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Author Topic: Another failed lateral release? Please help  (Read 7735 times)

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Offline Driden

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Another failed lateral release? Please help
« on: April 23, 2011, 09:01:55 PM »
I am new here and looking for guidance.
 
I got an arthroscopic lateral retinacular release 9 months ago after my OS observed a tight lateral retinaculum on clinical exam, stable knee on clinical exam, significant patellar tilt on x-ray, mild subluxation on x-ray, and likely lateral facet problems on x-ray.† (I had lateral knee pain from distance running, not front knee pain, with a diagnosis of IT Band syndrome; the OS decided to do a LRR in addition to an ITB release).†
 
I am now much worse; however, I seem to be getting a tiny bit better each month.† Still, my quadriceps in my surgical knee remain 3 cm smaller than my non-surgical leg despite diligent attempts at rehab.† My vastis lateralis, in particular, is much smaller.† The pain is not too severe with daily life; however, I cannot do much in the way of eccentric loading such as squats or lunges.† My walking gait is still not right.† Running and sports are impossible.† My often knee pops and snaps when I walk.
 
Iíve done everything a person can do:† lots of oral NSAIDs, Synvisc injections, corticosteroid injection, formal physical therapy (3 rounds with different therapists), work with a personal trainer, McConnell taping, knee braces, etc.† I am even getting acupuncture and about to start taking anabolic steroids under the guidance of a physiatrist!
 
I have flown to another state to see a highly regarded patellofemoral specialist (IPF Study Group member, top clinic, authored articles on LR reconstruction, etc.).† Just as I feared, he said there could be some medial instability based on laxity seen on his clinic examination (3 quadrants of passive medial glide compared to 1 quadrant on the non-surgical knee).† However, the diagnosis is not certain because other clinic signs are absent (i.e., negative apprehension test; negative Fulkerson relocation test for medial instability).† Therefore, he said we could do a lateral reconstruction in a few months after more attempts at rehab, but it may not help the problem since the diagnosis is so murky.† My local OS thinks medial problems are unlikely because his LR technique is so conservative (a small extra-synovial cut that stops short of the vastis lateralis and vastis lateralis obliqus tendons).
 
I feel stuck.† I hate to get a surgery with an unclear diagnosis.
 
Questions:
 
(1) Is there any hope of getting close to my pre-surgery level without more surgery?† Should I just try to be patient?† Are there cases of success in the long run, even though 9 months out the procedure appears to be a failure?
(2) Is there any way to get more certainty in the diagnosis of medial subluxation?
*Should I go see Dr. Teitge and get stress radiographs, where an instrument called a PatellaPusher pushes on the patella while the x-ray is being taken?† Has anybody else had these done?† Does anybody else do them besides Dr. Teitge? What else will that show since we already know there is increased laxity?
*What do folks think about kinematic (dynamic) MRI?† I read a paper where they can show medial subluxation.† Where can I find one of these machines? (I will travel).† Are there any good patellofemoral docs that use them?
*[Note:† My OS, physiatrist, and a local radiologist that I know basically dismissed the concept of stress radiographs and kinematic MRI]
(3)† Any success stories on lateral retinaculum reconstruction surgery?† Who are the surgeons that performed the procedures?
(4) Any other thoughts?

Offline crankerchick

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Re: Another failed lateral release? Please help
« Reply #1 on: April 23, 2011, 09:29:51 PM »
*Should I go see Dr. Teitge...
^This^
Although since you are willing to travel, there are others as well.

Who are the surgeons that performed the procedures?
Let's talk offline.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

drmark

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Re: Another failed lateral release? Please help
« Reply #2 on: April 23, 2011, 10:38:00 PM »
YOu most certainly don't need to travel to Detroit, Houston, London, or Honk Kong to get a stress Xray. You just need to get your doc to do one. The patella pusher isn't much more than the eraser end of a pencil pushing first one, then the other patellas medially while a Merchant view X-ray is being done. 

Even without an X-ray, just pushing on the patella from a lateral direction you can see how much it migrates medially and compare it to the other side.  I am terribly sorry to inform you, but this just isn't rocket science.  No disrespect meant to my friend and teacher, Dr. T. who I am certain would agree on this.

Offline crankerchick

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Re: Another failed lateral release? Please help
« Reply #3 on: April 23, 2011, 10:53:25 PM »
The diagnosis doesn't require travel, but I would venture to say that the fix just might.

Plus it sounds like the local doctor has already dismissed the idea of medial instability and the highly regarded second opinion is unsure based on examination. Also sounds like no doctor seen to date is willing to the imaging and the OP doesn't want surgery without a definitive diagnosis. All signs point to another opinion.
« Last Edit: April 23, 2011, 10:55:31 PM by crankerchick »
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Offline aaa

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Re: Another failed lateral release? Please help
« Reply #4 on: April 24, 2011, 01:49:02 AM »
I am even getting acupuncture and about to start taking anabolic steroids under the guidance of a physiatrist!

I would be careful of the steroids, I'm not sure that would help what sounds like a structural problem.

My local OS thinks medial problems are unlikely because his LR technique is so conservative (a small extra-synovial cut that stops short of the vastis lateralis and vastis lateralis obliqus tendons).

I've had a failed lateral release, that will need a repair.  Some OS's will say the LR technique is conservative, but they make an incision under the skin which you can't see (as opposed to open knee surgery), so I guess it could appear that its not a big deal.  I am sure my lateral release has had a drastic effect on my patella tracking, and caused significant medial instability.  It sounds you are in the same boat, so I wouldn't buy this at all that it is conservative.

From what you've described, it sounds like a LR might have been indicated .. where any other things looked for, e.g. patella alta, malrotations, TT-TG measure, trochlear dysplasia?




drmark

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Re: Another failed lateral release? Please help
« Reply #5 on: April 24, 2011, 01:58:15 AM »
The LPFL is in Layer 2 of the lateral knee.† Its entirely extrasynovial, so being extrasynovial is no more "conservative" than being intrasynovial.† The skin incision, as in all skin incisions are irrelavant.† "Minimally invasive" is a come-on really no better than a fraud perpetrated by the doctors on themselves and their patients.
It comes from drinking the Koolaid sold to the unsuspecting docs by the equiptment makers.

And it has nothing to do with the vastus lateralis tendon.  Medial instability can occur when the LPFL, a vital structure is unnecessarily sacrificed.
« Last Edit: April 24, 2011, 02:01:08 AM by drmark »

Offline TOMMAX

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Re: Another failed lateral release? Please help
« Reply #6 on: April 24, 2011, 03:20:12 AM »
Count me in to the failed lateral release club. I had mine done in april 2010 and my knee is mechanically screwed up now and I have medial instability. I also have problems with dynamic movement (squats/ lunges) and gait pattern. It all feels like its twisting medially and I have alot of medial PF compression. As long as I dont use the leg too much though, I can manage to avoid pain. If I use it for more than an hour, even noramlly standing and limping around, I get pain behind the knee cap and it feels like it is getting crushed in the joint spce.
March 2005: LK Plant & twist injury (full lateral patellar dislocation)
April 2010: LK scope (LRR, posteriolateral meniscus, medial plica)
Current: Medial instability
May 24, 2012: LPFL + MPFL recon scheduled

Offline Driden

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Re: Another failed lateral release? Please help
« Reply #7 on: April 26, 2011, 02:54:06 AM »
Does anybody else with a failed LR and suspected medial instability have a severely atrophied vastis lateralis muscle and a strong VMO that looks like the good leg?  I suppose the atrophy just might be more obvious because it is such a bigger muscle, but maybe there is something more to it.  The Hughston article on medial subluxation mentions VL atrophy as a symptom of medial instability, not generalized quad atrophy.  I don't know why that one muscle would be so inhibited if the VL tendons are intact.

I keep thinking that if I can just grow the VL back, it will pull the patella back over to the middle.  But even that logic may be suspect... one scholarly article says the medial translation occurs in the unloading phase when the quad is not activated, so I don't even know what good a stronger quad will do (if I ever get one).  As DrMark said, the soft tissues are the key .. but unfortunately require a scalpel rather than a leg press machine.  The latter is the only sense of control that I can exert over the process.


Offline aaa

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Re: Another failed lateral release? Please help
« Reply #8 on: April 26, 2011, 05:00:11 PM »
My VMO on the leg with lateral release looks bigger than my right leg.  In fact, the quads girth on my left is 21" while unaffected leg is 20". 

Is it possible the VMO over develops from a lateral release?  it looks and feels that way with my case, but maybe i'm being faked out by the alignment.  My vastus lateralis looks similar to my right leg, but there is loss of tone.  I'm just eyeballing it though, wonder if there is some imaging that could give real info.

My experience is trying to rehab from my lateral release has been challenging, and so i'm going the surgical route, I think I stand a better chance of having a stable knee and I don't want to be investing hours on end doing PT , core strengthening, stretching, for the rest of my life ... been at it for a year and its enough for me.  But, i've heard of others having success, user WorkinWings had some success - http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=41314.0











Offline Driden

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Re: Another failed lateral release? Please help
« Reply #9 on: April 27, 2011, 06:19:13 AM »
YB, do you mind sharing the name of the surgeon who will be doing your reconstruction? When are you having the surgery?

Offline Marantha

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Re: Another failed lateral release? Please help
« Reply #10 on: April 27, 2011, 02:54:32 PM »
My LR has failed to what I believe...I am hypermobile and always feeling my knee twist then lock (proper locking of the knee, cant move it and loads of pain), then it unlocks...I am over a year since my LR. I am on strong pain meds...my VMO is smaller than the other my physios won't touch my and want me to have more surgery. I am no longer with my OS he discharged me with saying I have CRPS...my GP thinks that's an excuse but am fed up and just want someone to take the bull by the horns as it were. I am doing all I can physio but it's not working and the physios knew that but it's ok for an OS too say carry on but doest know what's wrong with me..am only 22. Was a semi pro footballer now am nothing...

I wish someone would help me, my GP has just placed me On pain meds which are great (obviously) but my pain comes back and it does not stop locking and feeling like it's not in the right place.

The NHS screwed it up for my my GP states I've had a hell of a time, I've got all the letters...all the surgeons has diagnosed me with differed things what am I meant to believe??
« Last Edit: April 27, 2011, 02:56:36 PM by Marantha »
2009 Physio
30/10/2009 OS appointment confirmed patella tilt, very hypermobile, and a rare bone deformity called hypoplastic medial femoral condyle.
10/03/2010 LR preformed and chondromalacia grade 1 spotted

Offline aaa

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Re: Another failed lateral release? Please help
« Reply #11 on: April 27, 2011, 04:06:22 PM »
Driden, PM sent

I'm probably not the best person to ask, I thought crankerchick would be a great person to ask for suggestions, and also you have a top specialist posting here in this thread ...

Marantha, that is terrible, I hope you will find a way to get it fixed ... I don't know of any OS in the UK that I could recommend ... maybe somebody else can advise a UK patellofemoral specialist??
« Last Edit: April 27, 2011, 04:08:40 PM by yb »

Offline smillie

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Re: Another failed lateral release? Please help
« Reply #12 on: April 27, 2011, 04:35:30 PM »
Driden, I also sent you a private message. Let me know if it doesn't come through.
patella pain began early teens
'94 TTT/LR/VMO adv.
'94 MUA
'10 tried PT again
1/11 scope/hardware removal
4/11 (Finally!) dx medial instability due to LR
5/9/11 LPFL reconstruction scheduled

Offline Marantha

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Re: Another failed lateral release? Please help
« Reply #13 on: April 27, 2011, 05:32:38 PM »
Thank u! I've sent u a PM! xx
2009 Physio
30/10/2009 OS appointment confirmed patella tilt, very hypermobile, and a rare bone deformity called hypoplastic medial femoral condyle.
10/03/2010 LR preformed and chondromalacia grade 1 spotted

Offline Driden

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Re: Another failed lateral release? Please help
« Reply #14 on: April 28, 2011, 12:16:03 AM »
Thanks everyone for the PMs.  For some reason this won't let me respond... maybe I need more posts.

I guess I was looking for great success stories on the reconstruction procedure and the surgeon names that go with those stories, not just the names.  For example, are there instances of patients returning to distance running, cutting sports like tennis, etc., following lateral reconstruction?

If I were in Canada and needed an OS near the border to do a reconstruction, I would check out Jack Andrish (Cleveland Clinic) and Elizabeth Arendt (U. Minn.).















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