JON KARLSSON, MD, PhD Sahlgrenska University Hospital Gothenburg Sweden

JON KARLSSON, MD, PhD Sahlgrenska University Hospital Gothenburg Sweden

No company connections to disclose. Editor of KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY (KSSTA).

WHY DOES IT HAPPEN? The pathological process of Patellar tendinpathy involves various aspects Inflammation was believed to be central in the pathologic process but, hisptopathologic evidence has confirmed failed healing response nature of this condition

WHY DOES IT HAPPEN? Excessive or inapproriate loading is believed to be central in the disease process; the exact mechanism is unknown, however Location of the lesion is of importance, mid-portion or osteo-tendon junction

WHAT IS THE PROBLEM? Patellar tendinopathy (PT) Is a challenge to the Orthopaedic/knee surgeon First of all; physical training, particularly eccentric training appears to be the treatment of choice

WHAT IS THE PROBLEM? Patellar tendinopathy Is a challenge to the Orthopaedic/knee surgeon Second; which surgical technique is more/most effective in recalcitrant cases Open surgical or arthroscopic techniques

WHAT IS THE PROBLEM? Patellar tendinopathy surgery Open, inside the tendon Arthroscopic, outside the tendon Is there a difference? And, no difference, why? If there is a large tendon lesion, how can it be cured by not even touching it upon surgery?

TREATMENT ALTERNATIVES? Therapeutic exercises Extracorporeal shock-wave therapy (ESWT) Injection treatments, such as PRP, sclerosing polidocanol, steriods and aprotinin

TREATMENT ALTERNATIVES? Therapeutic exercises Physical training, and particularly eccentric exercise regimen/decline squats are effective and have been reported to be the treatment of choice for patients suffering from PT

TREATMENT ALTERNATIVES? Injection treatments, several studies have shown promising results but, the number of studies is low, few high-quality studies and the studies are hard to compare due to different methodology.

SURGICAL TREATMENT? If non-operative treatment fails, surgery is often recommended, although it is the last attempt of treatment A surgical approach is also usually only to be considered after at least 3-6 months of non-operative treatment

SURGICAL TREATMENT? There are numerous different surgical methods described in the literature, which may reflect the lack of randomized clinical trials comparing different procedures Again, lack of high-quality studies

SURGICAL TREATMENT? Concerning surgical treatment of patellar tendinopathy critical reviews show that studies with a less good scientific design generally have reported better clinical results And, studies with a better design have reported poorer clinical results

TREATMENT ALTERNATIVES? Surgery Open surgical treatment Arthroscopic treatment Arthroscopic, ultrasonpgraphy-assisted treatment, a promising technique

TREATMENT ALTERNATIVES? Arthroscopic, ultrasonpgraphy-assisted treatment, a promising new technique (Willberg et al. 2013)

OPEN SURGICAL TREATMENT Longitudinal splitting of the patellar tendon, excision of the grossly abnormal tissue and resection/drilling of the inferior patellar pole Outcome generally satisfactory, however, results less predictable in volleyball players

OPEN SURGICAL TREATMENT Ferretti et al. (JBJS, 2002); 5-year followup on 32 patients. Excellent result in 70%, fair/poor in 15%. 82% return to sports at the same level

OPEN SURGICAL TREATMENT Keading et al. (CORR, 2007); 71% success rate when open surgical treatment of the inferior patella pole was performed, compared with 92% when no bony work was done. No paratenon closure was better (n.s.) than closure (91% vs 85%) and there was high success rate with no post-operative immobilisation.

ARTHROSCOPIC TREATMENT Willberg et al. (KSSTA, 2007); treated patients with arthroscopic shaving of the dorsal aspect of the proximal patellar tendon. Short-term results showed that arthroscopic shaving (targeting the neovessels and nerves) reduced pain and allowed the majority to return to full tendon loading activity within 2 months after surgery.

ARTHROSCOPIC TREATMENT Ogon et al. (Arthoscopy, 2006), Kelly (Orthopaedics, 2009), Lorbach et al. (Arthroscopy 2008) and Pascarella et al. (AJSM 2011) have all shown similar promising results Similar techniques, short-term results, good pain reduction, effective technique, easy to perform and safe to apply. All these studies mention fast recovery and return to sports activities.

COMPARATIVE STUDIES Surgical treatment vs eccentric training (Bahr et al. JBJS, 2006); no advantage for surgical treatment Sclerosing polidocnol vs arthroscopy (Willberg et al. BJSM 2011); patients treated with arthroscopic shaving had a significantly lower pain score during activity and were significantly more satisfied

COMPARATIVE STUDIES Open vs arthroscopic surgery (Cucurolo et al. OTSR, 2009); retrospective fourcenter study; 64 patients were included (only 10 underwent arthroscopy) Arthroscopy as effective as open surgery similar delay to return to sports

A RECENT SYSTEMATIC REVIEW Open vs arthroscopic surgery (Muccioli et al. KSSTA, 2013) Success rate 87 vs 92 % (n.s.) and return to sports 77 vs 84% (n.s.) Conclusion; minimally-invasive arthroscopically assisted methods have not reported better results when compared with open surgery. Methodology of studies has improved over the last 15 years Well-designed RCTs using validated patient-related outcome measures are still lacking

WHAT IS THE NEGATIVE SIDE? Demanding technical skills Prolonged learning curve? Use of these techniques limited to experienced arthroscopists?

WHAT IS THE NEGATIVE SIDE? Scientific studies Non-comparative (most) Limited cohorts, sometimes less than 20 Comparisons difficult due to different techniques (surgical and evaluation)

WHAT CAN BE IMPROVED? Scientific studies Studies mention decreased morbidity and better outcome, compared with open methods Is it really so? But, very limited information from comparative studies

Take Home

Take home Interesting arthroscopic techniques Results in studies overall good Inside or outside the tendon does not matter! Study quality generally limited, Level IV and limited cohort size Comparisons difficult due to different types of evaluation and surgical techniques

Take home The issue is not open or arthroscopic surgery The decision concerning the method of surgical treatment is based on patient history, patient selection, physical examination, US, MRI and physician s surgical skills In other words; individualized treatment

Overall conclusion A large-scale, randomized, controlled study(ies) is(are) needed to answer whether this (these) technique(s) are really superior.