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Mohd Azizan Bin Abdullah

C11107372

Surgical Orthopedic


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Abstract Background Patellar tendinopathy (PT) presents a

challenge to orthopaedic surgeons. The purpose of

this review is to revise strategies for treatment ofPT

Materials and methods A PubMed (MEDLINE)search of the years 20022012 was performed using

patellar tendinopathy and treatment askeywords.


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Results Conservative treatment includes

therapeutic exercises (eccentric training),extracorporeal shock wave therapy (ESWT),and different injection treatments

(plateletrich plasma, sclerosing polidocanol,steroids, aprotinin,autologous skin-derivedtendon-like cells, and bone marrow

mononuclear cells).


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Abstract ConclusionPhysical training, and particularly eccentric

training, appears to be the treatment of

choice. The literature does not clarify which

surgical technique is more effective in

recalcitrant cases. Therefore, both open surgical techniques

and arthroscopic techniques can be used.


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Introduction There is agreement within the literature that the

patellar tendon is particularly vulnerable to injury

and often difficult to manage successfully. The pathological process of patellar tendinopathy

(PT) includes various aspects.

Inflammation was believed central to the

pathologic process, but histopathologic evidencehas confirmed the failed healing response natureof these conditions.


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the location of the lesion (for example, themidtendon or osteotendinous junction) hasbecome increasingly recognized asinfluencing both the pathologic process and

subsequent management.


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Materials and MethodsPubMed articles (MEDLINE) in English

related to the treatment of PT were

searched, using patellar tendinopathy andtreatment as key words.

Between 2002 and 2012, we found 186

references. We chose the 22 references thathad the higher level of evidence and thatwere closely related to the treatment of PT.


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Results There are several strategies for the management of

PT: therapeutic exercises, extracorporeal shock

wave therapy (ESWT), injections, open surgicalprocedures and arthroscopic techniques.

It is commonly accepted that surgical treatmentmust be indicated in motivated patients if

carefully followed conservative treatment (physicaltraining, injections, ESWT) is unsuccessful after 36 months .


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Therapeutic exercisesHyman studied showed that conservative

treatment was very effective using an

eccentric exercise regimen and declinesquats.

Physical training, and particularly eccentric

training, has been reported to be thetreatment of choice for patients sufferingfrom PT .


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Extracorporeal shockwave therapy ESWT appears to be a promising treatment in

patients with chronic PT.

ESWT is most often applied after the eccentrictraining has failed.

Zwerver et al studied the effectiveness of ESWT inathletes with PT who were still in training and

competition The only benefit found was a subjective

improvement.

Other objective parameters did not improve.


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Injection treatments Injection treatments are increasingly used as

treatment for PT.

Van Ark et al described different injection treatments:platelet-rich plasma (PRP), sclerosing polidocanol,steroids and aprotinin.

All the different injection treatments seem promising

for treating PT. Unlike the other injection treatments, steroid

treatment often showed a relapse of symptoms in thelong term.


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Ultrasound-guided injection of autologous

skin-derived tendon-like cells has beenshow to be more effective than plasma alonefor the treatment of refractory PT .

Pascual-Garrido et al tried to determine ifpatients with chronic PT will improveclinically after the inoculation of bone

marrow mononuclear cells (BM-MNCs).


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BM-MNCs were harvested from the iliac bone crest

and inoculated under ultrasound guide in thepatellar tendon lesion.

Improvement was assessed through established

clinical scores and ultrasound. Inoculation of BM-MNCs could be considered as a

potential therapy for those patients with chronicPT refractory to nonoperative treatments.


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Open surgical treatment Ferreti et al analyzed the results at a minimum of 5

years after the performance of a surgical technique

in competitive athletes. Thirty-two patients affected by PT were treated

surgically after failure of nonoperative treatment.

Surgical technique: longitudinal splitting of the

tendon, excision of any abnormal tissue that wasidentified, and resection and drilling of theinferior pole of the patella.


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The result was excellent in twenty-threeknees (70 %), good in five, fair in one, andpoor in four at the time of the long-termfollow-up.

Overall, tendonectomy, surgical tendonstimulation, and aggressive postoperativerehabilitation were found to be a safe,

effective way to return high-level athletes totheir sports.


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Arthroscopic treatmentArthroscopic shaving targeting the area with

neovessels and nerves on the dorsal side of

the patellar tendon has a potential to reducethe tendon pain and allow for the majorityof patients to go back to full tendon loading

activity within 2 months after surgery.


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Ogon et al described an arthroscopic technique for the

treatment of chronic PT. Diagnostic arthroscopy was performed and

hypertrophic synovitis around the inferior patellarpole was removed with a bipolar cautery system.

The bipolar cautery was used for a release of thparatenon and a bone denervation at the inferiorpatellar pole including the tendon insertion site withinthe marked area.

No tendon or bone material was removed or excisedthroughout the procedure.


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Lorbach et al performed a prospective study to

evaluate the clinical results of arthroscopicresection of the lower patellar pole in patients withPT.

The main conclusion was that arthroscopicresection of the lower patellar pole as a minimalinvasive method to treat PT provides satisfactoryclinical results in knee function and pain

reduction with fast recovery and return to sportactivities.


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Comparative studies

Surgery versus eccentric training Surgical treatment (patellar tenotomy) was

compared with eccentric training by Bahr et al.

No advantage was demonstrated for surgicaltreatment compared with eccentric strengthtraining.

They stated that eccentric training should be tried

for 12 weeks before open tenotomy is consideredfor the treatment of PT.


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Sclerosing polidocanol injections

versus arthroscopyPatients treated with arthroscopic shaving

had a significantly lower visual analogue

score (VAS) score at rest and during activity,and were significantly more satisfiedcompared with the patients in the sclerosing

injection group.


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Open surgery versus arthroscopic

surgerySurgical treatment is indicated in motivated

athletes if carefully followed conservative

treatment is unsuccessful after more than 6months, making it impossible to practice asport.

Arthroscopic techniques seemed to be aseffective as open surgery, with an equivalentdelay for beginning sports activities.


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DiscussionPT is a common, painful, overuse disorder.Although many different treatment

methods have been described, there is noconsensus regarding the optimal treatmentfor this condition.

Eccentric training should be tried for 12weeks before open tenotomy is consideredfor the treatment of PT.


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Both sclerosing polidocanol injections and

arthroscopic shaving have shown good clinicalresults, but patients treated with arthroscopicshaving had less pain and were more satisfied withthe treatment result

Commonly accepted that surgical treatment mustbe indicated in motivated patients if carefullyfollowed conservative treatment (physical training,

injections, ESWT) is unsuccessful after 36months.


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The literature, however, does not clarifywhich surgical technique is more effective.Therefore, both open surgical techniquesand arthroscopic techniques can be used.

Physical training, and particularly eccentrictraining, appears to be the treatment ofchoice for patients suffering from PT.


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