Patellar Tendinosis A FOLLOW-UP STUDY OF SURGICAL TREATMENT

Transcription

1 2179 COPYRIGHT 2002 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Patellar Tendinosis A FOLLOW-UP STUDY OF SURGICAL TREATMENT BY ANDREA FERRETTI, MD, FABIO CONTEDUCA, MD, EMANUELA CAMERUCCI, MST, AND FEDERICO MORELLI, MD Investigation performed at the Division of Orthopaedics, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy Background: Patellar tendinopathy (jumper s knee) is an overuse syndrome that frequently affects athletes. A retrospective study was done to analyze the results at a minimum of five years after the performance of a surgical technique in competitive athletes. Methods: From 1985 to 1995, thirty-two patients (thirty-eight knees) affected by patellar tendinopathy were treated surgically after failure of nonoperative treatment. All knees were operated on by the same surgeon using the same surgical technique: longitudinal splitting of the tendon, excision of any abnormal tissue that was identified, and resection and drilling of the inferior pole of the patella. The results in twenty-seven patients (thirty-three knees), including twenty-two athletes (twenty-seven knees) who were still involved in sports activities (or wished to still be involved) at a competitive level at the time of final follow-up, were reviewed at a mean of eight years postoperatively. The results were evaluated according to symptoms and the ability to return to full sports activities. Results: The result was excellent in twenty-three knees (70%), good in five, fair in one, and poor in four at the time of the long-term follow-up. Eighty-two percent of the patients who tried to pursue sports at their preinjury level were able to do so, and 63% of those knees were totally symptom-free. Conclusions: The outcome of the described surgical treatment appears to be satisfactory; however, the results are less predictable in volleyball players. Patellar tendinopathy (jumper s knee) is a relatively common clinical condition that affects athletes who use the knee extensor mechanism in a repetitive manner in explosive extension or eccentric flexion 1-3. Volleyball, basketball, soccer players and dancers are at particular risk for the development of patellar tendinopathy because rapid acceleration, deceleration, jumping, and landing concentrate a tremendous stress on the extensor mechanism. When the patellar tendon is subjected to extreme force, microruptures can occur. These lesions may heal completely or they may heal partially, resulting in a chronic degenerative process 4,5. Histological findings confirm that the abnormal tissue in patellar tendinosis is localized at the bone-tendon junction, similar to the way it is in lateral epicondylitis (tennis elbow). In a previous paper 6, one of us (A.F.) and colleagues described histological abnormalities that included pseudocystic cavities at the junction between mineralized cartilage and bone, disappearance of the tidemark ( blue line ), increased thickness of the insertional fibrocartilage with myxomatous and hyaline metaplasia, and ossification of the fibrocartilage. A program of nonoperative treatment is usually successful in alleviating symptoms and allowing athletes to resume sports participation 4,7. Operative treatment is considered when nonoperative treatment fails and the symptoms persist, interfering with sports activities 8,9. It has been estimated that no more than 10% of all athletes who have patellar tendinosis undergo surgery 2. In this study, we retrospectively evaluated the results of surgical treatment performed on twenty-seven patients (thirtythree knees) and reviewed after a minimum duration of followup of five years. Materials and Methods rom 1985 to 1995, thirty-two patients (thirty-eight knees) Faffected by patellar tendinopathy were treated surgically after failure of nonoperative treatment for at least three months. Patients who had complete rupture or visible partial rupture of the tendon at the time of surgery were not included in this study. A diagnosis of patellar tendinosis was made on the basis of the patient s history and physical examination. Eight knees were also evaluated preoperatively with the use of ultrasound, four underwent magnetic resonance imaging, and ten were evaluated with both ultrasound and magnetic resonance imaging. In all patients thus studied, degeneration of the tendon near the inferior pole of the patella was detected. Before surgery, all of the patients had followed a supervised rehabilitation program (isometric quadriceps exercise and hamstrings stretching) for at least three months. Five patients had received a maximum of three local steroid injections into the area of tenderness. In all five, the pain decreased only for a short period of time. Five patients were lost to follow-up, and twenty-seven patients (thirty-three knees) were subjectively evaluated at a minimum of five years after the operation. There were twenty-

2 2180 knees, in which a degenerated portion of the proximal part of the patellar tendon was observed; no patellar tendon was torn. The bone-tendon junction appeared to be normal macroscopically in all patients. No patient had a clearly identifiable local nidus of inflammation, as described by Bassett et al. 11. A cortical bone block was removed from the inferior patellar pole together with the proximal central portion of the patellar tendon and any abnormal tendon tissue that was identified. The cancellous patellar bone was curetted and drilled, and the bone-tendon junction was cauterized in both the medial and the lateral direction. Although the tendon was not reapproximated, the paratenon was closed with absorbable sutures. Histological examination, which was performed in selected patients, confirmed the presence of abnormalities of the bone-tendon junction such as hyaline and mucoid degeneration, pseudocystic cavities between mineralized fibro- Fig. 1-A Figs. 1-A through 1-F Splitting of the patellar tendon and exposure and excision of the inferior patellar pole. Fig. 1-A The surgical technique. four men and three women with a mean age at the time of the operation of 26.9 years (range, eighteen to thirty-one years). The mean time between the onset of symptoms and the surgery was thirty-three months (range, thirteen months to eight years). All of the patients were involved in sports activities at a competitive level (professional for thirteen and amateur for fourteen), and half of them were volleyball players. Twentytwo players (twenty-seven knees) were still participating in sports (or wished to still be participating) at the time of the final follow-up. The symptoms were graded preoperatively and postoperatively with use of a slightly modified version of the six-stage classification described by Blazina et al. 10 (Table I). The result was considered excellent when it was stage 0 at the time of follow-up, good when it was stage 1 with a postoperative improvement of at least two stages, fair when there had been improvement but the final result was stage 2 or higher, and poor when there had been no improvement. The patients were asked to report the outcome of the procedure when they returned to full sports participation after the surgery (first follow-up) and again at the time of final follow-up. Thus, two outcome scores were recorded. Surgical Technique (Figs. 1-A through 1-F) A 5-cm anterior longitudinal central skin incision was made just distal to the inferior patellar pole. The paratenon was divided, and the tendon was split longitudinally over the area of the greatest pain as identified clinically. In this series, the patellar tendon appeared normal at surgery in all but four Fig. 1-B Fig. 1-C Fig. 1-B The skin incision and exposure of the patellar tendon. Fig. 1-C Removal of the central portion of the patellar tendon near its insertion.

3 2181 Fig. 1-D Fig. 1-E Fig. 1-D The inferior pole of the patella is exposed. Fig. 1-E The inferior pole of the patella is excised. Fig. 1-F Drill holes in the inferior patellar pole. Fig. 1-F cartilage and bone, and increased thickness and ossification of the fibrocartilage. After surgery, a knee brace was applied in full extension allowing weight-bearing as tolerated for two weeks. A progressive range of motion and weight-bearing were encouraged as permitted by pain. Use of the brace was discontinued after four weeks. After six weeks, full weight-bearing and a full range of motion were achieved, and a sports-specific rehabilitation program was started, with the patient progressing to full sports participation as directed by clinical progress. In all bilateral cases, the two operations were carried out at the same time. Results n our study, professional athletes waited less time before sur- (mean time, 2.1 years) than did amateur athletes (mean Igery time, 5.4 years) because they were unwilling to participate in an extended nonoperative course (p < 0.05). Twenty-eight (85%) of the thirty-three knees had a good or excellent result at the time of the final follow-up. The result was excellent in twenty-three knees, good in five, fair in one, and poor in four (Table II). All five patients who had given up sports for reasons not related to the knee at the time of final follow-up (Cases 23 to 27; Table II) stated that they had had complete healing and no longer had pain in the patellar tendon. In this group, in which six knees had been operated on, there were two excellent, two good, and two fair results at the time of the first follow-up, and none of these five patients had stopped participating in sports because of persistent pain. Twenty-two patients (twenty-seven knees) tried to pursue sports activities for more than five years postoperatively. Preoperatively, eleven of these knees had been stage 5; thirteen, stage 4; one, stage 3; and two, stage 2; the mean score was 4.2. Eighteen patients (82%) were able to return to sports participation at their desired level at an average of 5.5 months (range, two to twelve months) after surgery. The mean dura- TABLE I Classification of Jumper s Knee According to Symptoms Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 No pain Pain only after intense sports activity; no undue functional impairment Pain at the beginning and after sports activity; still able to perform at a satisfactory level Pain during sports activity; increasing difficulty in performing at a satisfactory level Pain during sports activity; unable to participate in sport at a satisfactory level Pain during daily activity; unable to participate in sport at any level

4 2182 TABLE II Results for Twenty-seven Patients (Thirty-three Knees) at First and Final Postoperative Follow-up Intervals Case Age (yr) Sex Side Surgical Appearance of Patellar Tendon* Preop. Sport 1 30 M R Tennis (amateur) 2 24 M R Degen. Volleyball (amateur) 3 21 M R L Volleyball (prof.) 4 18 M R L Volleyball (prof.) 5 25 M L Tennis (prof.) 6 24 M L R Degen. Volleyball (amateur) 7 28 M R Football (prof.) 8 27 M L Dance (prof.) 9 23 M L R Basketball (amateur) F R Volleyball (amateur) M L Degen. Volleyball (amateur) M L Weight-lifting (amateur) M L R Degen. Volleyball (prof.) M R Skiing (amateur) M L Football (amateur) M R Volleyball (amateur) M L Basketball (amateur) M R Tennis (prof.) M R Dance (prof.) F L Basketball (prof.) M L Volleyball (prof.) M L Volleyball (prof.) M R L Basketball (prof.) M L Volleyball (amateur) F R Volleyball (amateur) M L Football (amateur) M R Volleyball (prof.) *Degen. = macroscopically degenerated patellar tendon near the insertion, and normal = apparently normal patellar tendon. tion until the final follow-up was eight years (range, five to eleven years), at which time the result was excellent in seventeen (63%) of the twenty-seven knees, good in five, fair in one, and poor in four; the mean score was 0.9 for these twentyseven knees. With the small number of patients available, no statistical correlation was found between the result at the time of final follow-up and the severity of the preoperative symptoms, the time elapsed from the onset of symptoms to the surgery, or the surgical findings. Four of the five unsatisfactory results were in volleyball players, who also had a higher mean score (1.2) than did the other athletes (0.5) at the time of final follow-up.

5 2183 TABLE II (continued) Stage Preop. First Follow-up Final Follow-up Sport at Follow-up: Time to Return Result Tennis (amateur): 4 mo Volleyball (amateur): 8 mo Poor No; postop. pain Poor Volleyball (prof.): 6 mo Good Tennis (amateur): 8 mo Volleyball (amateur): 12 mo Fair Football (prof.): 4 mo Dance (prof.): 5 mo Basketball (amateur): 5 mo Good Volleyball (amateur): 4 mo Volleyball (amateur): 6 mo Good Weight-lifting (amateur): 2 mo Volleyball (prof.): 7 mo Skiing (amateur): 5 mo Good Football (amateur): 6 mo Volleyball (amateur): 8 mo Basketball (amateur): 5 mo Tennis (prof.): 3 mo Good Dance (prof.): 4 mo No; postop. pain Poor Volleyball (prof.): 5 mo Volleyball (amateur): 12 mo Poor No; reason not related to knee No; reason not related to knee No; reason not related to knee No; reason not related to knee No; reason not related to knee The only complication was one superficial wound infection, which healed with systemic administration of antibiotics. Discussion atellar tendinopathy, or jumper s knee, is a relatively frequent disorder that most commonly occurs in athletes P participating in jumping activities; it is due to overuse of the knee extensor mechanism. It has been reported to be the most frequent injury in volleyball players, and as many as 40% of high-level volleyball players experience symptoms related to jumper s knee during their sports career 2. The diagnosis and the indications for surgery are based primarily on the pa-

6 2184 tient s history and physical examination. On examination, there is acute tenderness of the affected area, sometimes associated with localized swelling. As are other overuse injuries, jumper s knee is a selfresolving disease: patellar tendinosis heals when the extensor mechanism stops being overloaded. To our knowledge, all authors have agreed that, in the first phases of this disease, the therapy should be nonoperative, including relative rest, cryotherapy, stretching, and physical therapy focusing on hamstrings flexibility and quadriceps strengthening 2,4,7,9,12. Ultrasound therapy has also proved to be useful 4. Oral nonsteroidal anti-inflammatory medications are seldom effective. The role of corticosteroid injection is controversial. Local cortisone injections have a deleterious effect on the tendon s strength, thereby increasing the risk of rupture 8,13. Highly competitive athletes may be unwilling to give up sports activity for an adequate amount of time 12,14. Thus, a conservative program based on interrupting the overstressing and painful activities may not be suitable for professional or high-level amateur athletes, and several operative treatments have been proposed. Smillie 15 was, to our knowledge, the first to report on the surgical treatment of patellar tendinopathy; he recommended drilling of multiple holes in the inferior patellar pole. In 1973, Blazina et al. 10 reported five good results in five patients after excision of the inferior extraarticular patellar pole and reinsertion of the patellar tendon. However, other investigators using this technique did not confirm its reliability 4. Other authors have proposed resection of the damaged portion of the tendon tissue without disturbing the bone 8,16. Martens et al. 8 reported favorable short-term results in twenty-seven of twenty-nine patients treated with this technique. Verheyden et al. 16 employed a similar technique, which includes only resection of the damaged portion of the patellar tendon and abrading of the tendon insertion without performing a true osseous procedure. They recommended débridement of all of the damaged tendon tissue, which should be identified as a hard nodule in most patients. They reported an 87% rate of good and very good results in twenty-nine patients, seven of whom were volleyball players. However, in our experience, a clearly identifiable degenerated portion of the patellar tendon has been seldom found at surgery. Fritschy and Wallensten 4 proposed another, more aggressive procedure consisting of resection of the inferior pole of the patella and the central third of the patellar tendon. In their study, 81% of patients returned to sports activity at their preinjury level at about four months after the operation. Popp et al. 9 reported a 90% rate of excellent and good results after débridement of the tendon and drilling of the inferior patellar pole, but their prospective series was small (eleven knees) and the average duration of follow-up was only 2.1 years. Our surgical technique, which is based on the histological findings previously reported by one of us (A.F.) and colleagues 6, includes several steps: splitting of the tendon, excision of any abnormal tissue that is identified, resection and drilling of the inferior patellar pole, and cauterization of the bone-tendon junction. It is similar to the procedure described by Fritschy and Wallensten 4, but it differs with regard to the amount of tendon tissue removed. Overall, 82% (eighteen) of the twenty-two patients in our series who tried to pursue sports at their preinjury level for more than five years after the surgery were able to do so, and 63% (seventeen) of the twenty-seven knees became totally symptom-free without recurrence. Therefore, the outcome of our technique appears to be satisfactory and stable, especially when the long-term follow-up interval is taken into account. This seems to be a remarkable finding, as it is well known that jumper s knee tends to recur even long after the competitive sport has been resumed. It must be noted that, in our study, four of the five unsatisfactory results occurred in volleyball players, who seem to be the athletes who most frequently sustain this type of injury 1-3. The myriad jumping activities executed by volleyball players overload the patellar tendon, making their recovery more difficult. In conclusion, our experience confirms that the described surgical technique can be considered a reliable method of treatment of patellar tendon tendinopathy (jumper s knee). It is a relatively simple operation, but it can require a long rehabilitation period, with the time away from full sports activity after surgery ranging from two to twelve months for complete recovery. The results of the surgical technique seem satisfactory and stable overall. However, they are less predictable for volleyball players because of the high level of stress placed on the extensor mechanism in these athletes. NOTE: The authors thank Dr. Massimo Iachelli from the Division of Orthopaedics, University of Rome La Sapienza, Italy for his help in contacting patients. Andrea Ferretti, MD Fabio Conteduca, MD Emanuela Camerucci, MSt Federico Morelli, MD Division of Orthopaedics, Sant Andrea Hospital, University of Rome La Sapienza, Via Lidia 73, Rome, Italy. address for A. Ferretti: aferretti51@virgilio.it The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. References 1. Ferretti A, Puddu G, Mariani PP, Neri M. Jumper s knee: an epidemiological study of volleyball players. Phys Sports Med. 1984;12: Ferretti A, Puddu G, Mariani PP, Neri M. The natural history of jumper s knee. Patellar or quadriceps tendonitis. Int Orthop. 1985;8: Richards DP, Ajemian SV, Wiley JP, Zernicke RF. Knee joint dynamics predict patellar tendinitis in elite volleyball players. Am J Sports Med. 1996;24:

7 Fritschy D, Wallensten R. Surgical treatment of patellar tendinitis. Knee Surg Sports Traumatol Arthrosc. 1993;1: Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81: Ferretti A, Ippolito E, Mariani P, Puddu G. Jumper s knee. Am J Sports Med. 1983;11: Biedert R, Vogel U, Friederich NF. Chronic patellar tendinopathy: a new surgical treatment. Sports Exerc Inj. 1997;3: Martens M, Wouters P, Burssens A, Mulier JC. Patellar tendinitis: pathology and results of treatment. Acta Orthop Scand. 1982;53: Popp JE, Yu JS, Kaeding CC. Recalcitrant patellar tendinitis. Magnetic resonance imaging, histologic evaluation, and surgical treatment. Am J Sports Med. 1997;25: Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper s knee. Orthop Clin North Am. 1973;4: Del Pizzo W. Commentary to jumper s knee. Am J Sports Med. 1983;11: Griffiths GP, Selesnick FH. Operative treatment and arthroscopic findings in chronic patellar tendinitis. Arthroscopy. 1998;14: Ismail AM, Balakrishnan R, Rajakumar MK, Lumpur K. Rupture of patellar ligament after steroid infiltration. Report of a case. J Bone Joint Surg Br. 1969;51: Binfield PM, Maffulli N. Surgical management of common tendinopathies of the lower limb. Sports Exerc Inj. 1997;3: Smillie IS. Injuries of the knee joint. 3rd ed. Edinburgh: Livingstone; p Verheyden F, Geens G, Nelen G. Jumper s knee: results of surgical treatment. Acta Orthop Belg. 1997;63:102-5.