Arthroscopic patellar release allows timely return to performance in professional and amateur athletes with chronic patellar tendinopathy

Ultrasound-guided electrocoagulation of neovascularisation for persistent patellar tendinopathy in athletes: a cohort study of 25 patients with a mean follow-up of 5 years from the SANTI Study Group

Background

Patellar tendinopathy (PT) is a common condition characterised by persistent patellar tendon pain and dysfunction, particularly in athletes. Neovascularisation is frequently observed in the PT and is associated with increased pain. Ultrasound-guided electrocoagulation of neovascularisation has emerged as a minimally invasive alternative treatment for recalcitrant PT.

Hypothesis/purpose

The purpose of this study was to evaluate the clinical outcomes of ultrasound-guided electrocoagulation of neovascularisation in athletes with persistent PT.

Study design

Case series; level of evidence, IV.

Methods

A retrospective analysis of prospectively collected data was performed on 25 athletes who underwent ultrasound-guided electrocoagulation of neovascularisation for recalcitrant PT. Clinical outcomes including complications, reinterventions and patient-reported outcome measures were recorded. Comparisons between variables were assessed using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Wilcoxon test for quantitative variables.

Results

25 patients were included in the final analysis. 96% returned to their preoperative activity level at a mean of 3.8 months. At a mean follow-up of 5 years 4% did not receive significant benefit from electrocoagulation therapy. Significant improvements were observed in outcome measures, including the Victorian Institute of Sport Assessment Questionnaire for Patients with Patellar Tendinopathy, Kujala score, modified Blazina score and Visual Analogue Scale for pain.

Conclusion

Ultrasound-guided electrocoagulation of neovascularisation for persistent PT in elite athletes resulted in a low complication rate, a high rate and rapid return to sport and a significant improvement in outcome measures.

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.

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.

Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

BACKGROUND

Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance.

PURPOSE

To identify factors that contribute to an athlete's return to preinjury level of performance after ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review-demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)-were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance.

RESULTS

A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness (P < .0001), greater limb symmetry (P < .05), higher subjective knee scores (P = .01), and a higher activity level (P < .04) were all associated with a return to performance. In the multivariate model, psychological readiness was the only variable that remained a significant predictor (odds ratio = 1.03; 95% CI, 1.01-1.04; P < .0001).

CONCLUSION

A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.