect on the outcome. Lateral release without tourniquet using the novel “Lateral Release Portal” without the use of tourniquet is recommended.
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5. Lehman RC. The utility medial portal: a new arthroscopic approach to the knee. Contemp Orthop 1990;21:143–148.
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8. Stetson WB, Templin K. Two-versus three-portal technique for routine knee arthroscopy. Am J Sports Med 2002;30:108–111.
9. Vialle R, Tanguy JY, Cronier P, Fournier HD, Papon X, Mercier P. Anatomic and radioanatomic study of the lateral genicular arteries: application to prevention of postoperative hemarthrosis after arthroscopic lateral retinacular release. Surg Radiol Anat 1999;21:49–53.
© 2006 Lippincott Williams & Wilkins, Inc.