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Open patella tendon decompression

    Overview

    Learn the Open patella tendon decompression surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open patella tendon decompression surgical procedure.
    Patellar tendinopathy is a common condition that is, in the most part, self-limiting. Sometimes described as “jumper’s knee” it is seen in long and high jumpers, who repeatedly load the patellar tendon (PT) eccentrically during take-off. However it is not limited to this group of athletes, and in my practice I often see rugby players, basketball and netball players who suffer the same condition.
    Surgical decompression of patellar tendinopathy is rarely indicated, because most cases resolve with conservative management, though is entirely appropriate for managing recalcitrant cases. Tendinopathies as an entity are still not fully understood despite comprehensive published research in the field. They can be a debilitating condition in any tendon so afflicted and most commonly the elbow, knee, ankle and foot are.
    Recent theories on aetiology are that the tendon becomes “trapped” in a phase of degenerative damage and repair. This is supported by histological studies which show both degenerative tissue and also inflammatory tissue, making it therefore neither tendonitis nor tendinosis and most aptly called tendinopathy.
    This case involves a 23 year old semi-professional rugby player who had a previous successful decompression on the opposite side 2 years previously and had failed conservative management on the side in question. Investigations demonstrated a thickened proximal 1/3 of the tendon. No osteophyte was found effecting the inferior pole of the patella. However, this is a common finding and will need excision at the time of surgery.

    Indications

    Indications
    The overriding indication for decompression is recalcitrant pain that fails to respond to conservative treatments.
    History
    Pain limited to the proximal PT after loading activity in particular sport or descending slopes. Frequently this is the following day after the activity. Pain is described as a dull ache or occasionally a burning neuropathic pain (this may be fat pad radiated pain which is rich in sensory nerve endings). The pain crescendoes with increasing activity rather than an acute pain.
    Examination
    Point tenderness distal to the inferior pole of the patella in the proximal tendon is sought with the knee in both flexion and extension. As the tendinopathy effects the deep fibres of the patella tendon it is imperative to relax the superficial fibres. This provocative test is achieved by comparing the pain when pressing on the tendon when the knee is flexed (superficial fibres taut due to quads contraction) and in full extension when the quads are relaxed and superficial tendon fibres are relaxed. Pain is therefore greatest when the knee is in extension with a patella tendinopathy. This is a highly reproducible test with a positive predictive value of over 68% is described with similar tests by amongst others Cook et al (Cook JL, Khan KM, Kiss ZS, et al. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. British Journal of Sports Medicine 2001;35:65-69.).
    A thorough knee examination is required to exclude other causes of pain.
    Investigations
    Plain radiographs – Useful to easily identify inferior pole of patella osteophytes
    Ultrasound (including doppler) – user dependent but can be very useful as an adjunct to high volume injections (see below). Doppler imaging may show high vascularity of the underlying fat pad.
    MRI – mainstay of the investigation as this can aid the surgeon to pin-point the area effected. One of the main additional advantages of MRI over ultrasound is a the ability to uncover any concomitant injuries or damage such as retropatellar chondral damage that may present with similar symptoms.
    A recent study in Germany suggested that the pre-operative existence of tendinous oedema with or without inferior patellar pole bone oedema may be a poor prognostic factor in return to sport post-surgical decompression. (Ogen et al.)
    Management
    Conservative
    Physiotherapy : A stretching and eccentric loading program is most often advocated.
    Ultrasound guided high volume saline injection : The objective isto strip the fat pad off the proximal tendon. The theory is that this reverses the inflammatory pathological neovasculaisation seen on doppler investigations and prompt healing.
    Extra-corporeal shockwave therapy : This has been described as a safe mode of treatment but the evidence for its effectiveness is limited.
    Platelet-rich plasma (PRP) injections : A recent randomised controlled study published in the American Journal of Sports Medicine (Scott et al) showed no benefit in the use of PRP (leucocyte-rich and leukocyte-poor) versus normal saline injections.
    Surgical alternatives
    Arthroscopic decompression : This involves removing the overlying fat pad and deep fibres of the PT. The fat pad is a highly sensitive structure and it is my preference to avoid overly excising or interfering with the fat pad if possible, hence my use of the open procedure. Furthermore I prefer to have a direct view of the depth of resected tissue to avoid the rare but potentially disasterous risk of damaging healthy patellar tendon and subsequent rupture from over-excision.

    Setup

    High thigh tourniquet
    Side support
    Standard dissection equipment (15 blade)
    Small nibbler

    Operation

    The most helpful view is the fat-suppressed sagittal view of the knee. Note the difference between point A where the tendon is normal distally versus point B where the tendon is thickened and more grey in colour.

    The proximal diseased tendon is 8.33mm thick versus the normal 3.45mm thick tendon distally.
    Note that the lack of inferior pole bone oedema and limited oedema in the deep tendon-fat pad interface would be a good prognostic factor for surgical treatment.

    The patient is positioned supine on the operating table with the knee held in 90 flexion with the aid of a side support against the thigh and a sandbag.

    The patient is positioned supine on the operating table with the knee held in 90 flexion with the aid of a side support against the thigh and a sandbag.

    The patellar tendon is marked out on its medial and lateral border. In addition the outline of the patella and the tibial tuberosity are delineated.The knee is prepared with alcoholic skin preparation and draped.

    Make a longitudinal skin incision over the lateral third of the patella tendon, to reduce the chance of catching the infrapatellar branch of the saphenous nerve as it tracks across the tendon.This reduces the risk of a numb patch over the front of the knee, which can produce discomfort during kneeling.
    Beginning at the inferior border of the patella continue distally for 5-7 cm, parallel with the lateral border.

    The fat layer is dissected with some fine scissors to expose the paratenon.Superficial dissection down through the fat layer reveals the paratenon. This is an opaque thin layer immediately overlying the tendon.
    A – patella
    B – tibial tuberosity

    Incise the paratenon with a knife and using toothed forceps lift the paratenon off the underlying patella tendon.It is elevated with a fine toothed forcep and incised in line with the skin incision, revealing the shiny longitudinal fibres of the tendon beneath.
    As the paratenon incision is inline with the tendon there is minimal risk of damaging the underlying fibres. In my experience the paratenon is uneffected in these cases, which differs from Achilles tendinopathy where the paratenon is reportedly thickened and adherent.

    Once the paratenon is incised it is peeled back gently with a combination of traction and knife dissection to elevate it off the underlying tendon.The paratenon is 1-2mm thick and helpful to preserve so as to close at the end of the procedure. It acts to reduce the friction of the tendon on the overlying subdermal layers.
    The self-retainer can be used to hold the paratenon open revealing the longitudinal fibres of the underlying tendon.

    Digital palpation is used to identify the attachment of the tendon into the inferior pole of the patella, and hence the starting point of the incision.The area immediately distal to the hard patellar pole is the area in which the deep fibres become diseased.

    A longitudinal full thickness incision is made in the tendon commencing at the inferior pole of the patella.The length of the incision is individual on a case-by-case basis. The intention of the incision is to be able to fully access the diseased deep fibres for excision. As a general guide the length of the incision would be twice the depth of the diseased tissue:
    healthy tendon is 3-5mm thick
    diseased tendon is often >2x as thick as healthy tissue – up to 10mm
    length of incision up to 20mm but variable
    I continually check access to the deep tissue to ensure that the incision is not excessively long. In this case the incision is 16mm with the diseased tendon being 8.33mm thick.

    The incision is continued distally for the extent of the diseased tissueThere is no major risk in extending the incision distally as the tendon is merely split rather than cut.
    However unnecessary bleeding and hence scarring of the underlying fat pad can lead to retraction and therefore I limit the incision to only what is required to gain adequate access to the deep diseased fibres for their eventual excision.

    The deep tissue is palpated with fine forceps to identify the diseased tissueHealthy tendon is smooth and shiny. The diseased tissue and therefore the surgical target is course and haphazard. Often the surgeon feels the crunchy tissue as the tip of the 15 blade goes through to the deeper layers on the splitting incision.
    Retraction of the superficial fibres with handheld Langenbeck retractors allows the surgeon to palpate the deep tissue with the tips of the forceps or a Mcdonald, revealing the extent of the pathological fibres for excision.

    Diseased tendon tissue is excisedOnce identified, the pathological tissue can be excised using a small nibbler or sharp dissection using a 15 blade, protecting the healthy tissue with the retractors.
    I prefer to use the handheld retractors rather than a self-retainer so that the assistant can follow the blade or nibbler and therefore protect the healthy tissue.

    The excised tissue is inspected on the table
    The diseased tissue is thick, white and opaque rather than the healthy shiny tendon. The yellow tissue is the adjacent fat pad.

    Finger palpation is used to ensure complete excision of diseased tissueI find that the easiest way to check that all of the tissue has been removed is to use my finger. Remove the retractors for easier access.

    The edges of healthy superficial tissue are retracted to allow visual inspection of the deep fibresA visual check of the deep fibres also helps clear any residual diseased tissue.
    The ideal view is homogenous healthy tissue from superficial to deep and a clear view of the underlying fat pad.
    A – some residual diseased tissue
    B – healthy tendon
    C – fat pad – hypervascularity is common in this disease state

    Retractors are removed to approximate the superficial fibresClearance is confirmed as far as possible before removing the retractors allowing the tendon fibres to reapproximate.

    Paratenon is closed with 2/0 vicrylThe tendon itself does not require closure but this is an individual decision.

    2/0 undyed vicryl is used for closure of subcutaneous tissueSubcutaneous 2/0 vicryl (undyed) suture

    3/0 nylon suture is used to close the skinSkin closure should be interrupted as a continuous suture may gape as the knee goes through its range of motion.

    0.7% ropivacaine is infiltrated around the wound and deep into the tendon / fat pad.

    Opsite and wool and crepe is used to dress the knee

    Post Operative

    Patient can fully weight bear as pain allows. Often crutches are used to aid mobility in the early stages.
    Closed chain light load exercises can commence immediately.
    Open chain loading is avoided for 6 weeks post op.
    Sutures are removed at 14 days post-op.

    Recommended Reading

    Patellar tendinopathy can be successfully treated with conservative measures, including targetted physiotherapy in up to 90% of patients .
    Van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, Rio E. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19:702–6.)
    Recalcitrant cases however have a good response to open and arthroscopic decompression with the literature describing success of 70-80% with long term results:
    Ferretti A, Conteduca F, Camerucci E, Morelli F. Patellar tendinosis: a follow- up study of surgical treatment. J Bone Joint Surg Am. 2002;84-A:2179–85.
    Ferretti A, Conteduca F, Camerucci E, Morelli F. Patellar tendinosis: a follow- up study of surgical treatment. J Bone Joint Surg Am. 2002;84-A:2179–85.
    Maffulli N, Oliva F, Maffulli G, King JB, Del Buono A. Surgery for unilateral and bilateral patellar tendinopathy: a seven year comparative study. Int Orthop. 2014;38:1717–22.
    Pascarella A, Alam M, Pascarella F, Latte C, Di Salvatore MG, Maffulli N. Arthroscopic management of chronic patellar tendinopathy. Am J Sports Med. 2011;39:1975–83.
    A recent article by Lang et al suggested that rates of success are higher in younger athletes:
    Lang G, Pestka J, Maier D, Izadpanah K, Südkamp N, Ogon P. Arthroscopic patellar release for treatment
    of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population. BMC Musculoskeletal Disorders (2017) 18:486
    MRI and clinical study, from the same group, suggesting tendon and bone marrow oedema of the inferior pole of patellar in chronic cases have a poorer response to arhtroscopic decompression and return to sport:
    Ogon P, Izadpanah K, Eberbach H, Lang G, Südkamp NP, Maier D Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord. 2017 Apr 4;18(1):146.
    PRP no more effective than normal saline injections according to this randomised controlled trial:
    Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019 Jun;47(7):1654-1661.
    Pascarella A, Alam M, Pascarella F, Latte C, Di Salvatore MG, Maffulli N. Arthroscopic management of chronic patellar tendinopathy. Am J Sports Med. 2011;39:1975–83.
    A recent article by Lang et al suggested that rates of success are higher in younger athletes:
    Lang G, Pestka J, Maier D, Izadpanah K, Südkamp N, Ogon P. Arthroscopic patellar release for treatment
    of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population. BMC Musculoskeletal Disorders (2017) 18:486
    MRI and clinical study, from the same group, suggesting tendon and bone marrow oedema of the inferior pole of patellar in chronic cases have a poorer response to arhtroscopic decompression and return to sport:
    Ogon P, Izadpanah K, Eberbach H, Lang G, Südkamp NP, Maier D Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord. 2017 Apr 4;18(1):146.
    PRP no more effective than normal saline injections according to this randomised controlled trial:
    Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019 Jun;47(7):1654-1661.
    Lang G, Pestka J, Maier D, Izadpanah K, Südkamp N, Ogon P. Arthroscopic patellar release for treatment
    of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population. BMC Musculoskeletal Disorders (2017) 18:486
    MRI and clinical study, from the same group, suggesting tendon and bone marrow oedema of the inferior pole of patellar in chronic cases have a poorer response to arhtroscopic decompression and return to sport:
    Ogon P, Izadpanah K, Eberbach H, Lang G, Südkamp NP, Maier D Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord. 2017 Apr 4;18(1):146.
    PRP no more effective than normal saline injections according to this randomised controlled trial:
    Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019 Jun;47(7):1654-1661.
    MRI and clinical study, from the same group, suggesting tendon and bone marrow oedema of the inferior pole of patellar in chronic cases have a poorer response to arhtroscopic decompression and return to sport:
    Ogon P, Izadpanah K, Eberbach H, Lang G, Südkamp NP, Maier D Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord. 2017 Apr 4;18(1):146.
    PRP no more effective than normal saline injections according to this randomised controlled trial:
    Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019 Jun;47(7):1654-1661.

    Reference

    • orthoracle.com

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