PATELLAR TENDINOPATHY -Does surgery work?- Hideyuki Koga, MD, PhD - - PowerPoint PPT Presentation

PATELLAR TENDINOPATHY

• Does surgery work?-

Hideyuki Koga, MD, PhD

• Dept. of Joint Surgery and Sports Medicine

Tokyo Medical and Dental University Japan

Disclosure

I have nothing to disclose.

Treatment of patellar tendinopathy

• Conservative treatment

– Rest (restriction of sports activity) – Physical training

• Eccentric training
• Heavy slow resistance training

– Injection

• Sclerosing polidocanol
• PRP
• Hyaluronan

– Extracorporeal shock-wave therapy (ESWT)

• Surgical treatment

– Open surgery

• Removal of abnormal tissues
• Longitudinal tenotomy
• Excision and/or drilling of inferior patellar pole

– Arthroscopic surgery

• Shaving, arthroscopic patellar release (synovectomy, fat pad resection)
• Resection of inferior patellar pole
• Ultrasound-guided

Treatment of patellar tendinopathy

Ferretti, JBJS-B 2002

Overall…

First-line monotherapy

• Strong evidence

– Eccentric training

• Limited evidence

– Shockwave – Sclerosing injection – PRP – Surgery

Larsson, KSSTA 2012 Rodriguez-Merchan, 2013 J Orthopaed Traumatol Everhart, 2017 Arthroscopy

Overall…

First-line monotherapy

• Strong evidence

– Eccentric training

Second-line therapy

– Surgery: For patients who failed 6 mo. of conservative therapy – Shockwave: Those who failed physical therapy and declined surgery

Adjunct treatment

– PRP: Could accelerate recovery

Corticosteroid therapy is contraindicated!!!

Conservative vs. Surgery (As a first-line therapy)

• Sclerosing polidocanol injection vs. Arthroscopic shaving

(Willberg, BJSM 2011) – Both good clinical results – Surgery less pain, more satisfied

• Eccentric training vs. Open tenotomy

– (Bahr, JBJS-B 2006) – 20 training vs. 20 surgery – 5 failed training →Secondary surgery – Rest of training vs. primary surgery NO difference

Eccentric training should be tried for 12 weeks before surgery is considered!

Surgery (As a second-line therapy)

• Historically…Open surgeries
• Surgical procedures comparison (Kaeding, CORR 2006)

– Inferior patellar pole

• Success rate: 71% resection << 92% no patellar bony work

– Paratenon closure

• Success rate: closure 85% ≒ no closure 91%

– Post-op. immobilization

• Success rate: immobilization 82% < no immobilization 95%

• Arthroscopic management (case series)

(Pascarella, AJSM 2011) – Patients refractory to non-operative management – All arthroscopic surgery

• Debridement of IFP
• Debridement of abnormal patellar tendon
• Excision of the lower patellar pole

– 19 of 27 professional athletes returned to same level – All 64 patients returned to sports by 3 months – Failure rate at 3 years: 9.6%

Surgery (As a second-line therapy)

Arthroscopic treatment may achieve early return to sports, provide significant improvements

Surgery (As a second-line therapy)

• Open vs. Arthroscopic (Brockmeyer, Arthroscopy 2015)

– Success rate: 87% open vs. 91% arthroscopic – Faster return to sports with arthroscopic treatment

Arthroscopic treatment may lead to significantly faster return to sports and may be the preferred method

Surgery: prognostic factors

• Prognostic value on MRI in

arthroscopic treatment

(Ogon, BMC Muscloskelet Disord2017)

a. Bone marrow edema of the inferior patellar pole b. Patellar tendon thickening c. IFP edema d. Infrapatellar bursitis

IFP edema (with or w/o BME) was associated with inferior functional outcome and delayed return to sports

Summary

First-line monotherapy

• Strong evidence

– Eccentric training

• Limited evidence

– Surgery Second-line therapy – Surgery: For patients who failed 6 mo of conservative therapy

• Surgery does work for majority of patients who failed

conservative therapy

• Arthroscopic treatment may lead to significantly faster return to

sports and may be the preferred method

• There may be prognostic factors that worsen clinical outcomes

after surgery

Level 4-5 evidence (My preference)

First-line treatment

• Rehabilitation by physiotherapist

– Focusing on eccentric training

• Adjunct treatment by hyaluronan injection

(Muneta, Koga, J Orthop Sci 2012) – Hyaluronan: easy to perform hyaluronan injection under insurance in Japan (easier than PRP) – Injection between PT and IFP at proximal insertion under US guidance – Injection 2 times on average (range 1-11) – 94% success rate

US findings

Patella PT IFP

Thickening of the patellar tendon Disappearance of fibrillar pattern

Healthy side Patella Patella IFP IFP PT PT

Doppler mode

Patella PT IPFP

Before injection

Long axis Short axis

During injection

Short axis

After injection

Long axis Short axis

Immediate pain reduction

MRI 4 hours after injection

Surgery as a second-line treatment

US guided arthroscopic surgery

Operator：Arthroscopic debridement Assistant：Confirm regions by ultrasound

Arthroscopic surgery with simultaneous visualization by US

Courtesy of Dr. Nakase from Kanazawa Univ. (Willberg, BJSM 2011)

Case

Lt patellar tendinopathy

Case：17 y.o. female Sports：Badminton Failed after 6 months of conservative treatment

Image findings

MRI US: long axis

✓ Patellar tendon thickening & low intensity ✓ Fibrillar pattern disappearance ✓ Increased blood flow ✓ High intensity at proximal PT ✓ IFP edema

Arthroscopy US long axis

US guided arthroscopic surgery

US guided arthroscopic surgery

Weight bearing and ROM ex. permitted 1 day after surgery

Postoperative course

✓Return to preactivity level at 3 months (pain improved but residual pain persisted) ✓Pain totally disappeared at 13 months

Take home messages

• Does surgery work?-
• Limited evidence as a first-line treatment
• It does work as a second-line treatment, for patients who

failed conservative therapy

• Arthroscopic treatment may achieve faster return to

sports than open surgery, provide significant improvements

• Ultrasound-guided arthroscopic surgery may be the

effective surgical procedure

• More evidences needed to verify the benefit of surgery
• In real world… tailor-made treatment is important!