Lateral release (LR) is a common arthroscopic procedure performed on the knee to address patellar tracking problems. It involves selectively cutting a portion of the lateral retinaculum, a tight band of connective tissue on the outer side of the kneecap. The goal is to release excessive lateral tension pulling the patella out of its natural groove in the femur, aiming to relieve pain and improve alignment. While LR can be effective for patellofemoral issues, some patients continue to experience symptoms after the initial recovery period.
Determining When the Procedure Has Failed
It is important to differentiate between expected surgical recovery discomfort and a genuine failure of the procedure. Patients should expect a rehabilitation timeline extending from six to twelve months before maximum benefit is realized. Early post-operative pain, swelling, and stiffness are normal parts of healing and should not be confused with failure.
A non-successful outcome is defined by the persistence of significant patellofemoral pain or the onset of new instability symptoms continuing beyond this standard recovery window. Surgeons use objective criteria, including a thorough physical examination to assess patellar tracking and stability. Diagnostic imaging, such as X-rays and Magnetic Resonance Imaging (MRI), is also reviewed to check for structural issues that remained unaddressed.
Underlying Causes for Continued Symptoms
When a lateral release does not resolve symptoms, the cause often lies in issues the initial procedure was not designed to correct. One frequent problem is an incorrect initial diagnosis, where pain was mistakenly attributed to tight lateral retinaculum rather than another source. For example, the pain may have originated from underlying conditions like patellofemoral arthritis or generalized cartilage damage that the soft-tissue release cannot repair.
Another factor is underlying bony malalignment that is too severe for a soft-tissue procedure alone to overcome. Conditions such as a high Q-angle, trochlear dysplasia (a shallow groove in the femur), or patella alta (a high-riding kneecap) place uncorrected mechanical stress on the joint. In these cases, the lateral release only addresses a symptom of the maltracking, not the fundamental anatomical problem driving the instability.
Conversely, the procedure itself can introduce new problems, known as iatrogenic complications. If the surgeon performs an over-release, the kneecap loses its necessary lateral restraint, leading to medial instability. This complication causes the kneecap to shift toward the inner side of the knee. Excessive scar tissue formation, known as arthrofibrosis, can also occur, limiting the knee’s range of motion and causing persistent pain despite a technically successful release.
Conservative Strategies After Non-Success
If a lateral release is deemed unsuccessful, the first course of action is a renewed commitment to specialized non-surgical management. This approach serves as a necessary bridge before considering further surgery and focuses on optimizing the biomechanics of the entire leg. A primary focus is on specialized physical therapy aimed at strengthening the muscles that control the kneecap’s movement.
Therapy protocols emphasize the Vastus Medialis Oblique (VMO) muscle, the inner part of the quadriceps, to provide a stronger medial pull and counteract lateral forces. Specific patellar taping or bracing techniques are introduced to manually assist the kneecap in tracking correctly within the femoral groove during activity. Pain management modalities, such as anti-inflammatory medications or targeted injections, may be used to calm irritated tissues and facilitate rehabilitation.
Advanced Surgical Options for Revision
When the initial lateral release and subsequent intensive conservative treatment fail, more extensive revision procedures are considered. These operations are more complex than a lateral release and are designed to correct underlying structural or mechanical failures. A common procedure for definitive bony malalignment is the Tibial Tubercle Transfer (TTO).
TTO involves cutting a section of the shin bone (tibia) where the patellar tendon attaches, and repositioning this bony attachment to a more favorable location. This realignment changes the mechanical angle and pull of the quadriceps muscle, helping the kneecap track correctly and reducing joint pressure. For patients experiencing new medial instability due to an over-release, the Medial Patellofemoral Ligament (MPFL) Reconstruction is employed. This procedure uses a tendon graft to create a new ligament on the inner side of the knee, restoring the restraint that prevents the kneecap from shifting medially. These advanced procedures are reserved for mechanical failures and involve longer recovery periods due to the required bone or major soft-tissue reconstruction.