Open versus arthroscopic surgical treatment of chronic proximal patellar tendinopathy. A systematic review

The Best Current Research on Patellar Tendinopathy: A Review of Published Meta-Analyses

Patellar tendinopathy is a frequent overuse injury in sports that can cause significant pain and disability. It requires evidence-based guidelines on effective prevention and management. However, optimal treatments remain uncertain. We aimed to analyze available meta-analyses to summarize treatment recommendations, compare therapeutic modalities, examine included trials, and offer methodological suggestions to improve future systematic reviews. Meta-analyses were systematically searched for in PubMed (PROSPERO: CRD42023457963). A total of 21 meta-analyses were included. The AMSTAR-2 scale assessed study quality, which was low, with only 23.8% of the meta-analyses being of moderate quality, and none were considered to be of high quality. Heterogeneous outcomes are reported. Multiple platelet-rich plasma (PRP) injections appear superior to eccentric exercises and provide lasting improvements compared to eccentric exercises when conservative treatments fail. Extracorporeal shockwave therapy (ESWT) also seems superior to non-operative options and similar to surgery for patellar tendinopathy in the long term. However, evidence for eccentric exercise efficacy remains unclear due to inconclusive findings. Preliminary findings also emerged for genetic risk factors and diagnostic methods but require further confirmation. This review reveals a lack of high-quality evidence on optimal patellar tendinopathy treatments. While PRP and ESWT show promise, limitations persist. Further rigorous meta-analyses and trials are needed to strengthen the evidence base and guide clinical practice. Methodological enhancements are proposed to improve future meta-analyses.

Surgical Management of Patellar Tendinopathy Results in Improved Outcomes and High Rates of Return to Sport: A Systematic Review

Although the majority of patients with patellar tendinopathy (PT) can be treated nonoperatively, operative management may be indicated for recalcitrant cases. While several surgical techniques have been described, there is limited understanding of postoperative outcomes and expectations regarding return to activity and sport. The purpose of this study was to characterize the clinical outcomes associated with the surgical management of PT with an emphasis on return to sport (RTS) rates. We hypothesized that surgical management would lead to clinically important improvements in patient-reported outcomes (PROs) with high rates of RTS and RTS at the same level. A comprehensive search of the PubMed, Medline, and Embase databases was performed in December 2020. Level of evidence studies I through IV, investigating results of surgical management for PT (PRO, functional outcomes, pain, and/or RTS), were included. The search was performed in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Forty clinical studies reporting on surgery for PT satisfied inclusion criteria, with 1,238 total knees undergoing surgery for PT. A comparison of pre- and postoperative Victorian Institute of Sport Assessment, patellar tendon (VISA-P) scores (mean difference: 41.89, p < 0.00001), Lysholm scores (mean difference: 41.52, p < 0.00001), and visual analogue scale (VAS) pain scores (mean difference: 5, p < 0.00001) demonstrated clinically and statistically significant improvements after surgery. The overall RTS rate following operative management was 89.8% (95% confidence interval [CI]: 86.4-92.8, I ² = 56.5%) with 76.1% (95% CI: 69.7.5-81.9, I ² = 76.4%) of athletes returning to the same level of activity. Surgery for PT provides meaningful improvement in patient reported outcomes and pain while allowing athletes to RTS at high rates with levels of participation similar to that of preinjury. Comparative studies of open and/or arthroscopic surgery are still limited but current evidence suggests better rates of RTS for arthroscopic surgery compared with open surgery. This is a systematic review of level-I to -IV studies.

The association of patellar tendinosis with patellar maltracking and Hoffa's fat pad impingement: A case-control MRI study

OBJECTIVES

To assess whether proximal or distal patellar tendinosis is associated with patellar maltracking parameters and superolateral Hoffa's fat pad impingement.

METHODS

Institutional radiology database was reviewed for knee MRI scans performed over a 7-year period identifying cases of unequivocal patellar tendinosis, which were separated into 2 groups: proximal and distal tendinosis. For each group of proximal and distal patellar tendinosis, a control group of age and gender matched subjects was assigned. The scans were evaluated for patellar maltracking parameters including patellar alta, tibial tuberosity lateralization, trochlear dysplasia and lateral patellar tilt and for presence of superolateral Hoffa's fat pad edema. These parameters were compared between the case and control groups.

RESULTS

Out of 9852 MRI scans, 94 patellar tendinosis cases were included (65 proximal and 29 distal tendinosis) and matched with equal numbers of controls. In the proximal patellar tendinosis group, more subjects had patella alta (22 versus 6, p = 0.0006), lateralization of tibial tuberosity (16 versus 7, p = 0.0495) and superolateral Hoffa's fat pad edema (16 versus 4, p = 0.0073) compared to the control group. In the distal patellar tendinosis group, there was no significant difference in the prevalence of any maltracking indicator or superolateral Hoffa's fat pad edema compared to the control group.

CONCLUSION

Proximal patellar tendinosis was associated with patellar maltracking parameters including patella alta, lateralized tibial tuberosity and superolateral Hoffa's fat pad impingement. No association was demonstrated between distal patellar tendinosis and patellar maltracking indicators or superolateral Hoffa's fat pad impingement.

Results of Arthroscopic Treatment of Chronic Patellar Tendinopathy

BACKGROUND

The surgical treatment of chronic patellar tendinopathy could be open or arthroscopic. A general agreement on the best surgical treatment option is still lacking.

PURPOSE

The aim of our study was to evaluate the clinical results after a minimally invasive arthroscopic treatment of chronic patellar tendinopathy including a resection of the lower patellar pole.

METHODS

The study included 14 patients with a mean age of 26 years and chronic patellar tendinopathy refractory to non-operative treatment of more than 6 months. All patients underwent arthroscopic debridement of the adipose tissue of the Hoffa's body posterior to the patellar tendon, debridement of abnormal patellar tendon and resection of the lower patellar pole. Preoperative and postoperative evaluation was undertaken using clinical examination, magnetic resonance imaging (MRI) and the Lysholm and Victorian Institute of Sport Assessment-Patella (VISA-P) scores. Return to sports and postoperative complications were also assessed. The mean follow-up was 12.2 ± 0.9 months.

RESULTS

All 14 patients continued with sport activities, but only 12 of them (85.7%) achieved their presymptom sporting level. The median time to return to preinjury level of activity was 3.9 ± 0.8 months. Patients showed a major improvement in the mean Lysholm score from 51.1 ± 3.8 to 93.4 ± 4.2 (p=0.001) and in the mean VISA-P score from 42.1 ± 3.5 to 86.7 ± 8.4 (p=0.001) There were no postoperative complications.

CONCLUSION

We found that this arthroscopic technique gives reduced morbidity and satisfactory outcome resulting in significantly faster recovery and return to sports in patients with chronic patellar tendinopathy.

Surgical Technique for Chronic Proximal Patellar Tendinopathy (Jumper's Knee)

Chronic proximal patellar tendinopathy is a challenging condition for its troublesome management in the active patient and difficulty in defining the failure of conservative treatment to indicate surgery. Usually, patients with chronic proximal patellar tendinopathy have already tried several physiotherapeutic modalities and are away from their preferred physical activities for variable periods. The current literature presents some open and even arthroscopic options for treating recalcitrant patellar tendinopathy using a variable magnitude of resources and costs. The purpose of this article was to depict a very simple and inexpensive surgical option for treating this condition, which can be applied worldwide.

Surgery for patellar tendinopathy (jumper's knee)

BACKGROUND

Patellar tendinopathy is an overuse condition that commonly affects athletes. Surgery is usually offered if medical and physical therapies fail to treat it effectively. There is variation in the type of surgery performed for the condition.

OBJECTIVES

To assess the benefits and harms of surgery for patellar tendinopathy in adults.

SEARCH METHODS

We searched the following databases, to 17 July 2018: the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, OVID MEDLINE, OVID Embase, clinical trial registries (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared surgical techniques (open or arthroscopic) with non-operative treatment (including placebo surgery, exercise or other non-surgical modalities) in adults with patellar tendinopathy.Major outcomes assessed were knee pain, function, quality of life, participant global assessment of success, withdrawal rate, proportion with adverse events and proportion with tendon rupture.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion, extracted trial characteristics and outcome data, assessed the risk of bias and assessed the quality of the evidence using GRADE.

MAIN RESULTS

Two trials (92 participants) met our inclusion criteria. Participants in both trials were followed for 12 months. Neither trial compared surgery to placebo surgery. One trial (40 randomised participants) compared open surgical excision with eccentric exercises, and the other compared arthroscopic surgery with sclerosing injections (52 randomised participants). Due to the nature of the interventions, neither the participants or the investigators were blinded to the group allocation, resulting in the potential for performance and detection bias. Some outcomes were selectively not recorded, leading to reporting bias. Overall, the certainty of the evidence from these studies was low for all outcomes due to the potential for bias, and imprecision due to small sample sizes.Compared with eccentric exercises, low-certainty evidence indicates that open surgical excision provides no clinically important benefits with respect to knee pain, function or global assessment of success. At 12 months, mean knee pain - measured by pain with standing jump on a 10-point scale (lower scores indicating less pain) - was 1.7 points (standard deviation (SD) 1.6) in the eccentric training group and 1.3 (SD 0.8) in the surgical group (one trial, 40 participants). This equates to an absolute pain reduction of 4% (ranging from 4% worse to 12% better, the minimal clinically important difference being 15%) and a relative reduction in pain of 10% better (ranging from 30% better to 10% worse) in the treatment group. At 12 months, function on the zero- to 100-point Victorian Institute of Sport Assessment (VISA) scale was 65.7 (SD 23.8) in the eccentric training group and 72.9 (SD 11.7) in the surgical group (one trial, 40 participants). This equates to an absolute change of 7% better function (ranging from 4% worse to 19% better) and relative change of 25% better (ranging from 15% worse to 65% better, the minimal clinically important difference being 13%). Participant global assessment of success was measured by the number of people with no pain at 12 months: 7/20 participants in the eccentric training group reported no pain, compared with 5/20 in the open surgical group (risk ratio (RR) 0.71 (95% CI 0.27 to 1.88); one trial, 40 participants). There were no withdrawals, but five out of 20 people from the eccentric exercise group crossed over to open surgical excision. Quality of life, adverse events and tendon ruptures were not measured.Compared with sclerosing injection, low-certainty evidence indicates that arthroscopic surgery may provide a reduction in pain and improvement in participant global assessment of success, however further studies are likely to change these results. At 12 months, mean pain with activities, measured on a 100-point scale (lower scores indicating less pain), was 41.1 (SD 28.5) in the sclerosing injection group and 12.8 (SD 19.3) in the arthroscopic surgery group (one trial, 52 participants). This equates to an absolute pain reduction of 28% better (ranging from 15% to 42% better, the minimal clinically important difference being 15%), and a relative change of 41% better (ranging from 21% to 61% better). At 12 months, the mean participant global assessment of success, measured by satisfaction on a 100-point scale (scale zero to 100, higher scores indicating greater satisfaction), was 52.9 (SD 32.6) in the sclerosing injection group and 86.8 (SD 20.8) in the arthroscopic surgery group (one trial, 52 participants). This equates to an absolute improvement of 34% (ranging from 19% to 49%). In both groups, one participant (4%) withdrew from the study. Functional outcome scores, including the VISA score, were not reported. Quality-of-life assessment, adverse events, and specifically the proportion with a tendon rupture, were not reported.We did not perform subgroup analysis to assess differences in outcome between arthroscopic or open surgical excision, as we did not identify more than one study with a common comparator.

AUTHORS' CONCLUSIONS

We are uncertain if surgery is beneficial over other therapeutic interventions, namely eccentric exercises or injectables. Low-certainty evidence shows that surgery for patellar tendinopathy may not provide clinically important benefits over eccentric exercise in terms of pain, function or participant-reported treatment success, but may provide clinically meaningful pain reduction and treatment success when compared with sclerosing injections. However, further research is likely to change these results. The evidence was downgraded two levels due to the small sample sizes and susceptibility to bias. We are uncertain if there are additional risks associated with surgery as study authors failed to report adverse events. Surgery seems to be embedded in clinical practice for late-stage patella tendinopathy, due to exhaustion of other therapeutic methods rather than evidence of benefit.

Refractory patellar tendinopathy treated by arthroscopic decortication of the inferior patellar pole in athletes: Mid-term outcomes

BACKGROUND

This study aimed to evaluate the clinical outcomes of arthroscopic decortication of the inferior patellar pole in athletes with refractory chronic patellar tendinopathy.

METHODS

Thirty-seven athletes in whom conservative management for at least six months failed underwent arthroscopic patellar tendon debridement and decortication of the inferior pole of the patella. Clinical outcomes were evaluated using subjective knee scores and isokinetic muscle strength tests. The average duration taken and sports participation level were also assessed.

RESULTS

The mean follow-up period was 51.3 ± 14.8 months. At the last follow-up, all improvements in subjective knee scores including Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Victorian Institute of Sport Assessment -Patella (VISA-P) score, and Kujala score were statistically significant (p<.001). Tegner activity scale improved from 6.5±1.0 to 8.9±0.8 (p<.001). Limb symmetry index for extensor peak torque improved from 71.4±19.6% to 92.7±21.7% (p<.001). Thirty-two (86.5 %) athletes were able to return to full sports activities in a mean 3.5±1.7months, and 27 (73%) athletes maintained their previous sports activity level at the last follow-up. Symptoms recurred in two (5.2%).

CONCLUSIONS

Arthroscopic decortication of the inferior pole of the patella showed satisfactory clinical results and high rates of return to sports at mid-term follow-up in professional athletes with refractory chronic patellar tendinopathy. This technique could be an invasive, safe, and effective treatment for chronic patellar tendinopathy in professional athletes who want a faster return to sports.

LEVEL OF EVIDENCE

Level IV, case series.

Patellar tendinopathy with intratendinous alteration on MRI may be related to patellofemoral dysplasia

Patellar tendinopathy (PT) is a frequent overuse injury of the extensor knee apparatus, whereas as up to 30% of the athletes might suffer from persisting symptoms during their entire career. In the present case-control study, 47 patients (30.8 ± 11.4 years) with PT with intratendinous alteration (PTita) of a minimum of ≥25% of the axial surface on MRI and minimum Blazina score of II (pain during without limiting sports activity) were included; MR images were analyzed for trochlear geometry, patellar height/tilt, and tibial tubercle-trochlear groove distance (TT-TG). The control group (CG) comprised 87 age- and gender-matched patients without history of anterior knee pain or lateral patellar instability. It was hypothesized that patients with PT might be related to patellofemoral dysplasia. It was found that the patella was significantly higher in patients with PT compared to the CG (patellotrochlear index [PT-I]: 0.33 vs 0.37, P = .014; Insall-Salvati index [InSa]: 1.18 vs 1.07, P = .004). PT-I was above the cut-off value in 10.6% of PT knees (CG 5.7%, P = .27), and InSa in 42.6% (CG 21.8%, P = .012). TT-TG was significantly higher in patients with PT compared to CG (12.0 mm vs 9.9 mm, P = .002); however, TT-TG was only pathologic (>20 mm) in one patient. The trochlear facet ratio was above the cut-off value in 55.3% of PT patients and 23% of CG (P < .001), and was significantly greater in patients with PT (0.39 ± 0.09) than CG (0.48 ± 0.1, P < .001). Knees with PT have significantly more morphological characteristics of patellofemoral instability, which needs to be considered especially in recurrent or treatment-refractive cases.

Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population

BACKGROUND

Arthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR.

METHODS

Between 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively.

RESULTS

In total, 30 athletes were included in this study. At follow-up (8.8 ± 2.82 years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P < 0.001). The mean time required for return to sports was 4.03 ± 3.18 months. After stratification by age, patients younger than 30 years of age yielded superior outcome in the mean Blazina score and pain level when compared to patients ≥30 years (P = 0.0448). At 8 years of follow-up, patients yielded equivalent clinical and functional outcome scores compared to our previous investigation after four years following APR.

CONCLUSION

In summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR.

Open Patellar Tendon Tenotomy, Debridement, and Repair Technique Augmented With Platelet-Rich Plasma for Recalcitrant Patellar Tendinopathy

Patellar tendinopathy is a disabling condition that frequently affects the athletic population, especially athletes undergoing repetitive impact forces as a result of jumping and landing activities. Most cases are initially treated conservatively, but if symptoms persist, surgical treatment is warranted. Options for surgical treatment include both arthroscopic and open techniques. The purpose of this Technical Note is to detail our open patellar tendon tenotomy, debridement, and repair technique augmented with platelet-rich plasma.

Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study

Background

To date, prognostic outcome factors for patients undergoing arthroscopic treatment due to chronic patellar tendinopathy (PT) are lacking. The purpose of this study was to investigate whether preoperatively assessed MRI parameters might be of prognostic value for prediction of functional outcome and return to sports in arthroscopic treatment of chronic PT.

Methods

A prospective cohort study was conducted including 30 cases (4 female and 24 male competitive athletes) undergoing arthroscopic patellar release (APR) due to chronic PT. The mean age was 28.2 years (range, 18–49 years) at the time of surgery, and the mean follow-up period was 4.2 years (range, 2.2–10.4 years). Preoperatively assessed MRI parameters included bone marrow edema (BME) of the inferior patellar pole, patellar tendon thickening, infrapatellar fat pad (IFP) edema, and infrapatellar bursitis. Prevalences of preoperative MRI findings were correlated to functional outcome scores in order to determine statistically significant predictors.

Results

All athletes regained their preinjury sports levels. Athletes featuring preoperative IFP edema showed significantly inferior modified Blazina score (0.6 ± 0.7 vs. 0.2 ± 0.5), single assessment numeric evaluation (SANE; 86.0 ± 8.8 vs. 94.3 ± 7.5), and Visual Analogue Scale (VAS; 1.0 ± 1.2 vs. 0.3 ± 0.8) compared to subjects without IFP edema (p < 0.05). Return to sports required a mean of 4 ± 3.2 months. On average, patients with IFP edema needed significantly more time to return to sports than subjects without IFP edema (6.5 vs 2.8 months; p < 0.05). The simultaneous presence of BME and IFP edema was associated with significantly inferior outcomes by means of the Victorian Institute of Sport Assessment questionnaire for patients with patellar tendinopathy (VISA-P; 88.1 ± 11.9 vs. 98.6 ± 4.2), SANE (84.3 ± 10.2 vs. 93.1 ± 8.3), and VAS (1.3 ± 1.4 vs. 0.3 ± 0.9) compared to an isolated BME or isolated IFP edema.

Conclusions

This is the first study identifying prognostic outcome factors in arthroscopic treatment of chronic PT. Preoperative IFP edema alone or simultaneous BME and IFP edema on preoperative MRI were associated with inferior functional outcome and delayed return to sports. Knowledge of these predictive factors might improve risk stratification, individualize treatment and postoperative rehabilitation, and contribute to improve clinical outcome. Moreover, current findings offer the potential for novel therapeutic approaches.

Open Patellar Tendon Tenotomy and Debridement Combined with Suture-bridging Double-row Technique for Severe Patellar Tendinopathy

OBJECTIVE

To create a new surgical procedure for chronic severe patellar tendinopathy and to evaluate its clinical efficacy.

METHODS

In this retrospective study, the data of 12 patients with severe patellar tendinopathy in 14 knees who had undergone surgical treatment at Beijing Chao-Yang Hospital between 1 March 2009 and 1 August 2013 were analyzed. Inclusion criteria included severe patellar tendinopathy (Phase III), conservative therapy for more than 6 months, American Society of Anesthesiology status Grade I-II, and body mass index <30. Patients with severe osteoporosis, complete tendon disruption (Phase IV) and those who were unable to cooperate were excluded. There were 8 men (10 knees) and 4 women (4 knees) cases. The patients' ages ranged from 38 to 54 years (mean, 45.3 years). All surgeries had been performed by the same physician. Surgical treatment comprised incising open patellar midline tenotomy, complete debridement and suture-bridging double-row fixation. Isotonic and kinetic chain exercises were implemented after the second post-operative week. A gradual increase to full weight-bearing was allowed after the third post-operative week and a gradual return to unrestricted use of the leg after the eighth post-operative week. Preoperative and postoperative visual analogue scale (VAS) scores and Lysholm knee scores were obtained from the medical records or at recent postoperative follow-up visits and the results compared using Student's two-tailed paired t-test.

RESULTS

VAS scores decreased by a mean of 6.7 points (range, 1.1-7.8 points) during follow-up (minimum duration 14 months; range, 14-44 months) and Lysholm scores increased from 55.7 ± 6.5 points to 90.4 ± 6.2 points. Three cases (4 knees) achieved excellent outcomes (≥95 points) and 9 cases (10 knees) good outcomes (range, 86-94 points). No intraoperative or postoperative complications occurred. There were significant differences between preoperative and postoperative VAS and Lysholm scores (P < 0.01).

CONCLUSIONS

All study patients achieved good or excellent outcomes. No patellar tendon rupture or suture fixation failure occurred during follow-up. Suture-bridging double-row fixation is a simple and reliable method that not only improves patients' clinical symptoms, but also restores knee joint function.

Surgical Technique: Jumper's Knee-Arthroscopic Treatment of Chronic Tendinosis of the Patellar Tendon

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.

Current Concepts and the Role of Surgery in the Treatment of Jumper's Knee

Jumper's knee is a common cause of anterior knee pain among athletes and active populations. Numerous treatments have been described with variable results. To better delineate this, the authors reviewed all articles from 2000 to 2014 pertaining to the treatment of patellar tendinopathy, focusing namely on treatment of recalcitrant cases. Open and arthroscopic techniques were found to achieve similar satisfactory results in 81% (range, 45%-100%) and 91% (range, 86%-96%) of patients, respectively. Average time to return to play was 5.6 months and 5 months, respectively. A recently described technique, percutaneous ultrasonic tenotomy, potentially represents an attractive alternative option for definitive intervention. [Orthopedics. 2016; 39(6):e1028-e1035.].

Arthroscopic Treatment of Patellar Tendinopathy: Use of 70° Arthroscope and Superolateral Portal

Surgical treatment of recalcitrant patellar tendinopathy includes both the open surgical approach and minimally invasive arthroscopic debridement. A variety of arthroscopic techniques have been described that involve the use of a standard 30° arthroscope and standard anterolateral and anteromedial portals. As a result, visualization of the infrapatellar region can be variable, and it may be necessary to create additional portals. A 70° arthroscope provides the advantage of a wider field of view to the surgeon. By placing a 70° arthroscope through a superolaterally created portal around the knee joint, the surgeon acquires a complete view of the infrapatellar region and patellar tendon. Thus, debridement of the pathologic area can be accomplished just by the use of an additional working portal, typically the anterolateral one. This technical note describes a technique that involves the use of a 70° arthroscope for the treatment of patellar tendinopathy.

Results of Surgical Treatment of Chronic Patellar Tendinosis (Jumper's Knee): A Systematic Review of the Literature

PURPOSE

To review the literature concerning surgical treatment options for chronic patellar tendinosis (jumper's knee), a common problem among athletes. When conservative treatment fails, surgical treatment is required.

METHODS

Systematic review of the literature concerning the results of current surgical treatment options for chronic patellar tendinosis. All articles of studies with an evidence level ≥IV from January 2000 until February 2015 presenting the surgical outcome after arthroscopic as well as open treatment of chronic patellar tendinosis were included. The literature research of the PubMed database was performed using the following key words: "patellar" and "tendinitis," "tendonitis," "tendinosis" or "tendinopathy"; "inferior patellar pole"; "jumper's knee"; "surgical treatment" and "open" or "arthroscopic patellar tenotomy."

RESULTS

A systematic review of the literature was performed especially to point out the effectiveness of arthroscopic treatment of chronic patellar tendinosis. The results revealed good clinical results for arthroscopic as well as open treatment of chronic patellar tendinosis that is refractory to conservative treatment in athletes. An average success rate of 87% was found for the open treatment group and of 91% for the arthroscopic treatment group. However, after open surgery, the mean time of return to the preinjury level of activity is 8 to 12 months, with a certain number of patients/athletes who cannot return to the preinjury level of activity.

CONCLUSIONS

Minimally invasive, arthroscopically assisted or all-arthroscopic procedures may lead to a significantly faster return to sporting activities and may, therefore, be the preferred method of surgical treatment.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Patellar tendon: From tendinopathy to rupture

Patellar tendinopathy is very common in patients complaining of anterior knee pain. Its aetiology is still unclear, but neovascularisation seems to play a role. Different treatments have been proposed overtime, from rehabilitation to platelet-rich-plasma injections, but there is no agreement on the best treatment protocol. The final stage of patellar tendinopathy is patellar tendon rupture. In these cases surgical treatment is often required. The aim of this literature review is to focus on the aetiology, diagnosis, and treatment of both patellar tendinopathy and rupture. We report the conservative treatments proposed for patellar tendinopathy and the surgical techniques described for its rupture.

Progression of patellar tendinitis following treatment with platelet-rich plasma: case reports

PURPOSE

The use of platelet-rich plasma (PRP) is becoming more attractive given its favourable side effect profile and autologous nature, leading to rapid clinical adoption in the absence of high-level evidence. We are presenting three patients who developed a progression of patellar tendinitis following treatment, which to our knowledge is the first report of worsening of patellar tendinitis following PRP therapy.

METHODS

The records of three patients with symptom exacerbation of patellar tendinitis following treatment with PRP were reviewed. IRB exemption was obtained. Clinical and operative records, radiographs, and MR imaging were reviewed for all patients.

RESULTS

Three patients reported to our clinic for a second opinion with symptoms of anterior knee pain consistent with patellar tendinitis. Each patient had previously been treated with PRP therapy due to prolonged symptoms. Clinical and radiological findings following treatment included patellar tendon thickening, worsening pain, discontinuation of athletic participation in all three patients, and osteolysis of the distal pole of the patella in one patient identified during surgical intervention.

CONCLUSIONS

Growing interest in the use of autologous products for the management of chronic tendinopathies has led to widespread clinical implementation with minimal scientific support. It is tempting to apply a new treatment for management of a difficult clinical entity, especially when the risk/benefit ratio appears favourable. However, caution must be exercised as unexpected results may be encountered.

LEVEL OF EVIDENCE

Case reports, level V.