Should the 'no thumb technique' be the golden standard for evaluating patellar tracking in total knee arthroplasty?

We checked intraoperative patellar tracking with both 'towel clip technique' and the 'no thumb technique' on 97 patients (167 knees) who underwent primary total knee arthroplasty to decide whether to do or not to do lateral retinacular release. Patellar tracking was assessed under pneumatic tourniquet with the no thumb technique first and re-evaluated with the towel clip technique. The tracking was graded as total contact, good contact, lateral contact and subluxation. The knees graded as total or good contact with the no thumb technique were classified into group A; those graded lateral contact or subluxation by the no thumb technique but total or good contact by the towel clip technique were classified into group B; and those graded lateral contact or subluxation by both techniques were classified into group C; in which lateral releases were performed. One hundred three, 53 and 11 knees were classified into groups A, B and C respectively. Of the 167 knees, 64 (38.3%) showed poor tracking (lateral contact or subluxation) with the no thumb technique alone. Re-evaluation of these knees with the towel clip technique significantly reduced the number with poor tracking to 11 (6.6%) knees requiring lateral retinacular release (p < 0.05). The patients were followed up for 1 year without any patella-related complications occurring. Assessment of the patellar tracking using only the no thumb technique may overestimate the need for lateral retinacular release. The use of the no thumb technique as a screening test, and re-evaluation with the towel clip technique may reduce unnecessary lateral retinacular release.