Lotta Willberg

Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee? A randomised controlled study

Background Proximal patellar tendinopathy/jumpers knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon, sclerosing polidocanol injections and ultrasound-guided arthroscopic shaving, have shown promising clinical results. Objectives To compare the clinical effects after treatment with sclerosing polidocanol injections and arthroscopic shaving. Material and methods 52 patellar tendons (43 men and two women) with ultrasound and colour Doppler-verified diagnosis of PT/JK were randomly assigned to treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections (group A) or ultrasound and colour Doppler-guided arthroscopic shaving (group B). All patients were involved in patellar tendon loading sports or recreational activities, and had had a long duration of pain symptoms from the proximal patellar tendon. Pain during patellar tendon loading activity, and at rest, before and after treatment (visual analogue scale; VAS), and patient satisfaction with the result of the treatment, was registered. Results After treatment, the patients treated with arthroscopic shaving had a significantly lower VAS score at rest and during activity, and were significantly more satisfied compared with the patients in the sclerosing injection group. Conclusions Both treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections and arthroscopic shaving showed good clinical results, but patients treated with arthroscopic shaving had less pain and were more satisfied with the treatment result. Because surgical treatment is a one-stage treatment return to sports was faster in this group.

Postoperative Septic Arthritis After Anterior Cruciate Ligament Reconstruction: Does It Affect the Outcome? A Retrospective Controlled Study

PURPOSE To determine whether the outcome after septic arthritis after anterior cruciate ligament reconstruction (ACLR) is inferior compared with uncomplicated ACLR when treated promptly by use of a standard protocol. METHODS At Capio Artro Clinic, 4,384 primary ACLRs were performed during 2001-2009. All patients with postoperative septic arthritis were retrospectively reviewed, and 43 met the inclusion criteria. Twenty-seven patients agreed to re-examination (infection group) and were compared with 27 matched patients with uncomplicated ACLR (control group). The mean follow-up period was 60 months and 66 months in the infection group and control group, respectively. Re-examination included objective (radiographs, physical examination, functional testing, range of motion, strength, stability, International Knee Documentation Committee questionnaire) and subjective (Knee Injury and Osteoarthritis Outcome Score, Tegner score, Lysholm score, European Quality of Life-5 Dimensions, subjective satisfaction questions, Single Assessment Numeric Evaluation of knee function, visual analog scale pain rating) evaluation. RESULTS There were no significant differences in objective knee function between the groups at follow-up. For subjective knee function, no significant differences between the groups were detected with the Single Assessment Numeric Evaluation score, pain during activity, or Lysholm score. The infection group scored lower on 4 of 5 Knee Injury and Osteoarthritis Outcome Score subscales: pain (P = .014), function in daily living (P = .008), sports/recreation (P = .015), and quality of life (P = .007). The infection group scored lower versus control patients on the Tegner score (P = .001) and European Quality of Life-5 Dimensions scores (P = .004). Both groups improved over time, but the control group scored better only on the Tegner score (P = .004). CONCLUSIONS Septic arthritis after ACLR did not result in inferior objective knee function compared with uncomplicated ACLR. Subjectively, infection patients were as satisfied as non-infection patients, but rehabilitation took longer and fewer patients returned to sports. The findings of this study suggest that anterior cruciate ligament grafts may be retained with prompt, thorough arthroscopic lavage and debridement; correct antibiotics according to cultures; and repeated arthroscopy if necessary. LEVEL OF EVIDENCE Level III, retrospective case-control therapeutic study.

DOES THE TENDINOPATHIC PATELLAR TENDON NORMALISE, ACCORDING TO ULTRASOUND FINDINGS, AFTER TREATMENT WITH SCLEROSING INJECTIONS OR ARTHROSCOPIC SHAVING? A LONG TERM FOLLOW-UP (3–5 YEARS)

Introduction Treatment of patellar tendinopathy/jumpers knee with ultrasound-guided sclerosing injections and arthroscopic shaving has shown good clinical results, but patients treated with the one-stage procedure arthroscopic shaving had a faster return to full activity, less pain and were more satisfied with the treatment result at follow-up approximately 1 year after end of treatment.1 There are studies suggesting that tendon structure in a tendinotic, chronic painful tendon does not sonographically normalise after successful treatment. However those results are based on a relatively short term follow up. Methods We have evaluated patellar tendons according to a routine ultrasound examination protocol for chronic painful patellar tendons/proximal patellar tendinopathy, 3 to 5 years after treatment with sclerosing injections (n=19) or arthroscopic shaving (n=25). Tendon thickness was measured and tendon structure and the amount of neovascularization was evaluated and scored, to be compared with corresponding values at baseline and at the 1 year follow-up. Self-reported pain during rest and patellar tendon loading activity, and patient satisfaction with the result of the treatment was registered on a visual analogue scale (VAS). Results At the 3–5 years follow-up, preliminary results showed that tendon structure seemed to improve, and the neovascularisation was reduced, in both groups. There was a trend towards a decrease in antero-posterior thickness of the proximal part of the patellar tendon in patients treated with arthroscopic shaving, but not for tendons treated with sclerosing injections. There were no differences in VAS score at rest and during activity between the two treatment groups or in VAS score for satisfaction with treatment. Discussion Treatment of patellar tendinopathy/jumpers knee with ultrasound and colour Doppler-guided sclerosing injections and arthroscopic shaving showed remaining good clinical results after 3–5 years for both methods. Treatment with sclerosing injections requires multiple injections with 6–8 weeks in between, but in the 3–5 years perspective seems to reach the same result in terms of ultrasound findings and self-reported pain (VAS) as treatment with the one-stage procedure arthroscopic shaving. This is in contrast to the results at 1 year follow-up where the surgical method showed better results in all evaluated variables. One remaining difference between the two treatments was that only the surgical method showed a decrease in antero-posterior thickness. In fact tendon thickness in the group treated with sclerosing injections were increased at the 1 year follow-up, while now 3–5 years after treatment the thickness seems to be back at the same level as at baseline, before treatment.

Ultrasound and Doppler-Guided Arthroscopic Shaving for the Treatment of Patellar Tendinopathy/Jumper’s Knee: Biological Background and Description of Method

Treatment with ultrasound and Doppler-guided arthroscopic shaving of the region with vessels and nerves outside the dorsal tendon has shown promising clinical results in patients with proximal patellar tendinopathy/Jumper´s knee. The results concerning only a limited patient material has been published in a scientific paper. Results on larger materials are under evaluation for later publication. Proper understanding of the ultrasound and Doppler findings, to enable for a precise and minimal arthroscopic shaving procedure on the dorsal side of the tendon, are cornerstones using this new type of treatment.