Lateral Patellar Compression Syndrome

Introduction

Improper tracking of patella in trochlear groove
Caused by tight lateral retinaculum
- leads to excessive lateral tilt without excessive patellar mobility
Miserable Triad
- is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. They include:
  - femoral anteversion
  - genu valgum
  - external tibial torsion / pronated feet

Presentation

Presentation
- pain with stair climbing
- theatre sign (pain with sitting for long periods of time)
Physical exam
- pain with compression of patella and moderate lateral facet tenderness
- inability to evert the lateral edge of the patella

Imaging

Radiographs
- patellar tilt in lateral direction

Treatment

Nonoperative
- NSAIDS, activity modification, and therapy
  - indications
    - mainstay of treatment and should be done for extensive period of time
  - technique
    - therapy should emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises
Operative
- arthroscopic lateral release
  - indications
    - objective evidence of lateral tilting (neutral or negative tilt)
    - pain refractory to extensive rehabilitation
    - inability to evert the lateral edge of the patella
    - ideal candidate has no symptoms of instability
    - medial patellar glide of less than one quadrant
    - lateral patellar glide of less than three quadrants
- patellar realignment surgery
  - Maquet (tubercle anteriorization)
    - indicated only for distal pole lesions
    - only elevate 1 cm or else risk of skin necrosis
  - Elmslie-Trillat (medialization)
    - indicated only for instability with lateral translation (not isolated lateral tilt)
    - avoid if medial patellar facet arthrosis
  - Fulkerson alignment surgery (tubercle anteriorization and medialization)
    - indications (controversial)
      - lateral and distal pole lesions
      - increased Q angle
    - contraindications
      - superior medial arthrosis (scope before you perform the surgery)
      - skeletal immaturity

Techniques

Arthroscopic lateral release
- technique
  - viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion
  - be sure adequate hemostasis is obtained
  - postoperatively the patella should be able to be passively tilted 80°
- complications
  - persistent or worsened pain
  - patellar instability with medial translation

TAG

(OBQ11.34) 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? Topic

Review Topic

FIGURES: A

1. Lateral retinacular release
2. Anterolateral tibial tubercle osteotomy
3. Anterior tibial tubercle osteotomy (Maquet)
4. Medial tibial tubercle osteotomy (Elmslie-Trillat)
5. Medial plica resection

PREFERRED RESPONSE ▶

DISCUSSION: 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.

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.

Illustrations: A

REFERENCES:

1. Steiner T, Parker RD. Patellofemoral instability. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:1548-1572.

2. Calpur OU, Ozcan M, Gurbuz H, Turan FN. Full arthroscopic lateral retinacular release with hook knife and quadriceps pressure-pull test: long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2005 Apr;13(3):222-30. Epub 2004 Apr 6. PMID:15067501 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 5 Ratings

TAG

(OBQ05.184) 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? Topic

Review Topic

1. arthroscopic lateral retinacular release
2. tubercle elevation and medialization
3. strict immobilization and non-weight bearing for four weeks
4. open chain exercises and a focus on seated leg extensions
5. closed chain exercises with focus on quadriceps and hamstring strengthening

PREFERRED RESPONSE ▶

DISCUSSION: 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 verses 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.

Incorrect Answers:
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.

REFERENCES:

1. Theut PC, Fulkerson JP. Anterior knee pain and patellar subluxation in the adult, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philidelphia, PA, WB Saudners, 2003 pp 1772-1814

2. Hungerford DS, Lennox DW. Rehabilitation of the knee in disorders of the patellofermoral joint: Relevant Biomechanics. Orthop Clin North Am 1983;14:397-402 PMID:6843975 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

Level of Evidence 4 (Case Series)

Calpur OU, Ozcan M, Gurbuz H, Turan FN. Full arthroscopic lateral retinacular release with hook knife and quadriceps pressure-pull test: long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2005 Apr;13(3):222-30. Epub 2004 Apr 6. PMID:15067501 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Steiner T, Parker RD. Patellofemoral instability. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:1548-1572.

Undefined

Theut PC, Fulkerson JP. Anterior knee pain and patellar subluxation in the adult, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philidelphia, PA, WB Saudners, 2003 pp 1772-1814
Hungerford DS, Lennox DW. Rehabilitation of the knee in disorders of the patellofermoral joint: Relevant Biomechanics. Orthop Clin North Am 1983;14:397-402 PMID:6843975 (Link to Abstract)

	Arthroscopic lateral retinacular release Sports - Surgical Cases - Lateral Patellar Compression Syndrome Arthroscopic lateral retinacular release	1/26/2012 853 views 2
	Fulkerson tibial tubercle osteotomy Sports - Surgical Cases - Lateral Patellar Compression Syndrome Anteromedialization (Fulkerson) tibial tubercle osteotomy	1/24/2012 2744 views 4

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