Efficacy and experience of arthroscopic lateral patella retinaculum releasing through/outside synovial membrane for the treatment of lateral patellar compression syndrome

Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction

Purpose

To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up.

Methods

A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation.

Results

A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm).

Conclusions

MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups.

Level of Evidence

Level III, retrospective cohort study.

Isolated Arthroscopic Lateral Retinacular Release for Lateral Patellar Compression Syndrome

Introduction: Evidence concerning the role of isolated lateral retinacular release (LRR) for lateral patellar compression syndrome (LPCS) dates back at least three decades. Appropriate indications, execution and outcomes still remain unclear and controversial. The present investigation analyzed the midterm result of isolated and arthroscopic LRR for LPCS in a cohort of patients who underwent such procedure at our institution. Material and methods: Patients undergoing isolated arthroscopic LRR for LPCS were identified retrospectively from our electronic database. All procedures were performed by two experienced surgeons. Patients with bony and/or soft tissues abnormalities, patellofemoral instability, moderate to severe chondral damage were not included. Patients with previous surgeries were not included, as were those who underwent combined interventions. Clinical scores and complications were recorded. Results: 31 patients were recruited in the present investigation. The mean follow-up was 86.0 ± 22.8 months. The mean age of the patients at the index operation was 34.2 ± 13.1 years. A total 55% (17 of 31) were women, and 58% (18 of 31) had involved the right knee. The mean hospitalization length was 3.5 ± 1.4 days. At a mean follow-up of 86.0 ± 22.8 months, the numeric rating scale (NRS) was 1.2 ± 0.8, the Kujala score was 91.3 ± 11.3, the Lysholm score was 93.1 ± 15.0, and the Tegner score was 5.0 ± 1.8. At the latest follow-up, 9 of 31 (29.0%) of patients experienced compilations. One patient (3.2%) had a post-operative hemarthrosis which was managed conservatively. Six patients (19.4%) reported a persistent sensation of instability, without signs of patellar dislocation or subluxation. One patient underwent an arthroscopic meniscectomy, and another patient an anterior cruciate ligament (ACL) reconstruction. Conclusion: isolated arthroscopic lateral retinacular release for lateral patellar compression syndrome is feasible and effective, achieving satisfying results at more than seven years following the procedure.

Novel method for diagnosing lateral patellar compression syndrome using X-ray: a retrospective case-control study

Background

A well-established reference is lacking for diagnosing lateral patellar compression syndrome (LPCS), and this diagnosis currently depends on clinicians' subjective judgment and several examination results. X-rays are primarily used to diagnose LPCS, but they have low detection rates of patellar tilt using the congruence angle (CA) and patellar tilting angle (PTA).

Methods

We enrolled 87 patients (31 men and 56 women; mean age: 42.11±15.33 years) between 2016 and 2019 and divided them as per diagnosis into three groups of 29 each: LPCS, patellar dislocation (PD, control), and meniscus tear (MT, negative control) groups. A senior radiologist and the chief physician of sports medicine examined their patellar axial radiographs of the knee in 30° flexion using a computer imaging system, measuring LPCA, CA and PTA. Univariate analysis of variance and Kruskal-Wallis H test were used to compare measurement data with normal distribution and non-normal distribution, respectively. Bonferroni correction was used to analyze different indicators for different groups. The area under the curve (AUC) was calculated to verify the value of LPCA in the initial diagnosis of LPCS.

Results

LPCA (19.88±7.49) was significantly higher in LPCS group than in MT (13.68±4.69) and PD groups (10.16±4.43) (P<0.01) and was also significantly higher on affected side than on healthy side (16.44±5.00) (P=0.04). LPCA >13.9° had sensitivity and specificity of 89.66% and 68.97%, respectively, for LPCS diagnosis (AUC: 0.82, 95% confidence interval: 0.719-0.891, P<0.001).

Conclusions

We demonstrated that LPCA measured using an axial patellar radiograph of the knee in 30° flexion is high in patients with LPCS, and it may be used for diagnosing LPCS.

Management of Patellar Chondral Defects with Autologous Matrix Induced Chondrogenesis (AMIC) Compared to Microfractures: A Four Years Follow-Up Clinical Trial

Introduction: Evidence on the management of chondral defects of the patella arises from studies in which the patellofemoral joint was treated together with the femorotibial joint and primary and revision settings. Furthermore, the superiority of Autologous Matrix Induced Chondrogenesis (AMIC) over microfractures (MFx) for patellar chondral defects is uncertain. Therefore, the present study compared primary isolated AMIC versus MFx for focal unipolar chondral defects of the patellar facet joints at midterm follow-up. Methods: Patients undergoing AMIC or isolated MFx surgery for borderline-sized focal unipolar chondral defects of the patellar facet joints were followed at our institution. All surgeries were performed in the same fashion by experienced surgeons. A parapatellar arthrotomy was adopted in all surgeries. The outcomes of interest were: Visual Analogic Scale (VAS), Tegner Activity Scale, International Knee Documentation Committee (IKDC), and the Lysholm scores. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) was assessed by a blinded radiologist, who had not been involved in the clinical management of the patients. Results: 38 patients were enrolled in the present study: 27 underwent AMIC, and 11 MFx. The mean follow-up was 45.1 months. The mean age of the patients at baseline was 34.5 years. The mean size of the defect was 2.6 cm². The MFx cohort experienced a shorter length of the hospitalization (P = 0.008). There was no difference in terms of follow-up and previous symptoms duration, mean age, sex, side, defect size, and BMI. At last follow-up, the AMIC cohort reported greater IKDC (P = 0.01), Lysholm (P = 0.009), and Tegner (P = 0.02), along with a low rate of failure (P = 0.02). VAS was lower in the AMIC group (P = 0.002). No difference was found in the MOCART score (P = 0.09), rates of revision (P = 0.06), and arthroplasty (P = 0.2). Conclusion: The AMIC procedure achieves greater IKDC and Lysholm score, and a significant reduction of the VAS score in the management of patellar chondral defects. The Tegner scale demonstrated greater activity after AMIC procedure. Finally, the AMIC group evidenced a lower rate of failure. Similarity was found on MOCART score, rates of revision, and arthroplasty between the two procedures.

Outcome and experience of arthroscopic lateral retinacular release combined with lateral patelloplasty in the management of excessive lateral pressure syndrome

Background

Only a few studies have described the effect of full arthroscopic surgery in treatment of excessive lateral pressure syndrome (ELPS). Therefore, the purpose of this study was to assess the clinical efficacy and experience of total arthroscopic lateral retinacular (LR) release and lateral patelloplasty for the treatment of ELPS.

Methods

A total of 73 patients (88 knees) with ELPS underwent arthroscopic LR release and lateral patelloplasty. The visual analogue scale (VAS), Kujala score, Lysholm scores, patella medial pushing distance, patellar tilt angle (PTA), and lateral patellofemoral angle (LPFA) were measured and evaluated before and after surgery.

Results

Follow-up ranged from 12 to 36 months with an average of 24 ± 5.8 months. The VAS was significantly lower at the last follow-up than before surgery (P < 0.01). The patella medial pushing distance, Kujala score, Lysholm score, PTA, and LPFA were significantly higher at the last follow-up than before surgery (P < 0.01, respectively). Years and lateral patella Outerbridge classification at the last follow-up have negative correlation with Kujala score, Lysholm score, Patella medial pushing distance, PTA, and LPFA (P < 0.01, respectively) and have positive correlation with VAS (P < 0.01, respectively). Related complications were not reported.

Conclusions

Full arthroscopic LR release combined with lateral patelloplasty in the treatment of ELPS is an effective minimally invasive method, which can effectively correct anomalies of force line and skeleton of patella, relieve pain, and restore knee joint motor function with less complications.

Use of hyaluronic acid injection after arthroscopic release in lateral patellar compression syndrome with degenerative cartilage changes: randomized control trial

Background

Degenerative cartilage changes can be seen, in cases of lateral patellar compression syndrome, involving the patellofemoral joint. Hyaluronic acid is a natural component of the synovial fluid and responsible for its elastic features and function of articular surfaces. The aim of this study is to show the effect of intra-articular injection of Hyaluronic acid, after arthroscopic lateral release in lateral patellar compression syndrome, on the functional outcome and knee pain in those patients with degenerative cartilage changes.

Method

Ninety patients age (30–50) years with lateral patellar compression syndrome and degenerative cartilage changes were divided randomly into 2 groups. Group A was treated by arthroscopic lateral release and received intraarticular injection of Hyaluronic acid 2 weeks after surgery. Group B was treated by arthroscopic lateral release only. Both groups were assessed by Kujala score and visual analogue scale for knee pain preoperatively and re-assessed postoperatively at 3 months, 6 months, 12 months and 24 months.

Results

There was significant improvement in Kujala score and Visual analogue scale post-operatively in both groups (P-value< 0.001) with better improvement in Kujala score in group A after intra-articular injection of Hyaluronic acid up to 2 year of follow up (P-value = 0.006) as well as better improvement in visual analogue score at 6 months post-operatively (P-value = 0.035).

Conclusion

Intra-articular injection of Hyaluronic acid after arthroscopic release, in patients with lateral patellar compression syndrome and degenerative cartilage changes, can result in better improvement of knee pain and functional outcome up to 2 years of follow up.

Trial registration

NCT, NCT04134611. Registered 18 October 2019 -Retrospectively registered.