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Arthroscopic Lateral Retinacular Release

- Discussion:
    - lateral release detaches patella from lateral soft tissue structures, including lateral retinaculum, fibers from tensa fascia lata muscle, &
           joint capsule;
    - a tourniquet should not be used during this procedure since it has been shown to increase the occurance of postoperative hemarthrosis;
    - prior to performing the release, a complete arthroscopic exam is performed, which includes the knee flexion angle at patellar
           engagement and the knee flexion angle at patellar centralization;
          - normally, patellar centralization should take place between 30-45 deg;
    - part of the surgical statedgy is to avoid the superior geniculate artery;
    - a needle can be placed adjacent to the superior pole of the patella (1 cm proximal and lateral to the superior edge of the patella) which 
          serves as a intra-articular marker;
    - the arthroscope is switched from the anterolateral portal to the anteromedial portal;
    - scissor release:
          - metzenbaum scissors are inserted into the anterolateral portal and are used to bluntly spread over the retinaculum;
          - the tips of the scissors are then placed across the retinaculum and are pushed superiorly in order to effect the release;
          - care is taken to keep the curved tips of siccors directed posteriorly and 1 cm from the patellar edge;
          - the release should be visualized thru the anteromedial portal;
    - cautery release:
          - turn the cautery on the lowest setting that allows tissue cutting (avoids iatrogenic damage);
          - perform the retinacular release in layers starting from the superolaterally placed needle, and moving distally to the anterolateral portal;
                  - removing the fascia in layers allows a better opportunity to control bleeding;
          - the release procedes until the subcutaneous tissue is visualized;
          - care should be taken to avoid cutting the muscular fibers of the vastus lateralis;
    - judge the adequacy of release:
          - the patella should allow 45 deg of eversion following the release and/or should allow medial translation of 25% of the patellar width;
          - document the change in knee flexion angles for patellar engagement and centrallization;
    - following the release, hemstasis is achieved w/ cautery (note that bleeding often does not become manifest until several minutes following 
          the release, esp if a tourniquet is used)
    - references:
          - Arthroscopic determination of patellofemoral malalignment.
          - The percutaneous lateral retinacular release.
          - Arthroscopic lateral retinacular release and the lateral patellar compression syndrome.

Anatomy of the junction of the vastus lateralis tendon and the patellae.

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