Ultrasound-guided tendon debridement improves pain, function and structure in persistent patellar tendinopathy: short term follow-up of a case series

Football Was the Most Common Sport among 344 Consecutive Athletes Treated Surgically for Jumper's Knee at an International Tendon Clinic

Objectives

Jumper's knee, or proximal patellar tendinopathy, is commonly seen among athletes in leg explosive sports, and for a subgroup surgical treatment is needed. The aim of this study was to identify what type of sports were most frequent among athletes treated surgically for Jumper's knee at an international tendon clinic during a consecutive 13-year period.

Methods

The study included 344 consecutive patients (306 males, mean age 27 years, range 17-58; 38 females, mean age 24 years, range 18-44) from 21 different countries seeking help for therapy-resistant jumper's knee. There were 274 elite athletes, 168 being full-time professionals. All were diagnosed to have tendinopathy in the proximal patellar tendon and were operated on with ultrasound- and Doppler-guided arthroscopic shaving surgery.

Results

The single most common sport was football (n = 95, 28%), followed by rugby (n = 37, 11%) and handball (n = 32, 9%), with 117 (34%) playing at a professional level. The rest of the athletes participated in 17 other different elite sports and nine recreational sports (running/jogging, padel, squash, biking, gym training, bowling, cheerleading, dancing, and ultimate frisbee).

Conclusions

Football was the most common sport among patients requiring surgical treatment for jumper's knee, constituting 28% of all patients, and together with rugby and handball they constituted almost half of all patients. There was a wide sport distribution with 29 different team and individual sports represented.

Ultrasound- and Doppler-Guided WALANT Arthroscopic Surgery for Patellar Tendinopathy with Partial Rupture in Elite Athletes-A 2-Year Follow-Up of a Prospective Case Series

Background and Objectives: Patellar tendinopathy is difficult to treat, and when combined with partial rupture, there are additional challenges. The aim of this study was to evaluate the subjective outcome and return-to-sport status after ultrasound (US)- and colour doppler (CD)-guided wide awake local anaesthetic no tourniquet (WALANT) arthroscopic shaving in elite athletes. Material and Methods: Thirty Swedish and international elite athletes (27 males) with a long duration (>1 year) of persistent painful patellar tendinopathy in 35 patellar tendons, not responding to non-surgical treatment, were included. All patients were treated with the same protocol of arthroscopic shaving, including bone removal and debridement of partial rupture, followed by at least 3 months of structured rehabilitation. The VISA-P score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 2-year follow-up (mean 23, range 8-38 months), 25/30 patients (29/35 tendons) were satisfied with the treatment result and had returned to their pre-injury sport. The mean VISA-P score increased from 37 (range 7-69) before surgery to 80 (range 44-100) after surgery (p < 0.05). There was one drop-out (one tendon). There were no complications. Conclusions: US- and CD-guided WALANT arthroscopic shaving for persistent painful patellar tendinopathy, including bone removal and debridement of partial rupture, followed by structured rehabilitation showed good clinical results in the majority of the elite-level athletes.

Safety and Efficacy of Bone Marrow-Derived Mesenchymal Stem Cells for Chronic Patellar Tendinopathy (With Gap >3 mm) in Patients: 12-Month Follow-up Results of a Phase 1/2 Clinical Trial

Background

In a previous study, the authors found that at 6 months after treatment with a 20 × 106 dose of bone marrow-derived mesenchymal stem cells (BM-MSCs), patients showed improved tendon structure and regeneration of the gap area when compared with treatment using leukocyte-poor platelet-rich plasma (Lp-PRP). The Lp-PRP group (n = 10), which had not seen tendon regeneration at the 6-month follow-up, was subsequently offered treatment with BM-MSCs to see if structural changes would occur. In addition, the 12-month follow-up outcomes of the original BM-MSC group (n = 10) were evaluated.

Purpose

To evaluate the outcomes of all patients (n = 20) at 12 months after BM-MSC treatment and observe if the Lp-PRP pretreated group experienced any type of advantage.

Study Design

Cohort study; Level of evidence, 2.

Methods

Both the BM-MSC and original Lp-PRP groups were assessed at 12 months after BM-MSC treatment with clinical examination, the visual analog scale (VAS) for pain during daily activities and sports activities, the Victorian Institute of Sport Assessment-Patella score for patellar tendinopathy, dynamometry, and magnetic resonance imaging (MRI). Differences between the 2 groups were compared with the Student t test.

Results

The 10 patients originally treated with BM-MSCs continued to show improvement in tendon structure in their MRI scans (P < .0001), as well as in the clinical assessment of their pain by means of scales (P < .05). Ten patients who were originally treated with Lp-PRP and then with BM-MSCs exhibited an improvement in tendon structure in their MRI scans, as well as a clinical pain improvement, but this was not significant on the VAS for sports (P = .139). Thus, applying Lp-PRP before BM-MScs did not yield any type of advantage.

Conclusion

The 12-month follow-up outcomes after both groups of patients (n = 20) received BM-MSC treatment indicated that biological treatment was safe, there were no adverse effects, and the participants showed a highly statistically significant clinical improvement (P < .0002), as well as an improvement in tendon structure on MRI (P < .0001). Preinjection of Lp-PRP yielded no advantages.

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.

Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study

Background:

The diagnosis and monitoring of Achilles tendinopathy with imaging are challenging. There is a lack of studies comparing the diagnostic accuracy of magnetic resonance imaging (MRI), brightness mode ultrasound (B-mode), and power Doppler ultrasound with recent technologies such as ultrasound tissue characterization (UTC) and shear wave elastography (SWE).

Purpose:

To assess whether SWE and UTC, which offer quantitative values, show a superior diagnostic accuracy and capacity to detect structural improvement in Achilles tendinopathy compared with MRI, B-mode, or power Doppler.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Patients with insertional (n = 28) and midportion (n = 38) Achilles tendinopathy were evaluated at baseline and 6-month follow-up using MRI, B-mode, power Doppler, SWE, and UTC. Asymptomatic controls (n = 37) were evaluated at T₀. Diagnostic accuracy was analyzed based on a quantitative receiver operating characteristic (ROC) analysis with quantitative cutoff values (anteroposterior diameter, Öhberg score, UTC echo type, Young modulus) and by semiquantitative Likert scale–based assessment of experienced physicians.

Results:

For diagnosing insertional Achilles tendinopathy, semiquantitative MRI and power Doppler were most favorable (diagnostic accuracy, 95%), while the cross-sectional area of MRI revealed 89% accuracy in the ROC analyses (area under the curve [AUC], 0.911; P < .001). For diagnosing midportion Achilles tendinopathy, semiquantitative MRI and B-mode were most favorable (diagnostic accuracy, 87%), while UTC echo types 3 and 4 revealed 86% and 87% accuracy, respectively, in the ROC analyses (AUC, 0.911 and 0.941, respectively; P < .001). However, for quantitative and semiquantitative evaluation of diagnostic accuracy in both insertional and midportion Achilles tendinopathy, there was no significant difference in favor of one imaging modality over the others. Compared with baseline, only SWE showed a significant change at the 6-month follow-up (P = .003-.035), but there were only fair to poor monitoring accuracies of 71% (insertion) and 60% (midportion). However, compared with the other modalities, the monitoring accuracy of SWE was significantly higher (P = .002-.039).

Conclusion:

There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy.