Proximal realignment procedures improve the relationship of the patella to the underlying trochlear groove by altering the anatomy above the kneecap.
Proximal realignment procedures include -
The most common of these proximal realignment procedures is the 'lateral release' (also called 'lateral retinacular release').
Lateral release done for the right indications and done in the correct way may offer patients a significant improvement in their symptoms.
But done the wrong way or, more importantly, for the wrong reasons - and the procedure can be the beginning of a nightmare scenario for the patient, the physiotherapist and the surgeon.
A lateral release is a surgical procedure where tightstructures to the outer side of the kneecap (patella), when they are causing the patella to tilt abnormally, are cut to allow the kneecap to assume a better position. The cut is an inch or more from top to bottom.
The procedure can be done in different ways - from inside the knee as part of an arthroscopy (keyhole surgery) or from the outside via a small cut (incision).
What is cut is the 'lateral retinaculum', a fibrous support on the outer side of the kneecap, but some other structures may also be cut at the surgeon's discretion if the release needs to be more extensive.
There are several important things to note:
- the procedure needs to be followed up by very diligent physiotherapy to keep the patella mobile and in a better position, otherwise as the lateral release heals and scars up the patella can again be pulled over to the outer side and be in as bad, or worse, a position than before.
Important in rehab is strengthening of the quads muscles and 'patellar mobilisations'. Patellar mobilisations are passive stretches of the patella, massaging and forcing it over to the midline to stretch out the lateral release and prevent things tightening again.
- if the surgeon is too agressive with the release, the vastus lateralis muscle can be cut, rendering the kneecap unstable and prone to medial dislocation.
- Haemarthrosis, or bleeding into the joint, after lateral release is a common, but undesirable complication. The surgeon must be consulted. If the haemarthrosis is tense, it is sensible practice to wash the blood out of the joint and be careful to maintain flexibility, as internal scarring and stiffening of the joint may otherwise occur.
Medial reefing is a procedure to try and pull the kneecap towards the midline by tightening the structures on the inner side, rather than releasing the structures on the outer side (lateral release). It is often done in conjunction with a lateral release.
The procedure involves placing strong stitches through the inner structures and pulling them tight.
Similar to reefing, but involves taking 'tucks' through the inner structures, like dressmaker's pleats.
This procedure is seldom done. It involves taking one of the hamstrings tendons, the semitendinosis tendon, and attaching it to the patella to pull it medially (semitendinosus tenodesis).