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Medial Retinacular Plication (Modified Insall )

Planning

B

Preoperative Plan

1

Examine the knee under anesthesia

  • this should include a lachman test , anterior posterior drawer test, medial and lateral patellar instability test with the knee in 45 degrees of knee flexion
  • translation of the patella over 50% of the width of the patella laterally indicates incompetency of the medal patellofemoral ligament and the medal retinaculum

2

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

2

Room setup and equipment

  • standard OR table

3

Patient positioning

  • flex the foot of the table to 30 or 45 degrees
  • place a lateral post for valgus moment

Technique

D

Skin Incision

1

Perform arthroscopic lateral release

2

Make the skin incision

  • make a 4 to 5 cm limited medial approach centered on the widest portion of the patella

3

Create subcutaneous skin flaps

  • elevate subcutaneous flaps to allow great mobility of the prepatellar skin to limit the size of the incision

4

Dissect through the subcutaneous tissue

E

Medial Parapatellar Incision

1

Make a medial parapatellar incision

  • leave about 2 mm of tendon with the VMO
F

Tendon and Retinaculum Incision

1

Incise the tendon and the retinaculum

  • this incision in the tendon and the retinaculum should be 3 to 4 cm above the superior pole of the patella distally to 3-4 cm distal to the inferior pole of the patella
  • leave enough retinaculum with the tendon to suture later
  • incise the entire depth of the tendon and retinaculum
G

Patellar realignment

1

Position the knee

  • place and hold the knee in 45 degrees of flexion

2

Realign the patella

  • position the patella in the center of the trochlea

3

Places sutures

  • place three no. 1 or no. 2 sutures in a horizontal mattress fashion
  • these are placed 25 to 40 % across the width of the patella from medial to lateral while imbricating the edge of the tendon of the VMO and the retinaculum distally and laterally

4

Test realignment

  • hold the sutures tight while testing a thorough range of motion from full extension to 90 degrees of flexion
  • this is done to check if enough imbrication has been performed
H

Suture Tying

1

Tie the sutures for realignment

  • tie the sutures and use 0 absorbable suture above and below the imbrication for reinforcement
I

Wound Closure

1

Deep closure

  • close the subcutaneous tissue with 3-0 vicryl

2

Superficial wound closure

  • close the skin with running monocryl suture

3

Dressings and immobilization

  • place in a locked hinged knee brace in full extension

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

4

Perform operative consent

  • describe complications of surgery including
  • arthrofibrosis
  • continued pain
  • injury to the cutaneous nerves
  • recurrent instability
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • start active and passive range of motion in a few days to prevent any arthrofibrosis
  • use protected weightbearing with crutches until the patient is comfortable enough to walk in a locked knee brace in full extension
  • restrict range of motion to 0 to 90 degrees for the first 3 to 4 weeks

2

Discharges patient appropriately

  • pain control
  • schedule follow up in 3-4 weeks
  • wound care
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • symptoms
  • physical exam
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • radiographs

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 3-4 Week Postoperative Visit

  • wound check
  • start full range of motion at 4 with progressive quadriceps strengthening, edema control, pain control and gait training
  • continue to use the brace in community setting until adequate quadriceps strength has returned at about 6 weeks
  • diagnose and management of early complications
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
O

Complex Patient Care

1

Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings

 

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