In the JournalsPerspective

Arthroscopic surgery for patellar tendinopathy significantly increases function, decreases pain in long term

Pascarella, A. Am J Sports Med. Arthroscopic Management of Chronic Patellar Tendinopathy. 2011. doi: 10.1177/0363546511410413.

Patients with patellar tendinopathy who undergo arthroscopic surgery after failure of nonoperative treatment could see significant improvement in function and symptoms for at least 3 years, according to a recent study.

Antonio Pascarella, MD, and his team analyzed 64 patients with patellar tendinopathy, 42% of whom were professional athletes. All of the patients were present for follow-up at 1 and 3 years. 43 patients were analyzed after 5 years, and 29 patients were analyzed after 10 years.

The goals of the study were to analyze medium and long-term outcomes of these patients after undergoing arthroscopic surgery, as well as how effective the surgery was in rehabilitating and returning the athletes to pre-injury levels of play. The patients underwent arthroscopic debridement of the adipose tissue of the Hoffa’s body posterior to the patellar tendon, debridement of abnormal patellar tendon and an excision of the lower pole of the patella, the authors wrote.

The results show significant improvement in all International Knee Documentation Committee (IKDC), Lysholm knee scale, and Victorian Institute of Sports Assessment-Patella (VISA-P) scores used to assess the study. Seven patients developed pain after sports within 3 years of the operation, according to the study. All patients returned to sports within 3 months.

Preoperatively, the average IKDC score was 51.6, which improved to 86.4 at 1- and 3-year follow-ups. The average Lysholm score for the preoperative knees was 52.3, which increased to 94.7 at 1-year follow-up and 95.5 at 3-year follow-up. The average VISA-P score for the preoperative knees was 35.3, increased to 69.8 at 1 year and 70.7 at the 3-year follow-up. Limited results from the follow-up levels for 5 and 10 years showed comparable numbers, indicating that improvements from the surgery can be maintained for longer than the 3-year projection.

Perspective

Dr. Pascarella and coauthors are congratulated on a well-performed case series of patients with patellar tendinopathy treated with arthroscopic debridement. They provide an excellent description of the clinical treatment approach and the indications for surgery. They provide a good description of the surgical technique. They were able to obtain 100% follow-up and provide comparison of preoperative and postoperative patient-oriented outcome scores. They detail the uniformly good results in these patients and provide sound rationale to offer this treatment to patients with refractory patella tendinopathy.

I like this study. My experience with this technique has been similarly positive, and this article can be used to support this practice. The authors do an adequate job of describing their approach, but I would have appreciated more technical pearls on their technique as quantifying the appropriate amount of resection can be challenging. It is also unclear whether all patients at this facility were treated with this surgical approach, or if any were treated with open debridement. While clearly a control group would have strengthened the power of this study, the excellent results suggest that arthroscopic debridement may be considered as an acceptable first-line approach to cases of patellar tendinopathy requiring surgical intervention.

— Brett D. Owens, MD
Chief, Orthopaedic Surgery
Keller Army Hospital
West Point, NY

Disclosure: Owens has no relevant financial disclosure.

The study by Pascarella et al prospectively evaluates patients who failed non-operative management for patellar tendinopathy and underwent arthroscopic treatment. Criticisms of the study include the authors failure to have a single uniform non-operative protocol, as 38 patients had only 12 weeks of non-operative treatment. Additionally there is no comparison group, and it is possible that a portion of their cohort would have improved over the course of continued non-operative management without surgical intervention. While the authors measure patient outcomes using validated outcomes measures, they do not present any objective strength data, and they note many patients may not be able to return to their pre-symptom sporting level even after treatment.

Despite these shortcomings, the outcomes presented by the authors are good at mid-term follow-up. Additionally, these positive outcomes are maintained in a portion of the patients who had longer follow-up time report results at 5 and 10 years. Arthroscopic management appears to be a reasonable option for the elite athlete with recalcitrant patellar tendinopathy after failed non-operative management. Good results can be expected with shorter return to play compared to open treatment outcomes described in the literature.

— Robby Sikka, MD
TRIA Orthopaedic Center
Bloomington, MN

Disclosure: Sikka has no relevant financial disclosures.

Patellar tendinopathy is a common cause for anterior knee pain in recreational and professional athletes. As a gold standard approach, conservative treatment based on physical therapy for quadriceps stretching and eccentric exercises promote increasing strength of the patellar tendon and has shown good results. Some cases, however, resist to this treatment and patient persists with limiting pain. The first question that arises is how long the conservative treatment should be attempted? The time-point to objectify success or failure is poorly described leading to a lack of consensus in the literature.

With such uncertain time frame for definitive cure, other controversial treatment modalities as shockwave therapy, PRP and cortisone injections have been more and more indicated with questionable results.

On the other hand, as an alternative for conservative treatment failure, many authors advocate a surgical approach to the patellar tendon. The traditional open technique has the advantage of directly approach the affected portion of the tendon and excise it.

The arthroscopic procedure, conversely, is a less invasive surgery, which allows a prompt rehabilitation with lower morbidity. However, has the disadvantage of a poor visualization of the injured site.

The prospective study “Arthroscopic Management of Chronic Patellar Tendinopathy” by Pascarella et al. shows that — in a long term follow up — patients with refractory patellar tendinopathy improve after arthroscopic management. However, to be conclusive, a control group is essential, which is lacking in the discussed study. This article represents a good contribution to the search for a thorough treatment modality, although further research is still needed to be definitive.

— Paulo H. Araujo, MD
University of Pittsburgh
Pittsburgh, PA

Disclosure: Araujo has no relevant financial disclosures.

Patients with patellar tendinopathy who undergo arthroscopic surgery after failure of nonoperative treatment could see significant improvement in function and symptoms for at least 3 years, according to a recent study.

Antonio Pascarella, MD, and his team analyzed 64 patients with patellar tendinopathy, 42% of whom were professional athletes. All of the patients were present for follow-up at 1 and 3 years. 43 patients were analyzed after 5 years, and 29 patients were analyzed after 10 years.

The goals of the study were to analyze medium and long-term outcomes of these patients after undergoing arthroscopic surgery, as well as how effective the surgery was in rehabilitating and returning the athletes to pre-injury levels of play. The patients underwent arthroscopic debridement of the adipose tissue of the Hoffa’s body posterior to the patellar tendon, debridement of abnormal patellar tendon and an excision of the lower pole of the patella, the authors wrote.

The results show significant improvement in all International Knee Documentation Committee (IKDC), Lysholm knee scale, and Victorian Institute of Sports Assessment-Patella (VISA-P) scores used to assess the study. Seven patients developed pain after sports within 3 years of the operation, according to the study. All patients returned to sports within 3 months.

Preoperatively, the average IKDC score was 51.6, which improved to 86.4 at 1- and 3-year follow-ups. The average Lysholm score for the preoperative knees was 52.3, which increased to 94.7 at 1-year follow-up and 95.5 at 3-year follow-up. The average VISA-P score for the preoperative knees was 35.3, increased to 69.8 at 1 year and 70.7 at the 3-year follow-up. Limited results from the follow-up levels for 5 and 10 years showed comparable numbers, indicating that improvements from the surgery can be maintained for longer than the 3-year projection.

Perspective

Dr. Pascarella and coauthors are congratulated on a well-performed case series of patients with patellar tendinopathy treated with arthroscopic debridement. They provide an excellent description of the clinical treatment approach and the indications for surgery. They provide a good description of the surgical technique. They were able to obtain 100% follow-up and provide comparison of preoperative and postoperative patient-oriented outcome scores. They detail the uniformly good results in these patients and provide sound rationale to offer this treatment to patients with refractory patella tendinopathy.

I like this study. My experience with this technique has been similarly positive, and this article can be used to support this practice. The authors do an adequate job of describing their approach, but I would have appreciated more technical pearls on their technique as quantifying the appropriate amount of resection can be challenging. It is also unclear whether all patients at this facility were treated with this surgical approach, or if any were treated with open debridement. While clearly a control group would have strengthened the power of this study, the excellent results suggest that arthroscopic debridement may be considered as an acceptable first-line approach to cases of patellar tendinopathy requiring surgical intervention.

— Brett D. Owens, MD
Chief, Orthopaedic Surgery
Keller Army Hospital
West Point, NY

Disclosure: Owens has no relevant financial disclosure.

The study by Pascarella et al prospectively evaluates patients who failed non-operative management for patellar tendinopathy and underwent arthroscopic treatment. Criticisms of the study include the authors failure to have a single uniform non-operative protocol, as 38 patients had only 12 weeks of non-operative treatment. Additionally there is no comparison group, and it is possible that a portion of their cohort would have improved over the course of continued non-operative management without surgical intervention. While the authors measure patient outcomes using validated outcomes measures, they do not present any objective strength data, and they note many patients may not be able to return to their pre-symptom sporting level even after treatment.

Despite these shortcomings, the outcomes presented by the authors are good at mid-term follow-up. Additionally, these positive outcomes are maintained in a portion of the patients who had longer follow-up time report results at 5 and 10 years. Arthroscopic management appears to be a reasonable option for the elite athlete with recalcitrant patellar tendinopathy after failed non-operative management. Good results can be expected with shorter return to play compared to open treatment outcomes described in the literature.

— Robby Sikka, MD
TRIA Orthopaedic Center
Bloomington, MN

Disclosure: Sikka has no relevant financial disclosures.

Patellar tendinopathy is a common cause for anterior knee pain in recreational and professional athletes. As a gold standard approach, conservative treatment based on physical therapy for quadriceps stretching and eccentric exercises promote increasing strength of the patellar tendon and has shown good results. Some cases, however, resist to this treatment and patient persists with limiting pain. The first question that arises is how long the conservative treatment should be attempted? The time-point to objectify success or failure is poorly described leading to a lack of consensus in the literature.

With such uncertain time frame for definitive cure, other controversial treatment modalities as shockwave therapy, PRP and cortisone injections have been more and more indicated with questionable results.

On the other hand, as an alternative for conservative treatment failure, many authors advocate a surgical approach to the patellar tendon. The traditional open technique has the advantage of directly approach the affected portion of the tendon and excise it.

The arthroscopic procedure, conversely, is a less invasive surgery, which allows a prompt rehabilitation with lower morbidity. However, has the disadvantage of a poor visualization of the injured site.

The prospective study “Arthroscopic Management of Chronic Patellar Tendinopathy” by Pascarella et al. shows that — in a long term follow up — patients with refractory patellar tendinopathy improve after arthroscopic management. However, to be conclusive, a control group is essential, which is lacking in the discussed study. This article represents a good contribution to the search for a thorough treatment modality, although further research is still needed to be definitive.

— Paulo H. Araujo, MD
University of Pittsburgh
Pittsburgh, PA

Disclosure: Araujo has no relevant financial disclosures.