Patellar tendon-related pain is common in the athletic patient. When it occurs in skeletally mature patients participating in running, jumping, or kicking sports, the diagnosis of jumper’s knee patellar tendonitis is usually made. If patellar tendon pain is associated with a mass, the differential diagnosis should be broadened to include crystalline arthropathy.
This article presents a case of a highly athletic 45-year-old man with a history of gout, anterior knee pain, and an enlarging mass in the region of the patellar tendon. Conservative management failed, and an excisional biopsy found it to be an intra-tendinous gouty tophus. To our knowledge, only 1 report exists documenting a patellar tendon mass secondary to gout, and no case report exists documenting this problem in an athlete. The interplay between athletics and gout has not been well described. Despite the long-term protective nature of fitness, transient elevations in uric acid associated with athletic endeavors may contribute acutely to manifestations of gout in some athletes. Resultant intra- or extra-articular pathology may present as, and easily be mistaken for, a sports-related injury. Without appropriate medical management, tophaceous deposition may continue to occur and treatment of the resultant mass may require surgical intervention.
Background: Patellar tendinosis (PT), or "jumper's knee" is a common condition in athletes participating in jumping sports, and is characterised by proximal patellar tendon pain and focal tenderness to palpation. Hypoechoic lesions observed in the proximal patellar tendon associated with the tendinosis are typically described as being a result of degenerative change or "failed healing". We propose a new model for the development of the hypoechoic lesion observed in PT, in which the aetiology is an adaptive response to differential forces within the tendon.
Methods: We assessed the clinical, histopathological, and biomechanical literature surrounding the patellar tendon and integrated this with research into the response of tendons to differential forces.
Results and conclusions: We propose that the hypoechoic lesion commonly described in PT is the result of adaptation or partial adaptation of the proximal patellar tendon to a compressive load. We postulate that the biomechanics of the patellar–patellar tendon interface creates this compressive environment. Secondary failure of the surrounding tensile adapted tendon tissue may result in tissue overload and failure, with resultant stimulation of nociceptors. We believe that this "adaptive model" of patellar tendinosis is consistent with the clinical and histological findings.
Background: A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper's knee (patellar tendinosis).
Methods: In this prospective study, athletes (mean age 25 years) with jumper's knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation.
Results: In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections.
Conclusions: In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper's knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.
Background: The nature of tendon neovascularisation associated with pain over time has not been studied.
Objective: To prospectively study the patellar tendons in elite junior volleyball players.
Methods: The patellar tendons in all students at the Swedish National Centre for high school volleyball were evaluated clinically and by ultrasonography (US) and Power Doppler (PD) sonography.
Results: Altogether 120 patellar tendons were followed for 7 months. At inclusion, jumper's knee was diagnosed clinically in 17 patellar tendons. There were structural changes on US in 14 tendons, in 13 of which PD sonography showed neovascularisation. There were 70 clinically normal tendons with normal US and PD sonography, 24 clinically normal tendons with abnormal US but normal PD sonography, and nine clinically normal tendons with abnormal US and neovascularisation on PD sonography. At 7 month follow up, jumper's knee was diagnosed clinically and by US in 19 patellar tendons, in 17 of which there was neovascularisation. Three of nine clinically normal tendons with structural changes and neovascularisation at inclusion developed jumper's knee. Two of 24 tendons clinically normal at inclusion, with abnormal US but normal PD sonography, developed jumper's knee with abnormal US and neovascularisation on PD sonography. A total of 20 clinically normal tendons with normal US and PD sonography at inclusion developed structural tendon changes and 12 of these also developed neovascularisation.
Conclusions: The clinical diagnosis of jumper's knee is most often associated with neovascularisation in the area with structural tendon changes. The finding of neovessels might indicate a deterioration of the condition.
Background—Palpation is an important clinical test for jumper's knee.
Objectives—To (a) test the reproducibility of palpation tenderness, (b) evaluate the sensitivity and specificity of palpation in subjects with clinical symptoms of jumper's knee, and (c) determine whether tenderness to palpation may serve as a useful screening test for patellar tendinopathy. The yardstick for diagnosis of patellar tendinopathy was ultrasonographic abnormality.
Methods—In 326 junior symptomatic and asymptomatic athletes' tendons, palpation was performed by a single examiner before ultrasonographic examination by a certified ultrasound radiologist. In 58 tendons, palpation was performed twice to test reliability. Tenderness to palpation was scored on a scale from 0 to 3 where 0 represented no pain, and 1, 2, and 3 represented mild, moderate, and severe tenderness respectively.
Results—Patellar tendon palpation was a reliable examination for a single examiner (Pearson r = 0.82). In symptomatic tendons, the positive predictive value of palpation was 68%. As a screening examination in asymptomatic subjects, the positive predictive value of tendon palpation was 36–38%. Moderate and severe palpation tenderness were better predictors of ultrasonographic tendon pathology than absent or mild tenderness (p<0.001). Tender and symptomatic tendons were more likely to have ultrasound abnormality than tenderness alone (p<0.01).
Conclusions—In this age group, palpation is a reliable test but it is not cost effective in detecting patellar tendinopathy in a preparticipation examination. In symptomatic tendons, palpation is a moderately sensitive but not specific test. Mild tenderness in the patellar tendons in asymptomatic jumping athletes should be considered normal.
Key Words: patellar tendon; ultrasound; palpation; reliability; athletes
Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.
Materials and Methods:
Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.
The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.
MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.
Hamstring tendon; medial patellofemoral ligament; patellofemoral instability
Background: Jumper's knee is a common and troublesome condition among senior volleyball players, but its prevalence among elite junior players compared to matched non-sports active controls is not known.
Objective: To clinically, and by sonography, examine the patellar tendons in elite junior volleyball players (15–19 years) at the Swedish National Centre for volleyball and in matched controls.
Methods: The patellar tendons in the 57 students at the Swedish National Centre for high school volleyball and in 55 age, height, and weight matched not regularly sports active controls were evaluated clinically and by grey scale ultrasonography (US) and power Doppler (PD) sonography.
Results: There were no significant differences in mean age, height, and weight between the volleyball players and the controls. In the volleyball group, jumper's knee was diagnosed clinically and by US in 12 patellar tendons (10 male and two female). In 12/12 tendons, PD sonography demonstrated a neovascularisation in the area with structural tendon changes. In another 10 pain free tendons, there were structural tendon changes and neovessels. In the control group, no individual had a clinical diagnosis of jumper's knee. US demonstrated structural tendon changes in 11 tendons, but there was no neovascularisation on PD sonography.
Conclusions: A clinical diagnosis of jumper's knee, together with structural tendon changes and neovascularisation visualised with sonography, was seen among Swedish elite junior volleyball players but not in matched not regularly sports active controls. Structural tendon change alone was seen in 10% of the control tendons.
In the competitive athlete, there are many causes of anterior knee pain, one of which is patellar tendinitis. Repetition of explosive movements can cause microtrauma to the tendon and its insertion, resulting in patellar tendinitis and occasional tearing, either partial or total. Due to its refractory nature, the treatment of this disorder can be quite frustrating to all involved. A 20-year-old collegiate football player with patellar tendinitis was treated conservatively for more than 2 years. Despite aggressive training regimens, including quadriceps stretching, eccentric strengthening, and therapeutic modalities, the athlete was unable to participate at his preinjury level. Physical examination of his knee revealed inflammation and crepitation. Radiographs demonstrated an avulsion fragment from the inferior pole of the patella and magnetic resonance imaging showed cystic degeneration of the tendon. These findings confirmed the diagnosis of chronic patellar tendinitis. The patient underwent surgical debridement of the patellar tendon without complications. His postoperative rehabilitation was divided into three phases: passive range of motion, active strengthening, and sport-specific activities. At 14 weeks post-surgery, the athlete was able to return to his previous level of activity without pain. Follow-up 30 weeks postoperatively revealed no return of symptoms. At 40 weeks postsurgery, the athlete was participating at his preinjury level. This case report demonstrates the successful outcome of the surgical treatment of chronic patellar tendinitis, which was unresponsive to conservative treatment, in a competitive collegiate football player.
A 27-year-old professional martial arts athlete experienced recurrent right knee patellar tendon rupture on three occasions. He underwent two operations for complete patellar tendon rupture: an end-to-end tenorrhaphy the first time, and revision with a bone-patellar-tendon (BPT) allograft. After the third episode, he was referred to our department, where we performed a surgical reconstruction with the use of hamstring pro-patellar tendon, in a figure-of-eight configuration, followed by a careful rehabilitation protocol. Clinical and radiological follow-ups were realized at 1, 3, and 6 months and 1 and 2 years postop, with an accurate physical examination, the use of recognized international outcome scores, and radiograph and MRI studies. As far as we know, this is the first paper to report a re-revision of a patellar tendon rupture.
Patellar tendon rupture; Re-revision surgery; Rehabilitation protocol
Overload syndromes are caused by repetitive microtrauma, and the knee joint is most frequently affected in adolescents. The reason for this is that the knee joint is engaged in almost all sports activities. Pathologies related to the anterior aspect of the knee are: femoropatellar pain, jumper's knee syndromes, Osgood–Schlatter disease, Sinding-Larsen–Johansson syndrome and patellar stress fractures; to the medial aspect: semimembranous tendon enthesopathy and pes anserinus bursitis; to the lateral aspect: iliotibial band syndrome (runner's knee), popliteus and femoral biceps tendon enthesopathy; to the posterior aspect: fabella syndrome and medial gastrocnemius muscle tendon enthesopathy. Sonography plays a central role in the diagnosis and can also evaluate the evolution of diseases. This method is well accepted by the patients and by their parents, it does not involve exposure to X-rays and it is inexpensive. US imaging should, therefore, be considered a first-line imaging diagnostic technique in functional overuse syndromes of the knee.
Sonography; Knee; Overload syndromes
To present the history, surgery, rehabilitation management, and eventual functional and surgical outcomes of a collegiate basketball player with recalcitrant jumper's knee.
A 21-year-old, male collegiate basketball player had a 2-year history of anterior knee pain.
Injuries that often mimic symptoms of infrapatellar tendinitis include infrapatellar fat pad irritation, Hoffa fat pad disease, patellofemoral joint dysfunction, mucoid degeneration of the infrapatellar tendon, and, in preadolescents and adolescents, Sinding-Larsen-Johannsson disease.
After conservative treatment failed to improve his symptoms, the athlete underwent surgical excision of infrapatellar fibrous scar tissue and repair of the infrapatellar tendon.
This patient's case was unique in 3 distinct ways: (1) outcome surveys helped me to understand how this injury affected various aspects of this patient's life and how he viewed himself as he progressed through rehabilitation; (2) a modified functional test was used to help determine whether the athlete was ready to return to sport; and (3) the athlete progressed rapidly through rehabilitation and returned to competitive athletics in 3 months.
This patient was able to return to sport without functional limitations. The surgical outcome was also considered excellent.
jumper's knee; tendinitis; tendinosis; rehabilitation
Jumper's knee patellar tendinopathy is well known to be a common and difficult injury in volleyball. Knowledge about its aetiology and pathogenesis is sparse.
To prospectively follow clinical status, tendon structure and vascularity in elite junior volleyball players.
22 volleyball players (44 patellar tendons) beginning their first grade at the Swedish National Centre for high school volleyball were continuously evaluated clinically and by ultrasonography (US) and power Doppler (PD) over the 3 school years.
At inclusion, there were 44 tendons being assessed. Jumper's knee was diagnosed clinically in eight patellar tendons (seven of eight had structural changes and vascularity on US+PD). There were 27 normal (clinical and US+PD) tendons. At 3 years, there were 36 tendons still being assessed. Four individuals (eight tendons) had been excluded. Jumper's knee had developed in 2 of 25 (2 were excluded) tendons that were normal (clinical and US+PD) at inclusion. Jumper's knee (clinical and US+PD) was also present in six tendons.
Normal clinical tests and ultrasound findings at the start indicated a low risk for these elite junior volleyball players to sustain jumper's knee during three school years with intensive training and playing.
Patellar tendon ossification is a rare pathology that may be seen as a complication after sleeve fractures of the tibial tuberosity, total patellectomy during arthroplasty, intramedullary nailing of tibial fractures, anterior cruciate ligament reconstruction with patellar tendon autograft and knee injury without fracture. However, its occurrence after partial patellectomy surgery has never been reported in the literature.
We present the case of a 35-year-old Turkish man with a comminuted inferior patellar pole fracture that was treated with partial patellectomy. During the follow-up period, his patellar tendon healed with ossification and then ruptured from the inferior attachment to the tibial tubercle. The ossification was excised and the tendon was subsequently repaired.
To the best of our knowledge, this is the first report of patellar tendon ossification occurring after partial patellectomy. Orthopaedic surgeons are thus cautioned to be conscious of this rare complication after partial patellectomy.
A retrospective study was made of 270 patients and 284 knees with acute patellar dislocation treated operatively. The mean follow up time was 4.1 years. Medical history revealed 21.1% of cases with previous dislocations and 15.6% of cases with family occurrence of patellar dislocation. The dislocation resulted from an athletic performance in 41.5% of cases. The sport events most often associated with patellar dislocation were soccer, gymnastics, and ice hockey. All cases were treated with reefing of medial capsule. Release of lateral patellar retinacula was performed in 243 cases. Two cases were treated primarily with the Elmslie-Roux-Trillat procedure. The subjective result of operative treatment was better and the redislocation rate was lower if the injury mechanism was traumatic rather than non-traumatic and if there was no history for family occurrence of patellar dislocation.
Patellar tendinopathy is a major problem for many athletes, especially those involved in jumping activities. Despite its frequency and negative impact on athletic careers, no evidence-based guidelines for management of this overuse injury exist. Since functional outcomes of conservative and surgical treatments remain suboptimal, new diagnostic and therapeutic strategies have to be developed and evaluated.
Extracorporeal shockwave therapy (ESWT) appears to be a promising treatment in patients with chronic patellar tendinopathy. ESWT is most often applied after the known conservative treatments have failed. However, its effectiveness as primary therapy has not been studied in athletes who keep playing sports despite having patellar tendon pain.
The aim of this study is to determine the effectiveness of ESWT in athletes with patellar tendinopathy who are still in training and competition.
The TOPGAME-study (Tendinopathy of Patella Groningen Amsterdam Maastricht ESWT) is a multicentre two-armed randomised controlled trial with blinded participants and outcome assessors, in which the effectiveness of patient-guided focussed ESWT treatment (compared to placebo ESWT) on pain reduction and recovery of function in athletes with patellar tendinopathy will be investigated. Participants are volleyball, handball and basketball players with symptoms of patellar tendinopathy for a minimum of 3 to a maximum duration of 12 months who are still able to train and compete. The intervention group receives three patient-guided focussed medium-energy density ESWT treatments without local anaesthesia at a weekly interval in the first half of the competition. The control group receives placebo treatment. The follow-up measurements take place 1, 12 and 22 weeks after the final ESWT or placebo treatment, when athletes are still in competition. Primary outcome measure is the VISA-P (Victorian Institute of Sport Assessment - patella) score. Data with regard to pain during function tests (jump tests and single-leg decline squat) and ultrasound characteristics are also collected. During the follow-up period participants also register pain, symptoms, sports participation, side effects of treatment and additional medical consumption in an internet-based diary.
The TOPGAME-study is the first RCT to study the effectiveness of patient-guided ESWT in athletes with patellar tendinopathy who are still in training and competition.
Trial registration number NTR1408.
To the best of our knowledge there is no other report of an elderly patient who was surgically treated for a patellar fracture with tension band wiring and who subsequently suffered from an avulsion fracture of the tibial tuberosity. The combination of a patellar fracture and avulsion of the patellar ligament has only been described as complication after bone-patellar tendon-bone anterior cruciate ligament reconstructions. However, due to demographic changes and more elderly patients treated this injury may become more frequent in future.
We present the case of an 81 year old female who sustained an oblique patellar fracture after a direct contact injury of the left knee when falling on ice. Consequently the patellar fracture was openly reduced and stabilized with tension band wiring. The follow-up was uneventful till three months after surgery when the patient noticed a spontaneous avulsion fracture of the tibial tuberosity (Ogden type 3). The tibial tuberosity fragment was reattached with two non-resorbable sutures looped around two modified AO cortical 3.5 mm long neck screws. Intraoperatively multiple bone cysts were seen. Biopsies were not taken to prevent further fragmentation of the tibial tuberosity. The patient was followed up with anteroposterior and lateral full weight bearing radiographs and clinical assessment at 6, 12 weeks and 6 months after surgery. Recovery was completely pain free with full satisfaction.
In conclusion in elderly patients with a patella fracture a possible associated but not obvious fracture of the tibial tuberosity should be ruled out and the postoperative rehabilitation protocol after tension band wiring of the patella might have to be individually adjusted to bone quality and course of the fracture.
Patellar tendinopathy is a common source of pain in athletes, especially those involved in sports with a high incidence of jumping and cutting. Changes in training programs and exercises based on eccentric quadriceps contractions often relieve patients’ symptoms. For athletes unresponsive to this treatment, some authors suggest open and arthroscopic procedures débriding either the tendon alone, or the tendon and bone.
We asked whether an arthroscopically assisted approach to débride not only the tendon, bone, but also the peritenon could relieve pain and allow athletes to return to their former activities.
Patients and Methods
We retrospectively reviewed 23 patients with a history of at least 6 months of painful patellar tendinopathy unresponsive to nonoperative treatment treated with an arthroscopic technique that débrided the tendon, inferior pole of the patella, and peritenon: 22 males and one female. Mean age was 29 years. Patients were evaluated using the anterior knee pain score of Kujala et al. The minimum followup was 12 months (mean, 58 months; range, 12–121 months).
Twelve patients scored 100, one 99, one 98, five 97, two 94, one 90, and one 64. The Kujala et al. mean score was 96 (range, 64–100). All but four patients returned to their former sports activities. We observed no complications.
Arthroscopic treatment can relieve the pain of refractory chronic patellar tendinopathy. Our observations were comparable with those previously reported for open techniques and a high percentage of patients returned to their previous activity level.
Level of Evidence
Level IV, observational study. See Guidelines for Authors for a complete description of levels of evidence.
The impetus for the use of patellar straps in the treatment of patellar tendinopathy has largely been based on empirical evidence and not on any mechanistic rationale. A computational model suggests that patellar tendinopathy may be a result of high localized tendon strains that occur at smaller patella–patellar tendon angles (PPTAs).
Infrapatellar straps will decrease the mean localized computational strain in the area of the patellar tendon commonly involved in jumper’s knee by increasing the PPTA.
Controlled laboratory study.
Twenty adult males had lateral weightbearing and nonweightbearing radiographs of their knees taken with and without 1 of 2 infrapatellar straps at 60° of knee flexion. Morphologic measurements of PPTA and patellar tendon length with and without the straps were used as input data into a previously described computational model to calculate average and maximum strain at the common location of the jumper’s knee lesion during a simulated jump landing.
The infrapatellar bands decreased the predicted localized strain (average and maximum) in the majority of participants by increasing PPTA and/or decreasing patellar tendon length. When both PPTA and patellar tendon length were altered by the straps, there was a strong and significant correlation with the change in predicted average localized strain with both straps.
Infrapatellar straps may limit excessive patella tendon strain at the site of the jumper’s knee lesion by increasing PPTA and decreasing patellar tendon length rather than by correcting some inherent anatomic or functional abnormality in the extensor apparatus.
The use of infrapatellar straps may help prevent excessive localized tendon strains at the site of the jumper’s knee lesion during a jump landing.
infrapatellar straps; patellar tendon strain; patellar tendinopathy; patella–patellar tendon angle; computational model
Localized forms of giant cell tumors are defined as giant cell tumors of the tendon sheath (GCTTS). GCTTS arises from the synovium of a joint, bursa or tendon sheath, and 85% of the tumors occur in the fingers. GCTTS in the knee is extremely rare. We report an unusual case of a 15-year-old boy who presented with an occult growing swelling and a 2-month history of infra-patellar pain in the left knee. Magnetic resonance imaging (MRI) demonstrated a well-circumscribed soft tissue mass in the infra-patellar fat pad posterior to the patella tendon. Excision biopsy was performed by surgical removal. Histopathological examination revealed that it was GCTTS. During the follow-up period, his recovery was propitious and there was no recurrence. Owing to its few and non-specific symptoms, and local recurrence varying from 9 to 44%, its proper, early diagnosis and appropriate treatment is necessary. The purpose for which we report the case is to emphasize the possibility of GCTTS where there is a mass with non-specific symptoms such as infra-patellar pain of the knee, and to avoid misdiagnosis where possible.
giant cell tumor; knee; tendon sheath; diagnosis; histopathology; magnetic resonance imaging
Patellar tendinopathy is characterized by activity-related anterior knee pain. It is most commonly related to sports activity, but has also been reported in the non-athletic population. Most injuries are caused by microtrauma, resulting in tendinitis or tendinosis. Extraskeletal paraarticular osteochondromas, which occur in the soft tissues near the joint, are rare. The infrapatellar fat pad and joint capsule are the most common sites of these tumors. Here, a case of patellar tendinitis caused by an extraskeletal paraarticular osteochondroma is reported. The symptoms included intensifying pain upon flexion and a palpable click that was located at the medial side of the mass. The patient was pain-free within 3 weeks after excision of the tumor and the clicking disappeared. To our best knowledge, no other case of patellar tendinitis caused by an extraskeletal paraarticular osteochondroma has been reported in the English literature.
The surgical technique, medial patellar retinaculum plasty, can almost restore both static and dynamic stability and verge on anatomical repair for the treatment of habitual patellar dislocation in adolescents.
In accordance with the injury patterns of the medial patellar retinaculum through knee MRI, we repaired different injury sites with this surgical procedure. We reviewed this technique in 16 patients with an average age of 15 years. Retrospective review of charts and radiographs immediately after the surgery up to the latest follow-up (range 12–36 months) was undertaken.
All patients were evaluated clinically and radiologically over an average of 20.7 months. The recovery of knee mobility results were good. No recurrence of patellar instability has been found.
We think this could be a valid technique to treat habitual patellar dislocation in adolescents.
The aim of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy after previous classical treatments have failed. We treated 15 patients affected by chronic jumper’s knee, who had failed previous nonsurgical or surgical treatments, with multiple PRP injections and physiotherapy. We also compared the clinical outcome with a homogeneous group of 16 patients primarily treated exclusively with the physiotherapy approach. Multiple PRP injections were performed on three occasions two weeks apart into the site of patellar tendinopathy. Tegner, EQ VAS and pain level were used for clinical evaluation before, at the end of the treatment and at six months follow-up. Complications, functional recovery and patient satisfaction were also recorded. A statistically significant improvement in all scores was observed at the end of the PRP injections in patients with chronic refractory patellar tendinopathy and a further improvement was noted at six months, after physiotherapy was added. Moreover, comparable results were obtained with respect to the less severe cases in the EQ VAS score and pain level evaluation, as in time to recover and patient satisfaction, with an even higher improvement in the sport activity level achieved in the PRP group. The clinical results are encouraging, indicating that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.
A new reconstruction of the patellar tendon was performed in a 43-year-old patient who lost tendon and tibial tuberosity after a wide tumor resection for low-grade myofibroblastic sarcoma of the parapatellar tendon. In this technique, the patellar tendon was anatomically reconstructed using a fascia lata attached to the iliac bone. The iliac bone was fixed to the tibial bony trough with absorbable screws, and the fascia lata was fashioned into three branches: the central branch was folded through the tunnel in the patella, and the medial and lateral branches were tagged to the medial and lateral retinaculum, respectively, around the patella. The skin defect was covered by the bilateral head of the gastrocnemius flap and a split-thickness skin graft. At the 3-year follow-up, the active range of motion of the knee joint was 0 to 110 degrees. The functional result according to the Musculoskeletal Tumor Society scoring system was 97%. Radiographs showed that the grafted bone was united well to the tibial bone, and the grafted fascia was confirmed as a dark band on MRI. There was no evidence of disease and no complaint of the donor site. This procedure allows for the reconstruction of the patellar tendon in the original location. To our knowledge, this reconstructive procedure of the patellar tendon using the fascia lata attached to the iliac bone has never been reported in English literature.
Fascia lata; patellar tendon; reconstruction; soft tissue sarcoma
The Sinding-Larsen-Johansson syndrome has a pathogenesis similar to that of the Osgood-Schlatter disorder and is the result of excessive force exerted by the patellar tendon on the lower pole of the patella. Clinically it is characterized by pain, which increases when the patellar is loaded during flexion, subpatellar swelling and functional limitation. The authors present a case of a 13-year-old boy who was a competitive youth team football player. He presented with anterior, spontaneous knee pain and swelling at the inferior pole of the patella. Ultrasonography (US) confirmed clinical diagnosis showing lesions typical of the Sinding-Larsen-Johansson syndrome. The patient was told to refrain from sports activity; after five months recovery was complete and US follow-up revealed no anomaly. The authors consider the case worthy of reporting because it is paradigmatic and to emphasize the role of US in the evaluation of the Sinding-Larsen-Johansson syndrome.
Sinding-Larsen-Johansson syndrome; Knee; Ultrasound
Total knee arthroplasty is a well-established procedure with gratifying results. There is no consensus in the literature whether to routinely resurface the patella while performing total knee arthroplasty or not. Although an extremely rare occurrence in clinical practice, patellar prosthesis dislocation is a possible complication resulting from total knee arthroplasty.
We report a rare case of atraumatic spontaneous dislocation of patellar prosthesis in a 63-year-old Caucasian man of British origin with patellar tendon injury. The patient was treated successfully through a revision of the patellar component and tendon repair. In two years follow-up the patient is asymptomatic with no sign of loosening of his patellar prosthesis.
A thorough understanding of knee biomechanics is imperative in performing total knee arthroplasty in order to achieve a better functional outcome and to prevent early prosthetic failure.