Lateral release for anterior knee pain without instability. Outcome evaluation at long term follow up.

1. Lateral release for anterior knee
pain without instability.
Outcome evaluation at long
term follow up.
Dei Giudici L, Faini A, Coppa V, Gigante A

2. DISCLOSURE
None of the Authors have conflict of
interest to declare

3. BACKGROUND
 Lateral release is performed since 1980
 Open or arthroscopic
 1,5 lateral to the lateral patellar border
 Ostermeier, 2007
LR do not stabilize or medialize patellar tracking
during full articular ROM
It reduces the pression on the lateral facet during
flexion movements

4. BACKGROUND
 Merican and Amis, J Biomechanics 2009
“the effect of patellofemoral joint stability on selective cutting of lateral
retinaculum and capsular structure”

5. BACKGROUND
 CONTRASTING EVIDENCES
• Good/Excellent results 46-88%
• VAS and WOMAC
improvements up to 24 months
• Not related to the presence of
chondral lesions
• Up to 76% success rate is
obtainable with rehabilitation
alone
• Medial and lateral stability
reduction
• Treats only mechanical causes

6. BACKGROUND
 Extensive use. Proposed for every condition affecting the PFJ!!!
 Literature scarcity
 PF pain with instability
 PF pain without instability
 PF osteoarthritis
• Henry et al, AJSM 1986
• LRR in PF subluxation
• 88% positive results in terms of pain
reduction
• 25% recovery of sport activity levels
• Schonholtz et al, Arthroscopy 1987
• LRR of the patella
• 67% significant improvement (reduction
of dislocation)
• 84% negative results in patients
withouth instability
• First step after the failure of conservative
treatment
• Miller and Bartlett
• Recurrent patellar dislocation treated by
closed LRR
• Gerbino et al
• Long term functional outcome after
lateralpatella retinacular release in
adolescents
• 97% high satisfaction rate at 8.5y of FU
• Shellock et al, Arthroscopy 1990
• Evaluation of patients with persistent
symptoms after LR by kinematic MRI
• 23% rate of subluxation
• Aglietti et al, GIOT 1992
• LRR only give worst outcomes
• Only acceptable as associated
procedure
• 35% rate of dislocation
• Christoforakis et al, KSSTA 2006
• Effects of LR on the lateral stability of
the patella
• 14-20% reduction in the mean load
necessary for a lateral dislocation
between 0° and 30°
• ASSOCIATIONS
 LR+Medial Plication: better correction,
higher satisfaction, higher reduction of
dislocation and medial subluxation
 LR Vs LR+Medial Plication: better objective
and subjective outcomes for the association;
lower complications
• ASSOCIATIONS
 LR+Tibial Tubercle Transposition:
malalignment correction, better results on
the long term, up to 85% of excellent results
at 46 months
 Larson et al, CORR 1978
 The patellar compression syndrome:
surgical treatment by LRR
 Henry et al, AJSM 1986
 LRR in PF subluxation
 Fu and Maday, Orthop Clin Norh Am, 1992
 LRR and lateral compression syndrome
 Good results >80%
 Indicated for hyperpression syndrome
without chondral damage
 Micheli 1981, Dzioba 1990, Christoforiakis
2006, Lattermann 2007
 Worst outcomes in women
 Inadequate correction
 General associated to bad prognosis
 No benefits on the long run
 To accept ONLY as associated procedure
 INDICATIONS
 Fulkerson type II malalignment
 Fulkerson type III malalignment
(Hyperpression syndrome)
 Jackson et al 1991:
 good results
 Shen and Fulkerson 1992:
 Useful IF present minimal malalignment
 Aderinto and Cobb, 2002:
 80% pain reduction
 60% satisfaction rate
 Alendaroglu et al 2008:
 Useful in OA grade 2-4 AND without
instability
 Good results up to 24 months
 Wu et al 2011:
 Associated to drilling chondroplasty in
elderly patients
 84% improvement
 WHY IN OA?
Theory of retinacular neuromas
Fulkerson 1985
Kasim 1990
Mori 1991
Demonstration of neuronal terminations in
retinacular tissue

7. METHODS
 AIM: analyze the long term outcomes of patients suffering by anterior knee
pain, treated by LRR alone, in terms of pain reduction, functional scores, and
alignment modifications
 DESIGN: observational, independent, retrospective review
AKP patients
Personal
physician
Lyonnese CT scan @
our institution
(regional refellar
center)
Treatment
continuation with
personal physician
Follow up imaging
Exclusion:
- Missing data
- Traumatic injuries
- Dislocations
- Previous or associated surgeries
- Collagen disorders
- Surgery different from LRR alone
- No subsequent surgeries
FINAL POPULATION:
- Patellofemoral Pain
with and without
subjective instability
Screening for
enrollment

8. METHODS
 DATA GATHERING: demographic, clinical data, CT measurements (Fulkerson
grading, Lateral Patellar Angle, Lateral Patellar Displacement, Sulcus Angle, TT-
TG), NRS (pain), Kujala score, Tegner score
 ASSESSMENTS: symptoms progression, CT modifications, Kujala and Tegner
progression, recurrence of NSAID consumption, rehabilitation, and
intrarticular injection
 STATISTICAL ANALYSIS:
 Description of the study population in terms of mean and SD
 Subgroup analysis: instability versus stable group
 Paired t-test – Wilcoxon test
 Statistical significance: 0.05

9. RESULTS
 Population: 54 patients (43F – 11M)
 Age: 28,5 yo (m18 M41, SD5,21)
 Follow up: 74months (m32 M135, SD28,63)
INSTABILITY GRP
 21 patients (15F – 6M)
 Age 25,4 (SD 4,49)
 NRS: 7,86 (m6 M9 SD0,9)
 Kujala: 49,5 (m32 M70 SD10,88)
 Tegner: 5 (m3 M9 SD 2,12)
STABLE GRP
 33 patients (28F – 5M)
 Age 30,5 (SD 8)
 NRS: 6,48 (m5 M9 SD1,5)
 Kujala: 54,4 (m34 M72 SD10,77)
 Tegner: 5 (m3 M8 SD 1,63)

10. RESULTS
INSTABILITY GRP
0
10
20
30
40
50
60
70
80
90
NRS KUJALA TEGNER
PRE-OP FOLLOW UP
P<0.001

11. RESULTS
STABLE GRP
0
20
40
60
80
100
NRS KUJALA TEGNER
PRE-OP FOLLOW UP
P<0.001

12. RESULTS
 NO influence was observed by the procedure on the CT scans evaluations
 NO significant differences were noted comparing the two groups for pain
reduction and Tegner Activity score
 NO complications were reported
 Significant difference was observed for KUJALA Score between the two groups
(p=0,00145)

13. RESULTS
GRP COMPARISON - KUJALA
0
20
40
60
80
100
INSTABILITY STABILITY
PRE-OP FOLLOW UP IMPROVEMENT
P<0.001

14. DISCUSSION
 Effective procedure on patellofemoral pain
 Best results and satisfaction on patients withouth subjective
instability
 Patellofemoral pain without instability could be of
neurological origin due to the high amount of nervous
terminations in the lateral retinaculum and in the ileotibial
band
 Symptom resolution with good outcomes could be
explained by the associated denervation in the retinaculum,
caused by the procedure
 Patients presenting instability will benefit from the
denervation, but will still present a different and untreated
cause of pain that will be cause of discomfort, that explains
the lower outcomes, and that will require a different
procedure

15. CONCLUSIONS
 Not too proximal, and not in unstable (objective or subjective)
knees
 After conservative treatment fails (success rate 76%)
 Anterior knee pain without instability
 HyperPression syndrome (Fulkerson type III)
 Mild OA