Lateral Retinacular Lengthening Alongside Distalization TTO and Medial Ligamentous Complex Reconstruction: A Technical Note.

Background: Open lateral retinaculum (LR) lengthening has shown strong outcomes when combined with additional patellofemoral stabilization procedures, such as the tibial tubercle osteotomy (TTO) and medial patellofemoral ligament complex reconstruction (MPFLR). Here, we present an optimized technique for concurrently performing these 3 procedures to comprehensively stabilize the patellofemoral joint. Indications: Patients with a previous patellar dislocation and evidence of an MPFL tear on magnetic resonance imaging are indicated for reconstruction. Patella alta alongside previous patellar dislocation is an indication for a distalizing TTO. Finally, patients meeting indications for MPFLR can additionally exhibit increased LR tightness, indicating a concurrent LR lengthening, demonstrated by excessive patellar tilt and glide on examination or imaging. Technique Description: The procedure begins with a medial parapatellar incision extending past the tibial tuberosity. The LR is incised, and the superficial and deep layers are dissected apart. The free ends of each layer are then sutured together to lengthen the retinaculum. The TTO is performed by exposing the patellar tendon and detaching the tibial tuberosity. The tuberosity is mobilized distally and fixed with 3 cannulated headless compression screws. Last, according to previously published techniques, we anatomically reconstruct the MPFL, the medial quadriceps tendon-femoral ligament, and the medial patellotibial ligament. Results: Patients are placed in a hinged knee brace for 6 to 8 weeks with progressive increases in weightbearing. Clinical follow-up is conducted to monitor healing and adjust rehabilitation plans as necessary. Full return to activity occurs about 6 months after the procedure. Redislocation risk is rare after MPFLR and LR procedures. Medial instability is not typically observed after LR lengthening, unlike with a lateral release, where it can be a frequent occurrence. Discussion/Conclusion: LR lengthening procedures function effectively in conjunction with MPFLR and TTO. Here, we demonstrate our preferred technique for performing all 3 procedures simultaneously to achieve comprehensive stabilization of the patellofemoral joint. Key aspects of our technique include carefully dissecting the LR, directing the TTO cut at an angle of 30° to 45° to enhance healing potential, and positioning the fixation screws for the TTO from anterolateral to posteromedial to safeguard neurovascular structures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.