Surgical Treatment of Patellar Tendinopathy

Fig. 29.1
Sagittal T1 MRI showing tendon thickening and an abnormal signal at the proximal insertion of the patellar tendon


Fig. 29.2
Sagittal T1 MRI showing a marked tendon thickening and an increased signal intensity within the tendon

Despite the occurrence rate of patellar tendinopathy in different sports is mostly unknown, it has been reported a prevalence in sports with high demands on speed and power for the leg extensors, such as volleyball and basketball, soccer, and athletics (Zwerver et al. 2011; Lian et al. 2005).

The management of patellar tendinopathy is controversial (Blazina et al. 1973; Nichols 1992). The conservative treatment includes several options, such as rest, anti-inflammatory drugs, physical therapy, orthoses, stretching, eccentric exercises, extracorporeal shockwave therapy, dextrose prolotherapy (Ryan et al. 2011; Topol et al. 2011), platelet-rich plasma (Filardo et al. 2010) and autologous blood injection (James et al. 2007), and ultrasound-guided sclerotherapy (Zwerver 2008; Testa et al. 1999).

If conservative treatment fails after at least 6 months of therapies, surgical treatment is recommended (Cucurulo et al. 2009) in particular for athletes whose careers are put at risk, or in the presence of a complete tendon disruption (Brockmeyer et al. 2015).

Multiple surgical techniques can be adopted, depending on the site of the tendinopathy, i.e., along the main tendon body or the insertional area, and the characteristics of the lesions such as calcifications, cysts, or tears that may be present (Cucurulo et al. 2009).

However, a general agreement on the ideal surgical management option is still lacking (Marcheggiani Muccioli et al. 2013). In their systematic review, Coleman et al. highlighted too many methodological deficiencies which negatively impact on the validity of the reported outcomes (Coleman et al. 2000).

Both open and arthroscopic procedures are effective to restore function by minimizing tissue damaging, mitigate compression and pain, and promote vascularization (Maffulli et al. 2014).

Postoperative results are satisfying: it has been reported that the mean success rate after surgical treatment of chronic patellar tendinopathy ranges between 60% and 90% (Johnson 1998). Marcheggiani Muccioli et al. (2013) have provided an overview about the different surgical options for the treatment of patellar tendinopathy. This review shows better outcomes after the arthroscopic approach, with an average success rate of 92.4% against the 87.2% rate in the open surgery group. Better results after arthroscopy have been reported also by Brockmeyer et al. in a systematic review (Brockmeyer et al. 2015), with a success rate of 91% against the 81% after the open surgery.

Similarly, the average time and rate for returning to sport show some differences between the two approaches. The mean rate of return to sport after an arthroscopic treatment is 82.3%, within a mean of 3.9 months, while the rate decreases to 78.4% within 8.3 months after an open surgery (Brockmeyer et al. 2015). Stuhlman et al. have reported satisfactory results in 81% after an open approach, and 91% after an arthroscopic surgery (Stuhlman et al. 2016), thus confirming the slightly greater effectiveness of arthroscopy.

Gill et al. (2013) have described a surgical approach which combined open and arthroscopic techniques. Starting from arthroscopy, they managed intra-articular pathologic findings if present; then they switched to the open approach, with a midline incision into the patellar tendon and excising the thickened areas of tendinosis. Surgery was completed by performing fenestrations to encourage a healing response. The reported data were satisfying, especially in terms of time to return to sports activities.

This chapter aims to give an overview about the different surgical options for the treatment of patellar tendinopathy, describing both open and arthroscopic available techniques.

29.2 Open Surgical Techniques

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).


Fig. 29.3
Open surgery: resection of fibrotic tendon tissue


Fig. 29.4
Open surgery: pathologic patellar tendon resected and removed fibrotic synovial tissue

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).


Fig. 29.5
Preoperative lateral X-ray showing osteophytes at the proximal insertion of the patellar tendon

29.3 Arthroscopic Techniques for Patellar Tendinopathy

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).


Fig. 29.6
Arthroscopic resection of distal patellar bone with a burr

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)


Fig. 29.7
MRI showing right knee synovial hypertrophic nodular tissue behind the tendon


Fig. 29.8
Arthroscopic view: hypertrophic synovial tissue, right knee


Fig. 29.9
Nodular hypertrophic tissue behind the tendon


Fig. 29.10
Arthroscopic view of the inferior patellar pole after debridement, right knee

Sep 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Surgical Treatment of Patellar Tendinopathy

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