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Arthroscopic Treatment of Unresolved Osgood-Schlatter Lesions
Technical Note
Arthroscopic Treatment of Unresolved Osgood-Schlatter Lesions LTC(P) Thomas M. DeBerardino, M.D., CPT Joanna G. Branstetter, M.D., and MAJ Brett D. Owens, M.D.
Abstract: Osgood-Schlatter disease is a self-limiting condition in most cases. Those with unresolved pain after conservative treatment can obtain relief with surgical debridement of the mobile ossicles and tibial tuberosity. We present an arthroscopic technique for debridement. The location of the inferomedial and lateral parapatella tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofrequency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. The advantages of this technique include the avoidance of the patellar tendon longitudinal split required for open procedures and the ability to address concomitant intra-articular pathology. Key Words: Arthroscopy—Osgood-Schlatter disease—Debridement—Mobile ossicles—Tibial tuberosity.
O
sgood and Schlatter, in 1903, separately described traction apophysitis of the tibial insertion of the patellar tendon.1 This condition usually presents in the adolescent male aged 10 to 14 years, in bilateral knees 25% to 33%, and is self-limiting with resolution
From the Orthopedic Surgery Service, Keller Army Hospital, U.S. Military Academy, West Point, New York, U.S.A. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or U.S. government. The authors are employees of the U.S. government. No grant funding was received for this study. Address correspondence and reprint requests to MAJ Brett D. Owens, M.D., Keller Army Hospital, U.S. Military Academy, West Point, NY 10996. E-mail: [email protected] This is a U.S. government work. There are no restrictions on its use. Cite this article as: DeBerardino TM, Branstetter JG, Owens BD. Arthroscopic treatment of unresolved Osgood-Schlatter lesions. Arthroscopy 2007;23:1127.e1-1127.e3 [doi:10.1016/ j.arthro.2006.12.004]. 0749-8063/07/2310-6536$0.00/0 doi:10.1016/j.arthro.2006.12.004
of symptoms in about 90% of cases with or without some form of conservative treatment.2-4 Conservative treatments include rest, lidocaine injection, steroid injection,5 cylinder casts,6 and infrapatellar straps.7 Various surgical techniques have evolved to treat the unresolved Osgood-Schlatter lesions1,2,7,8 that are still symptomatic after conservative treatment to include open excision of any mobile ossicles and debridment of the tibial tubercle. We present our arthroscopic technique of ossicle and tibial tubercle debridement for continued symptomatic Osgood-Schlatter lesions. TECHNIQUE Arthroscopic debridement of Osgood-Schlatter lesions is performed through standard knee arthroscopy portals. The location of the inferomedial and lateral parapatellar tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofre-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 10 (October), 2007: pp 1127.e1-1127.e3
1127.e1
1127.e2
T. M. DEBERARDINO ET AL.
FIGURE 1. (A) Preoperative radiograph showing a prominent tibial tubercle with free ossicle formation. (B) Preoperative magnetic resonance imaging showing free ossicle posterior to the patellar tendon.
quency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. ILLUSTRATIVE CASE R. C. is a 37-year-old man with a symptomatic and prominent tibial tubercle with free ossicles (Fig 1) who consented to the reporting of his case. His chronic knee condition had become increasingly symptomatic with his job requirements and was limiting his ability to remain an active duty soldier. He was treated with knee arthroscopy and debridement of
FIGURE 2. (A) Arthroscopic view of tibial tubercle ossicle before removal. (B) Arthroscopic view of tibial tubercle (TT) after debridement. The insertion of the patella tendon (PT) has been preserved.
his tibial tubercle lesion (Fig 2). Postoperatively (Fig 3), he reported complete resolution of his anterior knee symptoms and was pleased with the removal of the prominence of his tubercle. DISCUSSION The natural history of Osgood-Schlatter lesions is that most resolve, although some patients may still have some pain and prominence with kneeling. Krause et al.4 looked at 50 patients at an average of 9 years follow-up and found 60% were still unable to kneel without pain or discomfort and 24% had additional continuing symptoms to include anterior knee pain and tibial tubercle pain. Ross and Villard8 looked at the disability levels of patients at an average of 8 years follow-up. Twenty-five patients with a history of Osgood-Schlatter lesions were age and sport matched to healthy volunteers and were found to have a significantly lower score on both the Knee Outcome Survey Activities of Daily Living Scale and Sports Activity Scale.
ARTHROSCOPIC TREATMENT OF OSGOOD-SCHLATTER
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good results after bone grafting and internal fixation of the ossicle. This technique of arthroscopic debridement of the tibial tubercle is applicable when the patient’s pain from Osgood-Schlatter disease is unresolved after conservative therapy. Arthroscopic treatment is beneficial over an open procedure because the patellar tendon is not violated. Other intra-articular knee pathology can also be addressed arthroscopically. The patient avoids an incision directly over the patellar tendon that can cause pain with kneeling. We have performed this technique on 2 patients with excellent short-terms results. We recommend this technique for those patients with recalcitrant Osgood-Schlatter lesions. REFERENCES
FIGURE 3. Postoperative radiograph showing decreased prominence of the tibial tubercle.
There are few case series that discuss open treatment of unresolved Osgood-Schlatter lesions. Flowers and Bhadreshwar3 in 1995 reported on 35 patients with 95% gaining pain relief after the open debridement procedure; however, 10% still had scar tenderness after 3.5 months. Binazzi et al.2 reported on 15 knees with 93% excellent/good results after debridement of the ossicle and 11 knees with 72% excellent/
1. Osgood RB. Lesions of the tibial tubercle occurring during adolescence. Boston Med Surg J 1903;148:114-117. 2. Binazzi R, Felli L, Vaccari V, Borelli P. Surgical treatment of unresolved Osgood-Schlatter lesion. Clin Orthop Rel Res 1993; 289:202-204. 3. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995; 15:292-296. 4. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990;10:65-68. 5. Liselotte M, Schott HJ. Local hydrocortisone therapy of Schlatter’s disease and its local side-effects. Med Klin 1961;56:18341838. 6. Smillie IS. Injuries of the knee joint. Edinburgh: Churchill Livingstone, 1978. 7. Levine J, Kashyap S. A new conservative treatment of OsgoodSchlatter disease. Clin Orthop Relat Res 1981;158:126-128. 8. Ross MD, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease. J Strength Cond Res 2003;17:659-663.
Arthroscopic Treatment of Unresolved Osgood-Schlatter Lesions LTC(P) Thomas M. DeBerardino, M.D., CPT Joanna G. Branstetter, M.D., and MAJ Brett D. Owens, M.D.
Abstract: Osgood-Schlatter disease is a self-limiting condition in most cases. Those with unresolved pain after conservative treatment can obtain relief with surgical debridement of the mobile ossicles and tibial tuberosity. We present an arthroscopic technique for debridement. The location of the inferomedial and lateral parapatella tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofrequency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. The advantages of this technique include the avoidance of the patellar tendon longitudinal split required for open procedures and the ability to address concomitant intra-articular pathology. Key Words: Arthroscopy—Osgood-Schlatter disease—Debridement—Mobile ossicles—Tibial tuberosity.
O
sgood and Schlatter, in 1903, separately described traction apophysitis of the tibial insertion of the patellar tendon.1 This condition usually presents in the adolescent male aged 10 to 14 years, in bilateral knees 25% to 33%, and is self-limiting with resolution
From the Orthopedic Surgery Service, Keller Army Hospital, U.S. Military Academy, West Point, New York, U.S.A. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or U.S. government. The authors are employees of the U.S. government. No grant funding was received for this study. Address correspondence and reprint requests to MAJ Brett D. Owens, M.D., Keller Army Hospital, U.S. Military Academy, West Point, NY 10996. E-mail: [email protected] This is a U.S. government work. There are no restrictions on its use. Cite this article as: DeBerardino TM, Branstetter JG, Owens BD. Arthroscopic treatment of unresolved Osgood-Schlatter lesions. Arthroscopy 2007;23:1127.e1-1127.e3 [doi:10.1016/ j.arthro.2006.12.004]. 0749-8063/07/2310-6536$0.00/0 doi:10.1016/j.arthro.2006.12.004
of symptoms in about 90% of cases with or without some form of conservative treatment.2-4 Conservative treatments include rest, lidocaine injection, steroid injection,5 cylinder casts,6 and infrapatellar straps.7 Various surgical techniques have evolved to treat the unresolved Osgood-Schlatter lesions1,2,7,8 that are still symptomatic after conservative treatment to include open excision of any mobile ossicles and debridment of the tibial tubercle. We present our arthroscopic technique of ossicle and tibial tubercle debridement for continued symptomatic Osgood-Schlatter lesions. TECHNIQUE Arthroscopic debridement of Osgood-Schlatter lesions is performed through standard knee arthroscopy portals. The location of the inferomedial and lateral parapatellar tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofre-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 10 (October), 2007: pp 1127.e1-1127.e3
1127.e1
1127.e2
T. M. DEBERARDINO ET AL.
FIGURE 1. (A) Preoperative radiograph showing a prominent tibial tubercle with free ossicle formation. (B) Preoperative magnetic resonance imaging showing free ossicle posterior to the patellar tendon.
quency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. ILLUSTRATIVE CASE R. C. is a 37-year-old man with a symptomatic and prominent tibial tubercle with free ossicles (Fig 1) who consented to the reporting of his case. His chronic knee condition had become increasingly symptomatic with his job requirements and was limiting his ability to remain an active duty soldier. He was treated with knee arthroscopy and debridement of
FIGURE 2. (A) Arthroscopic view of tibial tubercle ossicle before removal. (B) Arthroscopic view of tibial tubercle (TT) after debridement. The insertion of the patella tendon (PT) has been preserved.
his tibial tubercle lesion (Fig 2). Postoperatively (Fig 3), he reported complete resolution of his anterior knee symptoms and was pleased with the removal of the prominence of his tubercle. DISCUSSION The natural history of Osgood-Schlatter lesions is that most resolve, although some patients may still have some pain and prominence with kneeling. Krause et al.4 looked at 50 patients at an average of 9 years follow-up and found 60% were still unable to kneel without pain or discomfort and 24% had additional continuing symptoms to include anterior knee pain and tibial tubercle pain. Ross and Villard8 looked at the disability levels of patients at an average of 8 years follow-up. Twenty-five patients with a history of Osgood-Schlatter lesions were age and sport matched to healthy volunteers and were found to have a significantly lower score on both the Knee Outcome Survey Activities of Daily Living Scale and Sports Activity Scale.
ARTHROSCOPIC TREATMENT OF OSGOOD-SCHLATTER
1127.e3
good results after bone grafting and internal fixation of the ossicle. This technique of arthroscopic debridement of the tibial tubercle is applicable when the patient’s pain from Osgood-Schlatter disease is unresolved after conservative therapy. Arthroscopic treatment is beneficial over an open procedure because the patellar tendon is not violated. Other intra-articular knee pathology can also be addressed arthroscopically. The patient avoids an incision directly over the patellar tendon that can cause pain with kneeling. We have performed this technique on 2 patients with excellent short-terms results. We recommend this technique for those patients with recalcitrant Osgood-Schlatter lesions. REFERENCES
FIGURE 3. Postoperative radiograph showing decreased prominence of the tibial tubercle.
There are few case series that discuss open treatment of unresolved Osgood-Schlatter lesions. Flowers and Bhadreshwar3 in 1995 reported on 35 patients with 95% gaining pain relief after the open debridement procedure; however, 10% still had scar tenderness after 3.5 months. Binazzi et al.2 reported on 15 knees with 93% excellent/good results after debridement of the ossicle and 11 knees with 72% excellent/
1. Osgood RB. Lesions of the tibial tubercle occurring during adolescence. Boston Med Surg J 1903;148:114-117. 2. Binazzi R, Felli L, Vaccari V, Borelli P. Surgical treatment of unresolved Osgood-Schlatter lesion. Clin Orthop Rel Res 1993; 289:202-204. 3. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995; 15:292-296. 4. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990;10:65-68. 5. Liselotte M, Schott HJ. Local hydrocortisone therapy of Schlatter’s disease and its local side-effects. Med Klin 1961;56:18341838. 6. Smillie IS. Injuries of the knee joint. Edinburgh: Churchill Livingstone, 1978. 7. Levine J, Kashyap S. A new conservative treatment of OsgoodSchlatter disease. Clin Orthop Relat Res 1981;158:126-128. 8. Ross MD, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease. J Strength Cond Res 2003;17:659-663.