- Email: [email protected]
Surgical Technique: Jumper's Knee—Arthroscopic Treatment of Chronic Tendinosis of the Patellar Tendon
Technical Note
Surgical Technique: Jumper’s KneedArthroscopic Treatment of Chronic Tendinosis of the Patellar Tendon Matthias Brockmeyer, M.D., Alexander Haupert, M.D., Dieter Kohn, M.D., and Olaf Lorbach, M.D.
Abstract: Chronic patellar tendinosis (jumper’s knee) is a common problem among athletes. Conservative treatment is successful in most of the cases including, among others, the use of nonsteroidal anti-inflammatory drugs, local cryotherapy, eccentric muscle training, limitation of sports activity, and local infiltration. In approximately 10% of conservatively treated patients, conservative treatment fails and surgery is required. Different open and arthroscopic surgical techniques have been described in the literature. The presented all-arthroscopic surgical technique for the treatment of chronic patellar tendinosis includes debridement of soft tissue at the lower patellar pole and resection of the bony lower patellar pole. It leads to excellent clinical results comparable to described open treatment and provides the benefits of a minimally invasive and safe procedure with a faster recovery and return to sporting activities after surgery. An additional bony resection in case of a prominent lower patellar pole does not lead to a significant extension of the operation time and may avoid a relapse or treatment failure in selective cases. Therefore, arthroscopic treatment such as the presented technique may be the preferred method for surgical treatment of chronic patellar tendinosis.
C
hronic patellar tendinosis is a clinical syndrome that is characterized by pain and tenderness at the inferior patellar pole and/or the proximal part of the patellar tendon and by tendon abnormalities on imaging (magnetic resonance imaging, ultrasound).1,2 Histologically, abnormal tendon quality at the proximal bone-tendon interface could be found in most cases of chronic patellar tendinosis.3 The synonym “jumper’s knee” was introduced by Blazina et al.1 in 1973 because the condition is associated with highimpact sporting activities. Therefore, chronic patellar tendinosis is a common problem among athletes, especially elite athletes.4,5 It can result in persistent pain as well as functional limitations. This can influence training and competition as well as performance
From the Department of Orthopedic Surgery, Saarland University, Homburg/Saar, Germany. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 22, 2016; accepted August 19, 2016. Address correspondence to Olaf Lorbach, M.D., Department of Orthopedic Surgery, Saarland University, Kirrberger Strasse, Homburg/Saar 66421, Germany. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16455/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.010
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levels4 and may lead to the end of the career for top athletes in some cases. The cause of chronic patellar tendinosis is still uncertain. The main cause is probably overuse injury and chronic overload of the knee joint extensor mechanism.6 However, chronic patellar tendinosis does not develop in every athlete who is exposed to intense training. Therefore, other influencing factors should also be considered. There are several other predisposing factors associated with overuse of the knee extensor mechanism: the patella height, the Q angle, the state of flexibility of the extensor muscles, the ankle and knee joint dynamics, and the performance of the leg extensor apparatus (as intrinsic factors) and the high frequency and intensity of sporting activity, especially on a hard playing surface, as well as the kind of sport (as extrinsic factors). Johnson et al.7 described, as a cause of chronic patellar tendinosis, the mechanical impingement and compression of the inferior patellar pole onto the posterior aspect of the tendon in flexion. Chronic overload of the knee extensor mechanism leads to an increased tendon thickness with impingement of an elongated lower patellar pole against the patellar tendon or the corresponding abnormal soft tissue of the posterior part of the proximal patellar tendon in flexion. Lorbach et al.8 noted that chronic patellar tendinosis is often
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associated with a prominent lower patellar pole (Fig 1A). The results of the study showed a longer nonarticular patellar surface, significant changes in patellar tendon thickness, and a significantly higher ratio between the articular and the non-articular patellar surfaces for the jumper’s knee group in comparison to the control group. That is why the arthroscopic technique for treatment of chronic patellar tendinosis should include resection of the prominent lower patellar pole in addition to the obligatory debridement of soft tissue at the lower patellar pole. Different open and arthroscopic surgical techniques have been described in the literature.9-12 However, there is still no consensus on the best surgical treatment option for chronic patellar tendinosis. Arthroscopic resection of the lower patellar pole is a simple and safe technique that shows excellent clinical results, providing a fast return to sporting activities in patients with chronic patellar tendinosis.9,13
Surgical Technique The surgical technique according to Lorbach et al.14 for arthroscopic treatment of chronic patellar tendinosis is described in this report (Video 1). Figure 2 presents the step-by-step surgical technique. Arthroscopic resection of the lower patellar pole for treatment of chronic patellar tendinosis is performed with the patient under general or spinal anesthesia. A nonsterile tourniquet is used in most cases. The patient is positioned supine, and a thigh holder is used. Beginning with diagnostic arthroscopy using a high anterolateral standard portal, other possible
concomitant lesions of the knee joint, especially pathologies of the patellofemoral joint, can be excluded or additionally treated. The arthroscope is then moved to the inferior aspect of the lower patellar pole. An anteromedial accessory working portal is established beneath the patella directly next to the patellar tendon. Careful and accurate debridement and partial resection of the inflamed soft tissue are performed with an electrocautery device (VAPR; DePuy Synthes, Zuchwil, Switzerland) (Fig 3) and a synovial resector (4.5 mm; Smith & Nephew, Andover, MA). To identify the tip of the patella safely, the lower patellar pole is marked with cannulas or needles under fluoroscopic view (Fig 1B) to detect the whole and exact extent of the non-articular patellar surface. It is mandatory to adequately identify the lower patellar pole, as well as the insertion of the patellar tendon, using a probe to preserve the main fibers of the patellar tendon (Fig 4). However, partial resection of the Hoffa fat body, as well as careful resection of the most posterior fibers of the patellar tendon, may be necessary. This debridement of the soft tissue next to the lower patellar pole may be sufficient in some patients. In patients with a prominent lower patellar pole and changes in signal intensity within the lower patellar pole on magnetic resonance imaging, resection of the lower bony patellar pole is also performed in a step-by-step manner with a 4.0-mm burr (Smith & Nephew) under arthroscopic and fluoroscopic control (Fig 5). The sufficient amount of resection should be controlled arthroscopically and fluoroscopically to avoid over- or underresection of the lower patellar pole (Fig 6). In
Fig 1. (A) Chronic patellar tendinosis is often associated with a prominent lower patellar pole. A preoperative radiograph (lateral view) of the left knee shows a long, prominent, bony lower patellar pole (arrow). (B) Safe identification of the bony tip of the patella. An intraoperative fluoroscopic picture of the left knee (lateral view) shows the lower bony patellar pole marked by a needle (arrow).
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Anaesthesia: general (most cases) or spinal Positioning of patient: supine, thigh holder, unsterile tourniquet Diagnostic arthroscopy: High anterolateral standard portal (concomitant lesions?)
Creating an anteromedial accessory portal beneath the patella next to the patellar tendon after moving the arthroscope to the inferior aspect of the lower patellar pole: Debridement and partial resection of the inflamed soft tissue and partial resection of the Hoffa fad pad using an electrocautery device and a synovial-resector [view Figure 3]; preserve the main fibers of the patellar tendon
Marking and verification of the bone tip of the lower patellar pole with cannulas/needles under fluoroscopic view to identify the tip of the patella (non-articular patellar surface) [view Figure 1B and Figure 4], assessment of the bony tip of the patella after clear identification the lower patellar pole as well as the patellar tendon
Resection of the lower patellar pole is performed step-by-step using a 4.0 mm burr under arthroscopic and fluoroscopic control [view Figure 5]
Final arthroscopic evaluation after resection of the pathologic soft tissue as well as radiologically and arthroscopically controlled removal of the lower patellar pole: Control of the extent of resection: arthroscopically and fluoroscopically (over- or underresection of the lower patellar pole? Small bone peaks in the anterior part of the lower patellar pole?) [view Figure 6]
Detailed joint lavage, wound closure, intra-articular drainage (if required)
Fig 2. Step-by-step surgical technique for arthroscopic treatment of chronic patellar tendinosis.
particular, small bone peaks in the anterior part of the lower patellar pole should not be overlooked. After adequate resection of the lower patellar pole, as well as pathologic soft tissue at the posterior part of the proximal patellar tendon, detailed lavage of the joint and wound closure using nonabsorbable suture material are performed. If required, a drainage system can be placed intra-articularly, but this is not necessary in most patients. Tips, pearls, and pitfalls of the presented arthroscopic technique are shown in Table 1. The most important key points are listed in Table 2. Indications, contraindications, risks, and complications of this surgical technique are shown in Table 3. The postoperative treatment protocol includes full weight bearing with adaptations based on pain and swelling, as well as free range of motion as tolerated, but no deep knee flexion under load or weightbearing or jumping activities for 6 weeks
postoperatively. In cases of significant excision of patellar tendon fibers, partial weight bearing for 6 weeks may be necessary. Patients are allowed to begin participating in light sporting activities 6 weeks after surgery depending on the postoperative process. High-impact sporting activities may be allowed at a mean of 3 months after surgery. A suggested treatment algorithm for chronic patellar tendinosis is shown in Figure 7.
Discussion Different open and arthroscopic surgical techniques have been described in the literature.9-12,15 However, there is still no consensus on the best surgical treatment option for chronic patellar tendinosis. Comparable clinical results for open and arthroscopic treatment have been described in the literature.16 Romeo and Larson11 first described the arthroscopic treatment of infrapatellar tendinitis in 1999. Two
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Fig 3. Arthroscopic view from a high anterolateral standard portal showing debridement of inflamed soft tissue with an electrocautery device through an anteromedial accessory working portal beneath the patella directly next to the patellar tendon and identification of the lower patellar pole (X). (A left knee is shown with the patient in the supine position; regarding orientation, left is distal and top is ventral.)
Fig 5. Arthroscopic view from a high anterolateral standard portal of step-by-step resection of the lower patellar pole (X) using a 4.0-mm burr through an anteromedial accessory working portal beneath the patella directly next to the patellar tendon. (A left knee is shown with the patient in the supine position; regarding orientation, left is lateral and top is ventral.)
athletes with chronic patellar tendinosis were treated with an arthroscopic debridement. Both patients returned to full sporting activities without restrictions within 8 weeks after surgery. Arthroscopic resection of the lower patellar pole is a simple and safe technique that shows excellent clinical results, providing a fast return to sporting activities in patients with chronic patellar tendinosis.9,13,14,17 No severe complications of this technique were mentioned in the literature. Different arthroscopic techniques have been described, with some procedures including bony resection of the lower patellar pole.13,18 Debridement of soft tissue at the lower patellar pole without bony resection also leads to good clinical results.11,12,19 Most of the patients with chronic patellar tendinosis, however, show a prominent lower patellar pole and the above-described surgical technique already includes debridement of
soft tissue at the lower patellar pole. Performing an additional bony resection of the lower patellar pole would not lead to a significant extension of the operation time. Especially in cases of highly active patients, such as athletes with a high training intensity and frequency, bony resection of the lower patellar pole might be added to avoid a relapse or treatment failure. Possible risks and limitations of this technique include an underor over-resection of the lower patellar pole; in particular, residual overlooked small bone peaks in the anterior part of the lower patellar pole can lead to treatment failure. Although no severe complications for this technique, such as complete rupture of the proximal patellar tendon or bony avulsion of the distal patellar pole, were mentioned in the literature, significant damage to the main fibers of the proximal parts of the patellar tendon or of the distal bony patellar pole might occur if the debridement and partial resection of the
Fig 4. Arthroscopic view from a high anterolateral standard portal of the lower bony patellar pole marked by a needle. The asterisk indicates the articular-sided distal patellar pole; the X indicates the non-articular-sided lower patellar pole; and the pound sign indicates the proximal patellar tendon. (A left knee is shown with the patient in the supine position; regarding orientation, left is distal and top is ventral.)
Fig 6. Final arthroscopic control of the extent of bony resection of the lower patellar pole: arthroscopic view from a high anterolateral standard portal of the resection area at the lower bony patellar pole (X) and the debrided proximal patellar tendon (pound sign). (A left knee is shown with the patient in the supine position; regarding orientation, left is proximal and top is ventral.)
JUMPER’S KNEEdARTHROSCOPIC TREATMENT Table 1. Tips, Pearls, and Pitfalls of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) A nonsterile tourniquet should be used to ensure excellent visualization of the distal patellar pole and the proximal patellar tendon. The surgeon should use a standard high anterolateral portal and an anteromedial accessory working portal beneath the patella directly next to the patellar tendon for excellent visual control, as well as a safe and easy working process. Needles or cannulas should be used standardly to identify the tip of the patella safely. When performing the most important step, the surgeon must take his or her time for safe identification of the bony lower patellar pole under arthroscopic and fluoroscopic views. He or she must use fluoroscopy standardly. The surgeon should adequately identify the lower patellar pole, as well as the insertion of the patellar tendon, using a probe to preserve the main fibers of the patellar tendon. Careful partial resection of the Hoffa fat body is necessary in most cases. Resection of the lower bony patellar pole should be performed carefully and in a step-by-step manner using a 4.0-mm burr under arthroscopic and fluoroscopic views. The surgeon must use fluoroscopy standardly. The surgeon should be aware of over- or under-resection of the lower patellar pole and be aware of small bone peaks in the anterior part of the lower patellar pole (they should not be overlooked); the sufficient amount of resection should be controlled arthroscopically as well as fluoroscopically. The surgeon must use fluoroscopy standardly.
inflamed tissue and the Hoffa fat body or the bony resection of the distal patellar pole is not performed carefully. It is not known whether increased postoperative infection rates occur with this technique. The results of this arthroscopic technique were described by Lorbach et al.14 as part of a prospective clinical trial including 20 patients with chronic patellar tendinosis with unsuccessful conservative treatment undergoing an arthroscopic resection of the lower patellar pole. They found excellent clinical results with fast rehabilitation and significant improvements concerning the Lysholm score; Kujala score; and visual analog scales for pain, function, and satisfaction already after 6 weeks postoperatively. After 6 months, 75% of the patients reached their preinjury level of activity. No complications were found within the patient group.
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Table 3. Indications, Contraindications, Risks, and Complications of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) Indications Failure of conservative treatment (Blazina stages I-III) for 3 mo, persistent pain and functional limitation, young patients, athletes, and high functional requirements A prominent lower patellar pole and changes in signal intensity within the lower patellar pole on magnetic resonance imaging are the indications for additional resection of the lower bony patellar pole. Contraindications No attempt at conservative treatment Local infection of the tissue or infection of the knee joint Older patients, no sporting activities, and low functional requirements Complete tendon disruption (Blazina stage IV) Risks Relapse or treatment failure Over- or under-resection of the lower patellar pole, as well as residual small bone peaks in the anterior part of the lower patellar pole Complications Bony avulsion of the distal patellar pole Disruption of or damage to the proximal patellar tendon fibers Infection
Arthroscopic treatment of chronic patellar tendinosis is a safe and minimally invasive procedure to treat patients with jumper’s knee. It provides excellent clinical results in knee function and pain reduction, as well as a high satisfaction rate with a fast rehabilitation period, recovery period, and return to sporting activities.
Table 2. Key Points of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) Sufficient visualization and identification of the lower patellar pole and the proximal patellar tendondcannulas or needles and fluoroscopy should be used standardly, with the surgeon taking his or her time for this step Accurate and careful debridement and partial resection of the inflamed tissue and the Hoffa fat body at the lower patellar pole, as well as step-by-step resection of the bony tip of the patella in case of a prominent lower patellar pole, under arthroscopic and fluoroscopic control Precise arthroscopic and fluoroscopic control of the sufficient amount of resection
Fig 7. Treatment algorithm for chronic patellar tendinosis (jumper’s knee). (NSAIDs, nonsteroidal anti-inflammatory drugs.)
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Therefore, arthroscopic techniques such as the described technique may be a good alternative to current open procedures. With regard to a faster recovery and return to sporting activities, arthroscopic treatment may be the preferred method for surgical treatment of chronic patellar tendinosis.20
References 1. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper’s knee. Orthop Clin North Am 1973;4:665-678. 2. Shalaby M, Almekinders LC. Patellar tendinitis: The significance of magnetic resonance imaging findings. Am J Sports Med 1999;27:345-349. 3. Ferretti A, Conteduca F, Camerucci E, Morelli F. Patellar tendinosis: A follow-up study of surgical treatment. J Bone Joint Surg Am 2002;84:2179-2185. 4. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: A crosssectional study. Am J Sports Med 2005;33:561-567. 5. Durcan L, Coole A, McCarthy E, et al. The prevalence of patellar tendinopathy in elite academy rugby: A clinical and imaging study. J Sci Med Sport 2014;17:173-176. 6. Kujala UM, Aalto T, Osterman K, Dahlström S. The effect of volleyball playing on the knee extensor mechanism. Am J Sports Med 1989;17:766-769. 7. Johnson DP, Wakeley CJ, Watt I. Magnetic resonance imaging of patellar tendonitis. J Bone Joint Surg Br 1996;78:452-457. 8. Lorbach O, Diamantopoulos A, Kammerer KP, Paessler HH. The influence of the lower patellar pole in the pathogenesis of chronic patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2008;16:348-352. 9. Johnson DP. Arthroscopic surgery for patellar tendonitis: A new technique. Arthroscopy 1998;14:S44 (abstr). 10. Coleman BD, Khan KM, Kiss ZS, Bartlett J, Young DA, Wark JD. Open and arthroscopic patellar tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian Institute of Sport Tendon Study Group. Am J Sports Med 2000;28:183-190.
11. Romeo AA, Larson RV. Arthroscopic treatment of infrapatellar tendonitis. Arthroscopy 1999;15:341-345. 12. Ogon P, Maier D, Jaeger A, Suedkamp NP. Arthroscopic patellar release for the treatment of chronic patellar tendinopathy. Arthroscopy 2006;22:462.e1-462.e5. 13. Alaseirlis DA, Konstantinidis GA, Malliaropoulos N, Nakou LS, Korompilias A, Maffulli N. Arthroscopic treatment of chronic patellar tendinopathy in highlevel athletes. Muscles Ligaments Tendons J 2013;2: 267-272. 14. Lorbach O, Diamantopoulos A, Paessler HH. Arthroscopic resection of the lower patellar pole in patients with chronic patellar tendinosis. Arthroscopy 2008;24: 167-173. 15. Santander J, Zarba E, Iraporda H, Puleo S. Can arthroscopically assisted treatment of chronic patellar tendinopathy reduce pain and restore function? Clin Orthop Relat Res 2012;470:993-997. 16. Marcheggiani Muccioli GM, Zaffagnini S, Tsapralis K, et al. Open versus arthroscopic surgical treatment of chronic proximal patellar tendinopathy. A systematic review. Knee Surg Sports Traumatol Arthrosc 2013;21:351357. 17. Willberg L, Sunding K, Ohberg L, Forssblad M, Alfredson H. Treatment of Jumper’s knee: Promising short-term results in a pilot study using a new arthroscopic approach based on imaging findings. Knee Surg Sports Traumatol Arthrosc 2007;15:676-681. 18. Pascarella A, Alam M, Pascarella F, Latte C, Di Salvatore MG, Maffulli N. Arthroscopic management of chronic patellar tendinopathy. Am J Sports Med 2011;39: 1975-1983. 19. Maier D, Bornebusch L, Salzmann GM, Sudkamp NP, Ogon P. Mid- and long-term efficacy of the arthroscopic patellar release for treatment of patellar tendinopathy unresponsive to nonoperative management. Arthroscopy 2013;29:1338-1345. 20. Brockmeyer M, Diehl N, Schmitt C, Kohn DM, Lorbach O. Results of surgical treatment of chronic patellar tendinosis (jumper’s knee): A systematic review of the literature. Arthroscopy 2015;31:2424-2429.
Surgical Technique: Jumper’s KneedArthroscopic Treatment of Chronic Tendinosis of the Patellar Tendon Matthias Brockmeyer, M.D., Alexander Haupert, M.D., Dieter Kohn, M.D., and Olaf Lorbach, M.D.
Abstract: Chronic patellar tendinosis (jumper’s knee) is a common problem among athletes. Conservative treatment is successful in most of the cases including, among others, the use of nonsteroidal anti-inflammatory drugs, local cryotherapy, eccentric muscle training, limitation of sports activity, and local infiltration. In approximately 10% of conservatively treated patients, conservative treatment fails and surgery is required. Different open and arthroscopic surgical techniques have been described in the literature. The presented all-arthroscopic surgical technique for the treatment of chronic patellar tendinosis includes debridement of soft tissue at the lower patellar pole and resection of the bony lower patellar pole. It leads to excellent clinical results comparable to described open treatment and provides the benefits of a minimally invasive and safe procedure with a faster recovery and return to sporting activities after surgery. An additional bony resection in case of a prominent lower patellar pole does not lead to a significant extension of the operation time and may avoid a relapse or treatment failure in selective cases. Therefore, arthroscopic treatment such as the presented technique may be the preferred method for surgical treatment of chronic patellar tendinosis.
C
hronic patellar tendinosis is a clinical syndrome that is characterized by pain and tenderness at the inferior patellar pole and/or the proximal part of the patellar tendon and by tendon abnormalities on imaging (magnetic resonance imaging, ultrasound).1,2 Histologically, abnormal tendon quality at the proximal bone-tendon interface could be found in most cases of chronic patellar tendinosis.3 The synonym “jumper’s knee” was introduced by Blazina et al.1 in 1973 because the condition is associated with highimpact sporting activities. Therefore, chronic patellar tendinosis is a common problem among athletes, especially elite athletes.4,5 It can result in persistent pain as well as functional limitations. This can influence training and competition as well as performance
From the Department of Orthopedic Surgery, Saarland University, Homburg/Saar, Germany. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 22, 2016; accepted August 19, 2016. Address correspondence to Olaf Lorbach, M.D., Department of Orthopedic Surgery, Saarland University, Kirrberger Strasse, Homburg/Saar 66421, Germany. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16455/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.010
Arthroscopy Techniques, Vol
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levels4 and may lead to the end of the career for top athletes in some cases. The cause of chronic patellar tendinosis is still uncertain. The main cause is probably overuse injury and chronic overload of the knee joint extensor mechanism.6 However, chronic patellar tendinosis does not develop in every athlete who is exposed to intense training. Therefore, other influencing factors should also be considered. There are several other predisposing factors associated with overuse of the knee extensor mechanism: the patella height, the Q angle, the state of flexibility of the extensor muscles, the ankle and knee joint dynamics, and the performance of the leg extensor apparatus (as intrinsic factors) and the high frequency and intensity of sporting activity, especially on a hard playing surface, as well as the kind of sport (as extrinsic factors). Johnson et al.7 described, as a cause of chronic patellar tendinosis, the mechanical impingement and compression of the inferior patellar pole onto the posterior aspect of the tendon in flexion. Chronic overload of the knee extensor mechanism leads to an increased tendon thickness with impingement of an elongated lower patellar pole against the patellar tendon or the corresponding abnormal soft tissue of the posterior part of the proximal patellar tendon in flexion. Lorbach et al.8 noted that chronic patellar tendinosis is often
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associated with a prominent lower patellar pole (Fig 1A). The results of the study showed a longer nonarticular patellar surface, significant changes in patellar tendon thickness, and a significantly higher ratio between the articular and the non-articular patellar surfaces for the jumper’s knee group in comparison to the control group. That is why the arthroscopic technique for treatment of chronic patellar tendinosis should include resection of the prominent lower patellar pole in addition to the obligatory debridement of soft tissue at the lower patellar pole. Different open and arthroscopic surgical techniques have been described in the literature.9-12 However, there is still no consensus on the best surgical treatment option for chronic patellar tendinosis. Arthroscopic resection of the lower patellar pole is a simple and safe technique that shows excellent clinical results, providing a fast return to sporting activities in patients with chronic patellar tendinosis.9,13
Surgical Technique The surgical technique according to Lorbach et al.14 for arthroscopic treatment of chronic patellar tendinosis is described in this report (Video 1). Figure 2 presents the step-by-step surgical technique. Arthroscopic resection of the lower patellar pole for treatment of chronic patellar tendinosis is performed with the patient under general or spinal anesthesia. A nonsterile tourniquet is used in most cases. The patient is positioned supine, and a thigh holder is used. Beginning with diagnostic arthroscopy using a high anterolateral standard portal, other possible
concomitant lesions of the knee joint, especially pathologies of the patellofemoral joint, can be excluded or additionally treated. The arthroscope is then moved to the inferior aspect of the lower patellar pole. An anteromedial accessory working portal is established beneath the patella directly next to the patellar tendon. Careful and accurate debridement and partial resection of the inflamed soft tissue are performed with an electrocautery device (VAPR; DePuy Synthes, Zuchwil, Switzerland) (Fig 3) and a synovial resector (4.5 mm; Smith & Nephew, Andover, MA). To identify the tip of the patella safely, the lower patellar pole is marked with cannulas or needles under fluoroscopic view (Fig 1B) to detect the whole and exact extent of the non-articular patellar surface. It is mandatory to adequately identify the lower patellar pole, as well as the insertion of the patellar tendon, using a probe to preserve the main fibers of the patellar tendon (Fig 4). However, partial resection of the Hoffa fat body, as well as careful resection of the most posterior fibers of the patellar tendon, may be necessary. This debridement of the soft tissue next to the lower patellar pole may be sufficient in some patients. In patients with a prominent lower patellar pole and changes in signal intensity within the lower patellar pole on magnetic resonance imaging, resection of the lower bony patellar pole is also performed in a step-by-step manner with a 4.0-mm burr (Smith & Nephew) under arthroscopic and fluoroscopic control (Fig 5). The sufficient amount of resection should be controlled arthroscopically and fluoroscopically to avoid over- or underresection of the lower patellar pole (Fig 6). In
Fig 1. (A) Chronic patellar tendinosis is often associated with a prominent lower patellar pole. A preoperative radiograph (lateral view) of the left knee shows a long, prominent, bony lower patellar pole (arrow). (B) Safe identification of the bony tip of the patella. An intraoperative fluoroscopic picture of the left knee (lateral view) shows the lower bony patellar pole marked by a needle (arrow).
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Anaesthesia: general (most cases) or spinal Positioning of patient: supine, thigh holder, unsterile tourniquet Diagnostic arthroscopy: High anterolateral standard portal (concomitant lesions?)
Creating an anteromedial accessory portal beneath the patella next to the patellar tendon after moving the arthroscope to the inferior aspect of the lower patellar pole: Debridement and partial resection of the inflamed soft tissue and partial resection of the Hoffa fad pad using an electrocautery device and a synovial-resector [view Figure 3]; preserve the main fibers of the patellar tendon
Marking and verification of the bone tip of the lower patellar pole with cannulas/needles under fluoroscopic view to identify the tip of the patella (non-articular patellar surface) [view Figure 1B and Figure 4], assessment of the bony tip of the patella after clear identification the lower patellar pole as well as the patellar tendon
Resection of the lower patellar pole is performed step-by-step using a 4.0 mm burr under arthroscopic and fluoroscopic control [view Figure 5]
Final arthroscopic evaluation after resection of the pathologic soft tissue as well as radiologically and arthroscopically controlled removal of the lower patellar pole: Control of the extent of resection: arthroscopically and fluoroscopically (over- or underresection of the lower patellar pole? Small bone peaks in the anterior part of the lower patellar pole?) [view Figure 6]
Detailed joint lavage, wound closure, intra-articular drainage (if required)
Fig 2. Step-by-step surgical technique for arthroscopic treatment of chronic patellar tendinosis.
particular, small bone peaks in the anterior part of the lower patellar pole should not be overlooked. After adequate resection of the lower patellar pole, as well as pathologic soft tissue at the posterior part of the proximal patellar tendon, detailed lavage of the joint and wound closure using nonabsorbable suture material are performed. If required, a drainage system can be placed intra-articularly, but this is not necessary in most patients. Tips, pearls, and pitfalls of the presented arthroscopic technique are shown in Table 1. The most important key points are listed in Table 2. Indications, contraindications, risks, and complications of this surgical technique are shown in Table 3. The postoperative treatment protocol includes full weight bearing with adaptations based on pain and swelling, as well as free range of motion as tolerated, but no deep knee flexion under load or weightbearing or jumping activities for 6 weeks
postoperatively. In cases of significant excision of patellar tendon fibers, partial weight bearing for 6 weeks may be necessary. Patients are allowed to begin participating in light sporting activities 6 weeks after surgery depending on the postoperative process. High-impact sporting activities may be allowed at a mean of 3 months after surgery. A suggested treatment algorithm for chronic patellar tendinosis is shown in Figure 7.
Discussion Different open and arthroscopic surgical techniques have been described in the literature.9-12,15 However, there is still no consensus on the best surgical treatment option for chronic patellar tendinosis. Comparable clinical results for open and arthroscopic treatment have been described in the literature.16 Romeo and Larson11 first described the arthroscopic treatment of infrapatellar tendinitis in 1999. Two
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Fig 3. Arthroscopic view from a high anterolateral standard portal showing debridement of inflamed soft tissue with an electrocautery device through an anteromedial accessory working portal beneath the patella directly next to the patellar tendon and identification of the lower patellar pole (X). (A left knee is shown with the patient in the supine position; regarding orientation, left is distal and top is ventral.)
Fig 5. Arthroscopic view from a high anterolateral standard portal of step-by-step resection of the lower patellar pole (X) using a 4.0-mm burr through an anteromedial accessory working portal beneath the patella directly next to the patellar tendon. (A left knee is shown with the patient in the supine position; regarding orientation, left is lateral and top is ventral.)
athletes with chronic patellar tendinosis were treated with an arthroscopic debridement. Both patients returned to full sporting activities without restrictions within 8 weeks after surgery. Arthroscopic resection of the lower patellar pole is a simple and safe technique that shows excellent clinical results, providing a fast return to sporting activities in patients with chronic patellar tendinosis.9,13,14,17 No severe complications of this technique were mentioned in the literature. Different arthroscopic techniques have been described, with some procedures including bony resection of the lower patellar pole.13,18 Debridement of soft tissue at the lower patellar pole without bony resection also leads to good clinical results.11,12,19 Most of the patients with chronic patellar tendinosis, however, show a prominent lower patellar pole and the above-described surgical technique already includes debridement of
soft tissue at the lower patellar pole. Performing an additional bony resection of the lower patellar pole would not lead to a significant extension of the operation time. Especially in cases of highly active patients, such as athletes with a high training intensity and frequency, bony resection of the lower patellar pole might be added to avoid a relapse or treatment failure. Possible risks and limitations of this technique include an underor over-resection of the lower patellar pole; in particular, residual overlooked small bone peaks in the anterior part of the lower patellar pole can lead to treatment failure. Although no severe complications for this technique, such as complete rupture of the proximal patellar tendon or bony avulsion of the distal patellar pole, were mentioned in the literature, significant damage to the main fibers of the proximal parts of the patellar tendon or of the distal bony patellar pole might occur if the debridement and partial resection of the
Fig 4. Arthroscopic view from a high anterolateral standard portal of the lower bony patellar pole marked by a needle. The asterisk indicates the articular-sided distal patellar pole; the X indicates the non-articular-sided lower patellar pole; and the pound sign indicates the proximal patellar tendon. (A left knee is shown with the patient in the supine position; regarding orientation, left is distal and top is ventral.)
Fig 6. Final arthroscopic control of the extent of bony resection of the lower patellar pole: arthroscopic view from a high anterolateral standard portal of the resection area at the lower bony patellar pole (X) and the debrided proximal patellar tendon (pound sign). (A left knee is shown with the patient in the supine position; regarding orientation, left is proximal and top is ventral.)
JUMPER’S KNEEdARTHROSCOPIC TREATMENT Table 1. Tips, Pearls, and Pitfalls of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) A nonsterile tourniquet should be used to ensure excellent visualization of the distal patellar pole and the proximal patellar tendon. The surgeon should use a standard high anterolateral portal and an anteromedial accessory working portal beneath the patella directly next to the patellar tendon for excellent visual control, as well as a safe and easy working process. Needles or cannulas should be used standardly to identify the tip of the patella safely. When performing the most important step, the surgeon must take his or her time for safe identification of the bony lower patellar pole under arthroscopic and fluoroscopic views. He or she must use fluoroscopy standardly. The surgeon should adequately identify the lower patellar pole, as well as the insertion of the patellar tendon, using a probe to preserve the main fibers of the patellar tendon. Careful partial resection of the Hoffa fat body is necessary in most cases. Resection of the lower bony patellar pole should be performed carefully and in a step-by-step manner using a 4.0-mm burr under arthroscopic and fluoroscopic views. The surgeon must use fluoroscopy standardly. The surgeon should be aware of over- or under-resection of the lower patellar pole and be aware of small bone peaks in the anterior part of the lower patellar pole (they should not be overlooked); the sufficient amount of resection should be controlled arthroscopically as well as fluoroscopically. The surgeon must use fluoroscopy standardly.
inflamed tissue and the Hoffa fat body or the bony resection of the distal patellar pole is not performed carefully. It is not known whether increased postoperative infection rates occur with this technique. The results of this arthroscopic technique were described by Lorbach et al.14 as part of a prospective clinical trial including 20 patients with chronic patellar tendinosis with unsuccessful conservative treatment undergoing an arthroscopic resection of the lower patellar pole. They found excellent clinical results with fast rehabilitation and significant improvements concerning the Lysholm score; Kujala score; and visual analog scales for pain, function, and satisfaction already after 6 weeks postoperatively. After 6 months, 75% of the patients reached their preinjury level of activity. No complications were found within the patient group.
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Table 3. Indications, Contraindications, Risks, and Complications of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) Indications Failure of conservative treatment (Blazina stages I-III) for 3 mo, persistent pain and functional limitation, young patients, athletes, and high functional requirements A prominent lower patellar pole and changes in signal intensity within the lower patellar pole on magnetic resonance imaging are the indications for additional resection of the lower bony patellar pole. Contraindications No attempt at conservative treatment Local infection of the tissue or infection of the knee joint Older patients, no sporting activities, and low functional requirements Complete tendon disruption (Blazina stage IV) Risks Relapse or treatment failure Over- or under-resection of the lower patellar pole, as well as residual small bone peaks in the anterior part of the lower patellar pole Complications Bony avulsion of the distal patellar pole Disruption of or damage to the proximal patellar tendon fibers Infection
Arthroscopic treatment of chronic patellar tendinosis is a safe and minimally invasive procedure to treat patients with jumper’s knee. It provides excellent clinical results in knee function and pain reduction, as well as a high satisfaction rate with a fast rehabilitation period, recovery period, and return to sporting activities.
Table 2. Key Points of Arthroscopic Treatment of Chronic Patellar Tendinosis (Jumper’s Knee) Sufficient visualization and identification of the lower patellar pole and the proximal patellar tendondcannulas or needles and fluoroscopy should be used standardly, with the surgeon taking his or her time for this step Accurate and careful debridement and partial resection of the inflamed tissue and the Hoffa fat body at the lower patellar pole, as well as step-by-step resection of the bony tip of the patella in case of a prominent lower patellar pole, under arthroscopic and fluoroscopic control Precise arthroscopic and fluoroscopic control of the sufficient amount of resection
Fig 7. Treatment algorithm for chronic patellar tendinosis (jumper’s knee). (NSAIDs, nonsteroidal anti-inflammatory drugs.)
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Therefore, arthroscopic techniques such as the described technique may be a good alternative to current open procedures. With regard to a faster recovery and return to sporting activities, arthroscopic treatment may be the preferred method for surgical treatment of chronic patellar tendinosis.20
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