The patient's radiograph and clinical presentation are consistent with lateral patellar tilt and lateral facet compression syndrome, respectively. Of the options available, lateral retinacular release is the most appropriate treatment. The surgical treatment for this condition is rare and used only in cases that are recalcitrant to conservative measures.
Calpur et al present level 4 evidence of 169 lateral retinacular release cases. They divided this cohort into patients less than and older than 40 years of age. They found that both groups had a statistically significant improvement in Lysholm scores and there were only 3 patients with complications (fibrosis at the site of lateral release).
Video V shows a technique for arthroscopic lateral retinacular release. Arthroscopic viewing through the superior portal in lateral facet compression syndrome would demonstrate that the patella does not articulate medially with the trochlea when the knee is at 40 degrees of knee flexion.
Illustration A demonstrates how the tibia tubercle-trochlear groove (TT-TG) distance is measured by (A) first drawing a line from the trough of the trochlea perpendicular to the line connecting the posterior condyles. These lines are superimposed onto an image through the tibial tubercle (B), and the TT-TG distance is measured as that between the above-described line and the tibial tubercle (distance AB). A TT-TG distance greater than 20mm is an indicator that a medializing tibia tubercle osteotomy is needed.
2. An lateral tibial tubercle transfer would lead to an elevated TT-TG and malalignment.
3. An anterior transfer would further tension the lateral retinaculum and increase the negative tilt.
4. A medial transfer is not indicated for a normal TT-TG.
5. The clinical scenario does not support a symptomatic plica.
Steiner T, Parker RD. Patellofemoral instability. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:1548-1572.
Calpur OU, Ozcan M, Gurbuz H, Turan FN. Full arthroscopic lateral retinacular release with hook knife and quadriceps pressure-pull test: long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2005 Apr;13(3):222-30. Epub 2004 Apr 6.