Open surgical options for the treatment of patellar tendinopathy essentially include the affected tissue removal after sectioning the peritenon, as well as the removal or drilling of the patellar pole (Zhang et al. 2016). The operation may essentially involve a midline or medial parapatellar longitudinal skin incision, a paratenon incision and stripping, multiple longitudinal tenotomies and the excision of the damaged tendon tissue (Testa et al. 1999) (Figs. 29.3 and 29.4).

Whichever method is chosen, the aim of surgical management is to promote wound repair through a modulation of the tendon cell-matrix environment (Leadbetter et al. 1992).

Open surgery was firstly mentioned in 1946 by Smillie (1946), who described a technique still performed which consists in drilling multiple holes in the inferior patellar pole.

In 1973, Blazina et al. suggested excision of the extra-articular patella by opening the tendon along its axis and removing the abnormal tendinous tissue (1973).

Several derivative techniques have been developed later. The purpose essentially aimed to avoid an osseous procedure by removing the damaged part of the patella (Fritschy and Wallensten 1993; Verheyden et al. 1997), although bone-involving techniques are still performed. In fact, the technique described by Smillie is still in use (Popp et al. 1997; Raatikainen et al. 1994), while other authors prefer to create tendinoperiostal scars (Karlsson et al. 1991), or combine both the techniques (Ferretti et al. 2002).

Nevertheless, it has been demonstrated that bone excision should be avoided in the treatment of patellar tendinopathy: Kaeding et al. (2007) found a 71% success rate after approaching the inferior pole of the patella, compared to the 92% if there is no bony involvement. They also reported better outcomes if no paratenon closure was performed, as well as in case of no postoperative immobilization.

A further surgical choice consists in ultrasound-guided percutaneous longitudinal tenotomies (Testa et al. 1999; Lorbach et al. 2008): under ultrasound control, a surgical scalpel blade penetrates the whole thickness of the tendon during passive extensions and flexions of the knee leading to longitudinal and parallel tenotomies, with an average length of 2 cm. This process is repeated laterally and medially to the tendon width (Testa et al. 1999). The use of sonographic guidance in the treatment of musculoskeletal disorders has gained consensus in the literature: the ultrasound-guided percutaneous needle tenotomies reduce pain in patients with chronic patellar tendinopathy without complications (Housner et al. 2009).

An increasing number of authors choose the arthroscopic approach, not for its clinical superiority to others (Marcheggiani Muccioli et al. 2013; Rodriguez-Merchan 2013), rather because it is less invasive and provides a faster postoperative return to sport (Brockmeyer et al. 2015). Open surgery is still preferred when a calcification along the tendon is present (Fig. 29.5), or when a tendon tear has occurred (Cenni and Silva 2015).

Arthroscopic procedures for the treatment of patellar tendinopathy allows a better management of the painful areas of the proximal-posterior tendon fibers and of the infrapatellar fat pad (Pascarella et al. 2011).

New arthroscopic techniques have been developed (Coleman et al. 2000; Lorbach et al. 2008; Ogon et al. 2006; Willberg et al. 2007), even if synovectomy and/or apicectomy are the most widely used. The main purpose is to remove the damaged retrotendinous tissue through the debridement and the treatment of the patella only if necessary (Cucurulo et al. 2009). The surgeon may opt for a partial resection of Hoffa’s fat and of the lower pole of the patella (Cenni and Silva 2015). The final purpose is the excision of the neovascularization and the innervation of the degenerative area (Cucurulo et al. 2009).

Willberg et al. (2007) have proposed an arthroscopic shaving technique, which involves the area of interest on the dorsal surface of the tendon, combined with Ultrasound + Doppler examinations during surgery. The ultrasound and the color Doppler guidance effectively reduce the risk of “shaving too much,” thus minimizing trauma to the Hoffa’s fat pad and to the tendon.

The presence of abnormal neovascularity typically arises from the fat pad, thus its debridement and partial resection is recommended, as discussed by several authors (Brockmeyer et al. 2015; Pascarella et al. 2011; Alaseirlis et al. 2012). On the other hand, a total excision of the fat pad could excessively reduce the vascularity of the patella, causing anterior impingement and anterior knee pain, as noted by Pinsornsak et al. in total knee arthroplasty (Pinsornsak et al. 2014).

A further surgical issue is whether to perform the resection of the lower patellar pole or not. An impingement or a compression of the inferior pole of the patella onto the posterior aspect of the tendon during the flexion of the knee has been reported as one of the causes of patellar tendinopathy (Lorbach et al. 2008). It is common to find an elongation of the lower patellar pole on the X-rays (Blazina et al. 1973). In this case, an abrasion of the lower patella should be performed to release the deep fiber of the tendon from the inferior pole and to excise the bony protrusion (Lorbach et al. 2008) (Fig. 29.6). The result is an arthroscopic tenolysis, highly effective in terms of postoperative recovery and time to return to sport (Cenni and Silva 2015; Pascarella et al. 2011; Alaseirlis et al. 2012).

With regard to the specific arthroscopic technique, the conventional anteromedial and anterolateral portals and an optional central transtendinous accessory portal are performed (Cenni and Silva 2015). (Figs. 29.7, 29.8, 29.9, 29.10, 29.11 and 29.12)