CASE STUDY 20

Lateral retinacular over-release

Table CS20

What does over-release mean?

What are the causes for over-release?

How can we treat it?

Patellofemoral joint examination

Diagnostic clues

Findings

Diagnostic clues

Findings

Pain

Chronic, diffuse,
suprapatellar
Lateral
With overload
With overload
Centred

Patellar gliding
mechanism
Patellar apprehension
Q angle
Catching
Locking

Unstable, medialization
Severely positive to medial
Normal
Sometimes, medial
Sometimes, medial

Medialization

Range of motion

Normal

Medialization
Increased to medial
and lateral

Radiographs
Other

Normal
Excessive defect of the lateral
soft tissue structures,
quadriceps weakness

Tenderness
Effusion
Swelling
Patellar position,
relaxed, 0
Patellar position,
contracted, 0
Patellar position, 30
Patellar mobility

Patellofemoral Disorders: Diagnosis and Treatment. Edited by Roland M. Biedert

2004 John Wiley & Sons, Ltd ISBN: 0-470-85011-6

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CASE STUDY 20

LATERAL RETINACULAR OVER-RELEASE

History
This 31 year-old patient suffered from chronic
patellofemoral pain, severe weakness and instability on his left knee. At the age of 21 years he
had his first surgical intervention, with open revision and abrasion of the retropatellar cartilage.
The second operation was performed 4 years
later, repeating the abrasion and adding a lateral retinacular release. Because of persisting and
increasing pain, the third surgical intervention
was performed, extending the lateral retinacular
release. After this operation, the condition (pain,
weakness and instability) of his left knee continued to worsen.

Comments
Increasing and chronic patellofemoral pain, in
combination with weakness and feeling of instability, document a combination of severe symptoms and a disquieting condition of the knee.
Every time, the different surgical procedures
caused additional complaints (weakness, instability). They did not eliminate the initial problem
(pain).

Figure CS20.1 Anterolateral view showing an impressive

defect of the lateral soft tissue structures after three
operations

Course of action
Physical examination
Visual inspection of the left knee confirmed the
excessive persisting problem (Figure CS20.1). A
parapatellar lateral incision reached from the
tibial tuberosity to the vastus lateralis muscle
and ended 10 cm proximal to the proximal edge
of the patella. An extensive defect with a hole
was present proximal and lateral to the patella
(Figure CS20.2). At the site of the defect, the
tendon and muscle belly of the vastus lateralis
muscle no longer existed. In 30 of knee flexion,
the defect remained and the quadriceps tendon
(anterior) and the posterior part of the iliotibial band (posterolateral) became more visible

Figure CS20.2 Anterior view with the defect in the

distal part of the musculotendinous unit of the vastus
lateralis

PLAN

267

Table CS20.1 Complications following lateral retinacular release and over-release1 10

Medial patellar instability (subluxations,

dislocations)

Quadriceps muscle weakness

Loss of power of the extensor mechanism

Atrophy and retraction of the vastus lateralis

muscle

Loss of dynamic lateral stabilization of the
patella

Figure CS20.3 Defect of the lateral soft tissue structures in flexion

(Figure CS20.3).The physical examination documented a severe instability of the patella to

medial and lateral, with pathological patellar
glide and stability tests. Activation of the quadriceps was inhibited and caused medialization of
the patella. In addition, a very painful suprapatellar plica was palpated.

Radiographs
The standard radiographs showed no pathology
of the patellofemoral joint. Only dystrophy of the
patellar osseous structure with demineralization
caused by inactivity was found.
Axial CT evaluation was not performed
because the radiographs were normal and the
pathology clear.

Special considerations
The continued impairment of the condition of the
left knee with the extensive defect of the lateral

Complication following over-release.

soft tissue structures was caused by the various

steps of surgery. It is well described that lateral
retinacular release may cause secondary problems and complications (see Table CS20.1).1 11
Excessive superior extension of the lateral release,
which also severs the tendon of the vastus lateralis muscle, results in retraction and atrophy
of the muscle.6 This is combined with loss of
power to the extensor mechanism and eliminates
its function as a dynamic lateral stabilizer of the
patella. The present patient suffered from all of
these disabling complications. The initial cause of
his pains was an inflamed suprapatellar plica that
was never excised.

Plan
The goal of the treatment must be to eliminate
the medial patellar instability and pain. In cases
without over-release, lateral retinacular reconstruction using local scar tissue is often possible
and recommended 3,7 (see Case Studies 16 and
18). In cases with severe over-release, secondary
reconstruction of the lateral retinaculum and
the vastus lateralis musculotendinous unit with
a quadriceps graft is recommended (RA Teitge,
Handout, 1988). The bone block of the graft
is screwed to the lateral femoral condyle at the
most isometric point; the tendinous part of the
graft is passed through a transverse tunnel in the
patella, then turned onto the superficial surface of

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CASE STUDY 20

LATERAL RETINACULAR OVER-RELEASE

the patella and anchored there with sutures (see

Case Study 19). The inflamed suprapatellar plica
is removed during the lateral reconstruction.

Postoperative care and rehabilitation

See Case Studies 16, 18 and 19.

Discussion
The lateral retinaculum is a normal anatomical
structure with possible variations.3,8 It is abnormal when it is too short, tight or too thick. This
may cause passive patellar tilt. Lateral retinacular release 12 may not be the only option. Some
complications cannot always be eliminated, even
when using correct surgical techniques. Therefore, instead of release, we recommend a lengthening of the lateral retinaculum (see Case Studies
3, 5 and 6).
Over-release with transection of the musculotendinous unit of the vastus lateralis is the most
serious complication. The vastus lateralis muscle is composed of a vastus lateralis and a vastus
lateralis obliquus component.7,13 Over-release of
both parts change the stability and alignment of
the patellar balancing and should therefore absolutely be avoided.3,6,7 The physiological function
of the vastus lateralis muscle must be respected.

Summary
Over-release is the worst form of lateral retinacular release with the most serious complications. It
absolutely must be avoided. Although the reconstruction may be structurally possible, the physiological function of the lateral structures can never
be achieved again.

2. Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella:
indications and contraindications. Am J Sports
Med 18: 359365
3. Biedert RM, Friederich NF (1994) Failed lateral
retinacular release: clinical outcome. J Sports
Traumatol 16: 162173
4. Teitge RA, Faerber WW, Des Madryl P, Matelic
TM (1996) Stress radiographs of the patellofemoral joint. J Bone Joint Surg Am 78: 193203
5. Hughston JC, Walsh WM, Puddu G (1984)
Patellar Subluxation and Dislocation. Saunders
Monographs in Clinical Orthopaedics, volume V.
Philadelphia, PA, WB Saunders
6. Hughston JC, Deese M (1988) Medial subluxation
of the patella as a complication of lateral retinacular release. Am J Sports Med 16: 383388
7. Nonweiler DE, DeLee JC (1994) The diagnosis
and treatment of medial subluxation of the patella
after lateral retinacular release. Am J Sports Med
22: 680686
8. Busch MT, DeHaven KE (1989) Pitfalls of the
lateral retinacular release. Clin Sports Med 8:
279290
9. Henry JH, Goletz TH, Williamson B (1986)
Lateral retinacular release in patellofemoral
subluxation. Indications, results, and comparison
to open patellofemoral reconstruction. Am J
Sports Med 14: 121129
10. Marumoto JM, Jordan C, Akins R (1995) A
biomechanical comparison of lateral retinacular
releases. Am J Sports Med 23: 151155
11. Johnson DP, Wakeley C (2002) Reconstruction of
the lateral patellar retinaculum following lateral
release: a case report. Knee Surg Sports Traumatol
Arthrosc 10: 361363
12. Arendt EA, Fithian DC, Cohen E (2002) Current
concepts of lateral patella dislocation. Clin Sports
Med 21: 499519
13. Javadpour DP, Finegan PJ, OBrien M (1991)
The anatomy of the extensor mechanism and its
clinical relevance. Clin J Sport Med 1: 229235

References

1. Kramers-de Quervain IA, Biedert R, Stussi

E
(1997) Quantitative gait analysis in patients
with medial patellar instability following lateral
retinacular release. Knee Surg Sports Traumatol
Arthrosc 5: 95101

Suggested reading
Nonweiler DE, DeLee JC (1994) The diagnosis and
treatment of medial subluxation of the patella after
lateral retinacular release. Am J Sports Med 22:
680686