A Medial And Lateral Retinacular Plasty versus Medial Retinacular Plasty And Lateral Retinacular Release

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A Medial And Lateral Retinacular Plasty versus Medial Retinacular Plasty And Lateral Retinacular Release

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Medial-lateral retinacular plasty is a new surgical technique designed based on anatomical and biomechanical studies and the advantages of traditional proximal repositioning. To compare the complication rates and outcomes of lateral supportive ligamentoplasty and lateral supportive ligament release for lateral patellar dislocation. In a retrospective study, 71 patients (mean age, 14.40 ± 1.28 years; 45females and 26males) received either medial and lateral retinacular plasty (37 patients) or medial retinacular plasty and LR release (34 patients) between October 2013 and December 2017. The number of patellar apprehension signs, Kujala score and patellar tilt angle(PTA), patellar lateral shift(PLS), congruence angle(CA), and medial patellar glide (MPG) from computed tomography scan have been incorporated into the clinical evaluation. All patients were followed up, and the shortest follow-up time was 2 years. Patients were followed up for a mean period of 29 months (24–38 months). The mean Kujala score was significantly lower (P = 0.027) in the LR release group (82.00 points) than in the LR plasty group (86.35 points). Moreover, there was a significant difference between preoperative and postoperative outcomes for MPG. (P < 0.05). The MPG was smaller in the LR plasty group than the LR release group. In this retrospective study, medial and lateral brachioplasty can effectively correct patellofemoral joint tracking and improve knee function in patients with patellar dislocation.

Health sciences/Medical research/Study design/Clinical trials/Phase iv trials

Health sciences/Diseases

Patellar dislocation

Lateral retinaculum plasty

Lateral retinaculum release

Medial retinaculum plasty

Patellofemoral joint instability is the usual surgical issue, with a reported incidence rate of the initial dislocation of 7 per 100,000 across all age groups (Atkin, Fithian et al., 2000) and 29 per 100,000 between the ages of 10 and 17 years (Fithian, Paxton et al., 2004c). An amount of factors have been demonstrated in the pathogenesis of patellofemoral instability. When combined with other factors (including dysplastic trochlear, dysplastic patella, or an abnormal Q angle, the damage of medial parapatellar soft-tissue) (Arendt, Fithian et al., 2002; Fithian, Paxton et al., 2004a; Stefancin and Parker, 2007) the isolated use of a lateral retinacular release of the patella for the therapy of patellar instability is improper (Betz, Lonergan et al., 1982; Dandy and Griffiths, 1989).

Various surgical techniques for the therapy of recurrent patellofemoral instability have been reported in the publications (Fithian, Paxton et al., 2004a; Chen and Ramanathan, 1984; Metcalf, 1982; Sherman, Fox et al., 1987). Lateral retinacular release is a relatively simple procedure that became popular since it was thought that a tight lateral retinacular predisposed could easily lead to lateral patellar dislocation (Fithian, Paxton et al., 2004a). Patients without evidence of patellar malalignment, hyperlaxity, or tight lateral parapatellar soft-tissue structures can achieve satisfactory results (Gecha and Torg, 1990). So the experienced knee surgeons rarely perform the isolated LR release to treat patellar instability (Fithian, Paxton et al., 2004b).At this time, simultaneously multiple steps that soft-tissue realignment and lower limbs realignment were set as a standard program, for recurrent patellar dislocation, restores the general dissection of the patellofemoral joint (Desio, Burks et al., 1998; Koh and Stewart, 2014; Nomura, Horiuchi et al., 2002).

When the lower limbs alignment is normal, the medial and lateral soft-tissue realignment need to be adjusted. Various techniques, medial capsule reefing (Scuderi, Cuomo et al., 1988), medial retinacular plasty (Ji, Wang et al., 2012), and medial patellofemoral ligament reconstruction (Christiansen, Jacobsen et al., 2008; Smith, Walker et al., 2007) are used to tighten the medial side. There are varies treatment choices for patients with patella instability. In the last decade, when facing recurrent patellar dislocation, in order to restore the normal anatomy of the patellofemoral joint, medial patellofemoral ligament reconstruction was widely used (Desio, Burks et al., 1998; Koh and Stewart, 2014; Nomura, Horiuchi et al., 2002). Medial patella ligament reconstruction is regarded as an important procedure for patellar dislocation and has received perfect results in the clinic (Nomura, Horiuchi et al., 2000; Sanders, Morrison et al., 2001). However, this operation could casuse growth plate injured and the subsequently malformation. The medial capsule reefing is commonly used in children and adolescents with dislocation of the patella. However, it had a rather high recurrent instability rate (Conlan, Garth Jr et al., 1993; Hawkins, Bell et al., 1986). Therefore, we choose the medial retinacular plasty for repair the medial soft-tissues and reconstructed static and dynamic stability (Ma, Wang et al., 2013; hai Wang, Shu et al., 2013).

The lateral patellar retinacular release technique has been occupy the important position in the procedure of soft-tissue realignment. However, with the misuse and improper use of LRR, adverse outcomes and complications have occurred (Sanchis-Alfonso, Montesinos-Berry et al., 2015). The procedure resulted in decreased vastus lateral is strength and decreased lateral patella tracking. Without overly tight lateral retinacular or with hyperlaxity, may leads to an unstable patella. This may be even worse than the primary problem. Above all, the point was iatrogenic medial patellar instability, which Hughton and Dees first described in 1988 (Hughston and Deese, 1988). This is because the lateral patellar retinaculum was released too much and lost the restriction force. So, according to the lateral patellar anatomical structure, the author invented the lateral patellar retinacular plasty. We adopt this method to replace the LRR that avoid the release too much lateral retinacular and restoring biomechanical function of lateral patellar retinacular.

We speculated that in the initial surgical treatment of recurrent lateral patellar dislocation in adolescents, LR plication reduced the incidence of complications and improved the Kujala score compared with LR release.

In a retrospective study, 71 patients (mean age, 14.40±1.28 years; 45 females and 26males) received either medial and lateral retinacular plasty (37 patients) or medial retinacular plasty and LR release (34 patients) between October 2018 and December 2020. Informed consent was obtained from all subjects before testing. All participants provided written informed consent and the experimental protocol was approved by the Institutional Review Board of the Hospital's Human Ethics Committee (2023-002-1)and performed in accordance with the Declaration of Helsinki.

Inclusion criteria: (1) patellar lateral shift exceeding 1.5 cm with a soft endpoint by the lateral glide test; (2) patellar instability were confirmed through measuring the patellar tilt angle (PTA) and the congruence angle (CA); (3) the degree of MPFL injury depend on MRI diagnosis; (4)medial patellar glide test(MPG): patella cannot be shifted by 1 or more quadrants medially by the examiner with patient’s knee placed at 10° of flexion (Pagenstert, Wolf et al., 2012). Exclusion criteria: (1)Q-angle＞20°;(2) patellar position (Insall index＞ 1.2 or Insall index＜0.8); (3) tibial tuberosity-trochlear groove (TT-TG) distance＞15 mm; (4) positive crossing sign, shallow trochlear depth less than 3 mm, trochlea bump ＞4 mm or sulcus angle(SA) greater than 150°; (5) with patellar dysplasia grade IV and V (Wiberg classification); (6) complicated with other ligament injury; (7) rheumatoid arthritis, osteonecrosis patellofemoral osteoarthritis of more than stage Ⅰ.

All patients were standardized followed-up at 3, 6, 12, and 24 months after surgery. We analyzed CT and measured congruence angle, lateral patellofemoral angle,patella lateral shift,medial patellar translation (MPG). We also analysed Kujala score before and after the surgical procedure.

The diagnosis of patellar dislocation was confirmed by physical examination (patellar apprehension test, lateral glide test), MRI, and the CT scan. The diagnosis of patellar dislocation was confirmed by medial patellar glide (MPG). PTA is determined by the angle between a line parallel to the lateral surface of the patella and another line parallel to the posterior condyle line. A groove angle is formed between the two tangents of the articular surface of the medial and lateral condyles of the femur. The CA refers to the angle formed between the bisector line of a sulcus angle and the tip–tip line (A tip–tip line connects the tips of the sulcus angle and the patellar ridge). The Kujala score and with a subjective questionnaire were used to evaluate the knee function.

From October 2018 and December 2020, 76 patients with recurrent patellar dislocation were included in our study. There were 37 cases with medial patellar retinaculum platy and LRR(Group I). There were 39 cases with medial patellar retinaculum plasty and lateral retinacular plasty(LRP)(Group II).

Two examiners independent observer evaluated the results of all patients (second blind). They didn't know about the different surgical procedures.

Surgical technique

All those patients were treated using the LRR or LRP operation combinated with the MRP method by the same experienced orthopaedic surgeons. With the patient lying supine and under subarachnoid anesthesia or lumbar anesthesia, arthroscopic assessment was performed to evaluate the patellar tracking and checked the possible chondral lesions and any associated pathology inside the knee.

In Group I: Complete lateral release was carried out through the lateral arthroscopic portal, cutting at least one layers in into the vastus lateralis muscle. If necessary，all 3 layers(including the patellotibial ligament)of the lateral retinacular were released. After an LRR was performed under arthroscopy, withdrawal of the arthroscope. A 3-cm longitudinal incision in the medial edge of the patella was made and the skin was dissected.After the subcutaneous tissue and deep fascia were dissected, the vastus medialis(VM) , the medial retinaculum of the patella, and the patellar tendon were exposed. A transverse dissection was made along the junction of the vastus medialis and medial retinaculum to the medial femoral condyle to dividing two sections. The medial retinaculum was pulled proximally and forward near the upper pole of the patella. This coincided with the vastus medialis was pulled distally and laterally near the middle line of the patella with temporary fixation. The tracking of patella was observed with the naked eye during the knee flexion0°~30°. The patellofemoral joint relationship was observed under arthroscope during flexion and extension. On the basis of patellar tracing, the fixation position of the medial retinaculum and the vastus medialis was adjusted and sutured on the medial aspect of the patella. Finally, the overlapped tissues which including the medial retinaculum, vastus medial is and the proximal and distal section of medial retinaculum were sutured together by PDS-1 sutures (Fig.1).

In Group II：The surgery process of the medial retinacular plasty as the group I.A 3-cm longitudinal incision in the lateral edge of the patella was made, and the skin was dissected, subcutaneous tissue and deep fascia in turn that would expose the lateral patellar retinaculum. A section with a 1cm width in the lateral patellar retinaculum along the line from the lateral upper margin of the patella to the lateral femoral condyle was grafted to the junction of the lateral patellar retinaculum and the tensor fasciae latae. The free end of the lateral patellar retinaculum was pulled to the center of the patellar lateral edge and temporarily fixed on the lateral edge of the patella (Fig.2).

Postoperative Rehabilitation And Follow-up

The rehabilitation prescription was the same for all patients. The patients required wear a brace for external fixation. Isometric quadriceps strenghtening exercises and patellar gliding training were started on the first postoperative day. Patients began continuous passive motion exercises and active and assisted knee range of motion exercises everyday. Knee flexion was allowed to 30° on one postoperative week. Partial weight bearing with crutches and maximum knee flexion of 90° was obtained on two postoperative weeks. After 4 postoperative weeks, full weight bearing was allowed. After patients who achieved enough quadriceps strength, patellar stability and sufficient range of motion were allowed to begin normal physical activities 2 months after surgery ; athletic exercises 3 months after surgery.

The patellofemoral joint was evaluated with CT scans. The patellar tilt angle (PTA),patellar lateral shift (PLS),patellar medial glide (MPG), sulcus angle (SA),congruence angle(CA)and patellar tilt angle (PTA) were measured in CT scan. And the knee function was determined by the Kujala score and with a subjective questionnaire.

STATISTICAL ANALYSIS

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS, Chicago, IL, USA). Each of the measures were calculated by descriptive statistics. A two-samples t test and Chi-squareor Fisher test for continuous variables and categorical data were used to exam the differences in age, gender respectively.

The two-samples t-test was used to compare the differences in sulcus angle (SA),congruence angle(CA),patellar medial glide(MPG)and lateral patellofemoral angle(LPA) between both treatment groups. Differences in Kujala score between both treatment groups were determined with an unpaired-samples t test or Mann-Whitney rank sum test, according to normal or not normal distribution of data. Quantitative variables were described with means and standard deviations (S±D).The level of significance was set at P< 0.05.

MRI examination showed the MPFL injury in all patients. Physical examination showed that lateral retinaculum is too tight in all patients. Five patients lost follow-up after 1 year, including 3 in group I and 2 in group II, and the remaining 71 patients, including 34 in group I and 37 in group II, were included in the final analysis. In addition, there were no differences in preoperative data between the two groups (Table 1). Patients were followed up for an average period of 29 months (24–38 months).

Table 1

Patient preoperative demographics
Indexes	GroupI(n = 29)	Group II (n = 32)	t(χ2) (95% CI)	P values
Age	14.5 ± 1.5	14.0 ± 2.4	0.968	0.337
Gender(M\F)	12/22	14/23	0.049	0.824
X-ray
Insall index	1.01 ± 0.12	0.95 ± 0.13	1.942	0.056
CTscan
TT-TG (mm)	12.25 ± 1.47	12.86 ± 1.27	-1.879	0.064
CA (°)	18.62 ± 1.79	18.60 ± 1.69	0.037	0.971
PTA (°)	14.26 ± 1.80	15.24 ± 2.61	-1.84	0.700
SA (°)	133.43 ± 3.73	134.73 ± 4.32	-1.352	0.181
PLS (mm)	20.18 ± 2.24	20.91 ± 2.57	-1.283	0.204
Kujala score	52.06 ± 0.66	51.41 ± 2.91	0.984	0.328
TT-TG tibial tuberosity-trochlear groove distance, CA congruence angle, SA sulcus angle, PTA patellar tilt angle, PLS patellar lateral shift, CI confidence interval

During the observational period, the subcutaneous or intra-articular hematoma was occurred. The CA, the PTAand the PLS was not significantly different between the two groups.On CT scans, and MPGwas significantly different between the two groups(P = 0.000). (Table 2) The Kujala score had significantly improved after surgery, from 52.06 ± 0.66 to 82.00 ± 8.70 in Group I and from 51.41 ± 2.91 to 86.35 ± 7.56in Group II. The Kujala score with a statistically significant difference between the two groups (Table 3). Five patients in Group I initially complained of weakness when extending the knee, none patients in Group II; No extension nor flexion deficit of 5° or more was observed in the range of knee motion compared with the contralateral knee at the final evaluation.

Table 2

Follow-up results of knee function
Indexes	GroupI(n = 34)	Group II (n = 37)	t(v2) (95% CI)	P values
CA(°)	2.84 ± 1.20	3.30 ± 1.53	-1.397	0.167
PTA (°)	8.73 ± 1.89	8.04 ± 1.83	1.576	0.12
PLS (mm)	14.73 ± 2.69	14.17 ± 3.14	0.809	0.421
MPG (Quadrants)	2.48 ± 0.64	1.67 ± 0.36	6.518	0.000
Kujala score	82.00 ± 8.70	86.35 ± 7.56	-2.257	0.027
TT-TG tibial tuberosity-trochlear groove distance, CA congruence angle, PTA patellar tilt angle, PLS patellar lateral shift, MPG medial patellar glide, CI confidence interval

Table 3

Preoperative and postoperative functional scores
Kujala score	GroupI	Group II
Preoperatively	52.06 ± 0.66	51.41 ± 2.91
Postoperativly	82.00 ± 8.70	86.35 ± 7.56*
Differences with other groups, P < 0.05.

We tried to determine the clinical outcomes of retinaculum release and lateral retinaculum plasty for patellar dislocation. The primary finding was that lateral retinacular plasty ameliorate functional status better than lateral retinacular release in the therapy of recurrent patellar dislocation. This experiment, Kujala score increased respectively from 52.06 ± 0.66 (Group Ⅰ), 51.41 ± 2.91 (Group Ⅱ) preoperatively to 82.00 ± 8.70 (Group Ⅰ) 86.35 ± 7.56 (Group Ⅱ) postoperatively. Medial and lateral retinaculum plasty significantly ameliorates knee function and living quality over medial retinaculum plasty and lateral retinaculum release.

The etiological factor of lateral patellar dislocation is various such as malalignment of lower extremity, trochlear dysplasia, patella alta, as well as medial soft tissue insufficiency and lateral soft tissue contracture (Amis, Firer et al., 2003; Dejour, Walch et al., 1994). Various operative options are available for the treatment of patellar dislocation. Generally it consists of two parts, one part is bony realignment procedure, the other part is soft-tissue realignment procedure. Exclusion criteria in this experiment including abnormal bony structure, so the author only need to realign soft-tissue. Most soft tissue procedures include variations of two basic techniques: medial and lateral soft tissue realignment that can yield a good prognosis.

The medial side can be settled by various techniques, including medial capsule reefing (Scuderi, Cuomo et al., 1988),medial retinacular plasty (Ji, Wang et al., 2012) and medial patellofemoral ligament reconstruction (Christiansen, Jacobsen et al., 2008; Smith, Walker et al., 2007). Consequently, as a general soft tissue surgical approach, medial capsule reefing is a deeply accepted surgical procedure for the treatment of children and adolescents with patellar dislocation. Whereas, a retrospective survey by Matthias Buchner claimed a high incidence of recurrent instability after reduction of the medial capsule of 27%.

A prospective study by LF Ma (Ji, Wang et al., 2012) reported a higher recurrent instability rate of 31.1% after medial capsule reefing, a lower recurrent instability rate of 6.2%after medial retinacular plasty respectively; the Subjective questionnaire indicated that the medial retinacular plasty could get a better result. So, the medial retinacular plasty is better choice to treat the patellar dislocation. MPFL reconstruction is acknowledged as a critical procedure for patellar dislocation. The recurrence rate after MPFL reconstruction is low and the clinical effect is good (Nomura, Horiuchi et al., 2000; Sanders, Morrison et al., 2001; Elias, White et al., 2002; Kirsch, Fitzgerald et al., 1993; Spritzer, Courneya et al., 1997). However, in adolescents with an open growth plate, most scholars do not recommend this surgical technique due to damage to the growth plate and subsequent deformity. What is more, it has proved that the clinical results of MPFL reconstruction and MR plasty is similar by Ma et al (Ma, Wang et al., 2013). Therefore, the author chose medial retinoplasty as the main treatment for recurrent patellar dislocation. Our experiments have established that MR plasty could repair knee medial stability effectively. The patellar lateral shift postoperative (14.73 ± 2.69; 14.17 ± 3.14) decrease obviously contrast with preoperative (20.18 ± 2.24; 20.91 ± 2.57). The congruence angle postoperative decrease obviously contrast with preoperative.

As it is believed that a tight lateral retinaculum predisposed can easily lead to lateral subluxation or dislocation of the patella, lateral retinacular release was used to treat the instability as a necessary process (Sherman, Fox et al., 1987; Fithian, Paxton et al., 2004b). These scholars noted that lateral retinacular release it has been occupy the important position in the procedure of soft-tissue realignment (Prejbeanu, Vermeşan et al., 2006). The misuse and improper use of LRR has brought about undesirable results and complications (Sanchis-Alfonso, Montesinos-Berry et al., 2015). Nevertheless, some current studies also indicate that the overall effect of LRR is not sustainable in the long term (Betz, Lonergan et al., 1982; Dandy and Griffiths, 1989; Dandy and Desai, 1994). Desio et al (Desio, Burks et al., 1998) found that lateral patellar stability decreased by 10% at the knee flexion 20° after LR released, The structure relaxation may enhance patellar instability. Betzet al (Betz, Lonergan et al., 1982) reported that only 29% did not appear patellar instability 39 patients after LR released, and aggravating illness following the subsequent time.

However, with the anatomic and biomechanical of patella was most extensively studied, the application of LRR in recurrent instability has been questioned. The accurate and comprehensive understanding of the anatomy and biomechanics of the patellofemoral joint is critical to the success of the procedure. Excessive overrelease of the lateral soft tissues is the major reasons for poor results after lateral release surgery. This results in a decrease in vastus lateralis strength and a decrease in lateral patella tracking. In the treatment of lateral patellar hyper compression syndrome, to prevent LR release leading to synovial herniation, Z-plasty LR lengthening is an alternative technique (Larson, Cabaud et al., 1978). Z-plasty LR lengthening lengthened the lateral retinaculum, decompressed the hypercompression and maintained continuous and muscle attachment unit. Geert (Pagenstert, Wolf et al., 2012) proved that retinacular lengthening (z -plasty) led to less medial instability, less quadriceps atrophy, and better clinical effects compared to retinacular release. Thus we got hints, the author chosen the LR plasty (V-plasty) instead of LRR for keeping patellar lateral stability while release the lateral soft-tissue.

In this study, patients treated with LR release had a marked deviation in MPG values from less than quadrant 1 to quadrant 4 (demonstrating over the release and medial patellar subluxation). The patella glide test results were approximately 1.5 quadrants after LR plication, with small deviations in values at follow-up (Table 2).

We used medial and lateral retinaculum plasty to treat patients with patellar dislocation, changing patellar retinaculum tension, and attachment points. This procedure may allows the patella to switch from an abnormal position to the central position of the femoral trochlea and maintained muscle attachment unit and myodynamia.

The limitation of our clinical research is the relatively young age of the limited number of subjects. This is a retrospective study with small amount of subjects, different from the number of subjects in the control group. The clinical examinations, especially endpoint examinations, are examiner-dependent and may be inaccurate. In addition, there may be bias in the measurement results of CT images.

Our retrospective research demonstrates that medial and lateral retinacular plasty surgery ameliorates knee function and quality of patients' livings with recurrent patellofemoral instability with beneficial patellofemoral and knee function. The efficacy of LRP for recurrent patellar instability is superior to that of LPR.

CONFLICT OF INTEREST STATEMENT

We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled.

ETHICAL REVIEW COMMITTEE STATEMENT

This material has not been published and is not under consideration elsewhere. The study was approved by the medical ethics committees of the Third Hospital of Hebei Medical University.

ACKNOWLEDGEMENT

No.

DATA AVAILABILITY STATEMENT

The data presented in this study are available on request from the corresponding author.

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No competing interests reported.

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A Medial And Lateral Retinacular Plasty versus Medial Retinacular Plasty And Lateral Retinacular Release

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