Abstract
Tophaceous deposition of tendon can result in spontaneous patellar tendon rupture. Surgical therapy may be needed to control symptoms and prevent tendon rupture. Open debridement of the lesion requires a lengthy incision over the lesion; this may result in symptomatic scar adhesion of the patellar tendon or an unhealed wound with persistent tophaceous discharge. Moreover, the other part of the patellar tendon cannot be examined through the incision. We describe a technique for endoscopic resection of a gouty tophus of the patellar tendon. It has the advantage of small incisions away from the lesion and tendon and minimizes wound problems. The whole patellar tendon can be examined endoscopically.
Tophaceous deposition of tendon, including the flexor tendons of the hand,1 Achilles tendon,2, 3 quadriceps tendon,4, 5, 6 patellar tendon,2, 5, 7, 8, 9 tibialis anterior tendon,10 and peroneal tendons,11 has been reported. Monosodium urate crystals can directly interact with tenocytes to reduce cell viability and function.12 This may result in spontaneous ruptures of involved tendons.3, 6, 10, 11 Patellar tendon rupture will jeopardize the extensor mechanism of the knee. Reconstruction of the patellar tendon is a difficult task. Although medical therapy is the cornerstone of treatment for diseases that result in crystal deposition, surgical therapy may be needed to control symptoms and prevent tendon rupture.1 Besides the risk of tendon rupture, crystal deposition at the patellar tendon can result in a lump (Fig 1) that is painful on kneeling or direct contusion. In such cases, resection of the tophus is needed. We describe an endoscopic approach to resection of gouty deposits of the patellar tendon. Magnetic resonance imaging is an important preoperative investigation to aid in surgical planning (Fig 2).
Fig 1.
Clinical photographs show a tophus (arrows) at the tibial tuberosity that is painful on kneeling or contusion.
Fig 2.
Magnetic resonance imaging of the illustrated case shows lower patellar tendinosis associated with prepatellar soft-tissue thickening and T2 hyperintense change, which suggests prepatellar bursa thickening. These findings help the surgeon to understand the extent and location of the lesion and plan the endoscopic surgical procedure.
Technique
A 4.0-mm 30° arthroscope (Dyonics Smith & Nephew, Andover, MA) is used for this procedure. The patient is in the supine position, and a thigh tourniquet is applied. The knee is flexed with support at the popliteal fossa. The patella, patellar tendon, and lesion are outlined. Portal incisions are made at the proximal-lateral and distal-medial corners of the lump and outside the boundary of the patellar tendon. A plane superficial to the lesion and tendon and deep to the superficial fascia is developed by a hemostat. The trocar-cannula is inserted from the proximal-lateral portal to the distal-medial portal through this plane. The portals act like coaxial portals. The arthroscopic shaver (Dyonics Smith & Nephew) is inserted through the distal-medial portal. Advancement of the instrument toward the lesion is performed under arthroscopic guidance, with withdrawal of the arthroscope at the same time. The pseudocapsule of the lesion is resected with an arthroscopic shaver. The underlying tophaceous materials are exposed and removed by the shaver and biopsy forceps until the normal tendinous structure is exposed. The tophaceous deposits can be enucleated out by an arthroscopic probe before removal by the shaver or forceps. This can minimize the risk of debridement of the normal tendinous structure. It is especially important for deposits close to the tendon insertion at the tibial tuberosity because excessive resection of the normal tendinous structure can result in tendon rupture at its insertion. The remaining tendon is examined to ensure completeness of debridement (Video 1). The portals can be switched, serving as the visualization and instrumentation portals. Postoperatively, the patient is advised to perform knee mobilization and partial weight-bearing walking for 2 weeks.
Discussion
The conventional enucleating procedure for a gouty tophus might cause complications. In severe cases, skin necrosis and tendon or joint exposure can occur after debridement.13, 14 Open debridement of the lesion requires a long incision directly over the tophus. This can result in symptomatic scar adhesion of the patellar tendon or an unhealed wound with persistent tophaceous discharge. Moreover, the other part of the patellar tendon cannot be examined for residual tophaceous deposits through the incision. A technique of percutaneous shaving of the tophus by an arthroscopic shaver has been described.13, 14 It has the advantage of being a minimally invasive surgical procedure, with fewer wound complications and better cosmetic results. However, it is not suitable for a gouty tophus of the patellar tendon because the tendon cannot be examined and debrided during the percutaneous procedure.
Endoscopic resection of a gouty tophus has been reported.15 Patellar tendoscopy has been used to treat chronic patellar tendinitis and tendinosis,16, 17 recalcitrant bursitis around the tendon,18 Osgood-Schlatter disease,19 jumper's knee,20, 21 and synovial lipoma of the tendon.22 Endoscopic resection of a gouty tophus and tophaceous deposits of the patellar tendon through small incisions away from the lesion and tendon can minimize the risk of wound dehiscence and persistent tophaceous discharge. The portal incisions away from the tendon and tibial tuberosity can minimize the risk of a painful surgical scar especially during kneeling. Moreover, the remaining patellar tendon can be examined endoscopically for any residual deposits through the small portal incisions. Precise debridement of the tendon under arthroscopic guidance hopefully can reduce the risk of subsequent spontaneous tendon rupture.
Preoperative magnetic resonance imaging is essential for preoperative planning. The exact location of the tophus should be studied with care. This determines the location of the portals. Debridement of the superficial and deep surfaces of the patellar tendon can be performed through the same portals.22
The main contraindication to use of the described technique is diffuse involvement of the patellar tendon with extensive tendinopathic change. Tophaceous deposition at the tibial insertion is a relative contraindication because the debridement may weaken the tendon insertion and result in tendon rupture (Table 1). In conclusion, endoscopic resection of a gouty tophus of the patellar tendon is a viable alternative to the open procedure.
Table 1.
Pearls of Endoscopic Resection of Gouty Tophus of Patellar Tendon
| Preoperative MRI is essential for surgical planning. |
| The portals should be away from the lesion, the tendon, and any bony prominence. |
| Debridement of the normal tendon tissue should be avoided, especially close to its tibial insertion. |
| The area of debridement of the tendon should be fusiform in shape, and debridement should be performed along the axis of the patellar tendon. This can reduce the risk of tendon rupture. Moreover, this will facilitate closure of the tendon gap by a percutaneous suture technique. |
MRI, magnetic resonance imaging.
Footnotes
The author reports that he has no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Endoscopic resection of gouty tophus. Step 1 is resection of the pseudocapsule of the tophus. Step 2 is removal of the tophaceous materials until the normal tendinous tissue is seen. Step 3 is examination of the remaining portion of the patellar tendon for residual tophaceous deposits.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Endoscopic resection of gouty tophus. Step 1 is resection of the pseudocapsule of the tophus. Step 2 is removal of the tophaceous materials until the normal tendinous tissue is seen. Step 3 is examination of the remaining portion of the patellar tendon for residual tophaceous deposits.