Michael Hughes MD
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An 18-year-old female has 9 months of anterior knee pain recalcitrant to physical therapy that includes VMO strengthening, NSAIDS, and lifestyle modification. On physical examination she has no effusion in the knee and her Q angle is measured at 15 degrees. She has less than one quadrant of medial patella translation and less than two quadrants of lateral patella translation. The lateral edge of the patella is unable to be everted. A merchant view radiograph is shown in Figure A. The tibia tubercle-trochlear groove distance is measured as 14mm on a CT scan. Which of the following procedures is MOST appropriate?
Lateral retinacular release
Anterolateral tibial tubercle osteotomy
Anterior tibial tubercle osteotomy (Maquet)
Medial tibial tubercle osteotomy (Elmslie-Trillat)
Medial plica resection
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The patient's radiograph and clinical presentation are consistent with lateral patellar tilt and lateral facet compression syndrome, respectively. Of the options available, lateral retinacular release is the most appropriate treatment. The surgical treatment for this condition is rare and used only in cases that are recalcitrant to conservative measures.
Calpur et al present level 4 evidence of 169 lateral retinacular release cases. They divided this cohort into patients less than and older than 40 years of age. They found that both groups had a statistically significant improvement in Lysholm scores and there were only 3 patients with complications (fibrosis at the site of lateral release).
Video V shows a technique for arthroscopic lateral retinacular release. Arthroscopic viewing through the superior portal in lateral facet compression syndrome would demonstrate that the patella does not articulate medially with the trochlea when the knee is at 40 degrees of knee flexion.
Illustration A demonstrates how the tibia tubercle-trochlear groove (TT-TG) distance is measured by (A) first drawing a line from the trough of the trochlea perpendicular to the line connecting the posterior condyles. These lines are superimposed onto an image through the tibial tubercle (B), and the TT-TG distance is measured as that between the above-described line and the tibial tubercle (distance AB). A TT-TG distance greater than 20mm is an indicator that a medializing tibia tubercle osteotomy is needed.
2. An lateral tibial tubercle transfer would lead to an elevated TT-TG and malalignment.
3. An anterior transfer would further tension the lateral retinaculum and increase the negative tilt.
4. A medial transfer is not indicated for a normal TT-TG.
5. The clinical scenario does not support a symptomatic plica.
Calpur OU, Ozcan M, Gurbuz H, Turan FN
Knee Surg Sports Traumatol Arthrosc. 2005 Apr;13(3):222-30. PMID: 15067501 (Link to Abstract)
Am J Sports Med. 2002 May-Jun;30(3):447-56. PMID: 12016090 (Link to Abstract)
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A 21-year-old female presents with left knee pain for six months. The symptoms are worse climbing stairs and sitting for long periods of time. On physical exam she has a stable knee with no effusion and pain with compression of the patella. Her Q angle is 21 degrees. What is the first step in management?
arthroscopic lateral retinacular release
tubercle elevation and medialization
strict immobilization and non-weight bearing for four weeks
open chain exercises and a focus on seated leg extensions
closed chain exercises with focus on quadriceps and hamstring strengthening
This patient has anterior knee pain with an increased Q angle (normal is 17 degrees in a female). The first line of treatment is physical therapy. Rehab should focus on isometrics and closed chain exercises.
Hungerford et al investigated the patellofemoral joint reaction force (PFJR) during closed chain exercises versus and open chain exercise. They found an increase in the PFJR during open chain exercises and with seated leg extensions that can cause further wear and irritation of the patellofemoral joint.
Answer 1 & 2: Surgery would not be indicated as the first line of treatment.
Answer 3: Immobilization would lead to deconditioning and stiffness and is not indicated.
Answer 4: Open chain exercises and with seated leg extensions that can cause further wear and irritation of the patellofemoral joint.
Hungerford DS, Lennox DW.
Orthop Clin North Am. 1983 Apr;14(2):397-402. PMID: 6843975 (Link to Abstract)
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HPI - 29 yr female with anterior knee pain for many years. Saw orthopod who scoped her without picking up on patella alta. Had "crabmeat" condromalacia according to op note which he treated with heat probe.
Now presents to me a year later with extreme pain much worse than before surgery.
Arthroscopic lateral retinacular release
Anteromedialization (Fulkerson) tibial tubercle osteotomy