In this video, I will be describing my technique for a lateral retinacular lengthening. Initially, we want to make sure we have nice, thick subcutaneous flaps so that we can find that superficial layer. Once we've found the superficial layer, then we feel the patella and the lateral aspect, and we're looking for the supralateral aspect of the patella, trying to identify the interface between the superficial layer, which is primarily the IT band, and the indirect fibers to the patella, which are primarily arcuate fibers on the superficial side, and then the vastus lateralis on the deep side. Once we have identified those fibers, then I place my dissecting scissors underneath the superficial layer and superficial to the deep layer. Sometimes it's more than one cell layer thick and requires a little bit more dissection. Once that layer has been identified, though, between the superficial and deep layers, then the superficial layer is incised on the patellar side. I prefer to use Bovy cautery to help control the bleeding. This is carried along the patella and then along the patellar tendon all the way down between GERDES tubercle and the tibial tubercle. This then separates the indirect fibers of the IT band both to the patella and to the patellar tendon. Once the superficial layer has been released from the patella, then I take a dissecting scissors and one key trick is to use a pickup to help put tension on the IT band fibers so that you can effectively create a wall of tissue and then dissect parallel to that wall and deep to that wall. That allows separation between the two layers, the superficial and deep, and allows the deep layer to remain intact until we get further posterior towards the femoral side. There are oftentimes connections or interdigitations between the two layers and that can be separated either via dissecting scissors or via cautery. Particularly as we get more distal, like distal to the patella and in the region of the fat pad, the inferior lateral geniculate will be encountered and there's oftentimes a lot of bleeding in that area. For that reason I like to use cautery where we are working at the moment. Continuing to work posterior here, you can see that wall of tissue being developed. Once we have adequately developed that wall of tissue directly lateral to the patella, we want to make sure that we extend far enough distally and proximally. And then we identify the deep layer, and I like to put my dissecting scissors now deep to the deep layer, and as posterior, or in other words, as close to the femoral side as possible, while protecting the superficial layer. And then we use the bovie cautery to incise the deep layer. Which is what you're seeing here. Again, this starts by dissecting this at the lateral aspect of the patella, and then we extend distally and proximally. You can see the lateral geniculate bleeding here as we get into an area where there's kind of a confluence of layers more distally. The layers separate out much better proximally, either directly lateral to the patella or even super lateral. Therefore, it's easier to identify those layers in those areas, and then dissect distally from there. Once we have dissected out the deep layer, then we want to take the deep layer and dissect it off the capsule. So you're seeing us lift off the deep layer here, and capsule remains intact deep to the deep layer. This allows for mobility of both the deep and superficial layers. Once again, once you come more distally, there tends to be a confluence, and so we'll often use cautery to help make sure that the deep layer is adequately freed, so that then the deep and superficial layers eventually can be sewn together. You can see that deep layer peeling off. We want to make sure that we've extended it adequately in the proximal direction and distal directions. Because then we want to make sure that we can feel the patella. I like to put my thumbs on the lateral facet and ensure that I can tip the patella to neutral. In many cases the capsule is still too tight and we end up having to also incise the capsule. Don't hesitate to incise the capsule if that's necessary. The key for me to know that I've done adequate amount of dissection is the ability to tip the patella to neutral. Once we've completed the dissection then we're going to close the superficial to the deep layers. You can see that happening here. Notice that it's a full thickness bite, but it is not wide on either area so that we don't end up imbricating these tissues back under tension. It should also be noted the depth at which the dissection occurs from superficial to deep, in other words from anterior to posterior, dictates the amount of lengthening. So if you want you can actually measure that. We work our way down. Typically I put a minimum of two in. Sometimes the layers line up nicely so that we can basically zip it up all the way from proximal to distal. Once that's completed, then we feel, and we can see the patella moves nicely in a medial to lateral direction. Also, it's still possible to tip the patella to neutral. The first case that I demonstrated there, obviously, is an open case with concomitant procedures, but I'll also show you how it can be done alongside an isolated MPFL through a small incision. So roughly three centimeters or so, based off the lateral aspect of the patella, usually it runs pretty much the length of the patella. In some cases, we do not extend all the way to the distal pole of the patella. The same process is repeated. So this is the superficial layer being removed or dissected out here, and we're dissecting down between the two layers, the superficial and deep, making that wall of tissue, separating with the dissecting scissors. Any interdigitations are removed with the bovie. Then we've identified the deep layer. Make sure that we carry it adequately in both proximal and distal directions. Once again, we're aiming between IT band at GERDI's tubercle and the tibial tubercle. Once we've adequately dissected, then again we feel and make sure that we can tip the patella to neutral and we're also evaluating the translation in medial to lateral direction. The MPFL has been performed prior to performing a lateral retinacular lengthening. And then we close again in the same manner, the superficial and deep layers taking full thickness but not wide bites. And that is how I perform the lateral retinacular lengthening. Thank you very much.

lateral retinacular lengthening procedure

knee conditions treatment

tissue dissection

cautery for bleeding control

manipulating the patella