Abstract
Osgood-Schlatter disease is a common cause of anterior knee pain in sports-practicing adolescents. The long-term outcomes have not always been favorable, and some adolescents have persisting knee pain into adulthood. Excision of the ossicle together with debridement of the tibial tuberosity is indicated if the pain is not relieved with conservative measures. An endoscopic technique for excision of the ossicle associated with Osgood-Schlatter disease is reported. It has the advantages of avoidance of painful surgical scars and preservation of the integrity of the patellar tendon, with the potential for improved cosmetic and functional results.
Osgood-Schlatter disease (osteochondrosis of the tibial tubercle) is a common cause of anterior knee pain in sports-practicing adolescents.1, 2 Traditionally, it is treated with restriction from sports alone or in conjunction with undertaking physiotherapy. The goals of conservative treatment are to lessen the stress on the tibial tubercle and to reduce the tension in the quadriceps muscle.3 However, resolution of symptoms may take several years. A proportion of teenagers are prevented from participating in sports for a prolonged period as a result of the condition, and some have persisting knee pain into adulthood.2 Conservative treatment with rest, lidocaine injections, steroid injections, cylinder casts, and infrapatellar straps has been proposed for adults with continued symptoms.4 Surgical treatment is indicated if they do not respond to conservative measures. The surgical options include excision of the ossicle together with reduction osteotomy or debridement of the tibial tuberosity, drilling of the tubercle, autogenous bone peg insertion through the tubercle, or sequestrectomy (i.e., excision of the ununited ossicles and free cartilaginous pieces).3, 4, 5, 6, 7, 8, 9 These are usually performed as open procedures. Recently, endoscopic resection of the ossicle and debridement of the tibial tuberosity have been reported.3, 4, 6 We describe a technique for endoscopic resection of the ossicle and reduction of the tibial tuberosity in the case of a loose ossicle and prominence of the tibial tuberosity at the anterior surface of the patellar tendon (Table 1, Fig 1).
Table 1.
Pearls of Endoscopic Management of Osgood-Schlatter Disease
| 1. Unresolved Osgood-Schlatter lesions can cause persistent pain in adults. |
| 2. Arthroscopic resection of the ossicle and debridement of the tibial tuberosity comprise a feasible surgical choice. |
| 3. Preoperative MRI provides important information for surgical planning. |
| 4. Resection of the ossicle can be facilitated by knee flexion. |
| 5. The completeness of resection should be confirmed by intraoperative fluoroscopy. |
| 6. Caution should be paid to avoid damage to the patellar tendon insertion. |
MRI, magnetic resonance imaging.
Fig 1.
(A) Lateral radiograph of the left knee of the illustrated case shows a prominent tibial tuberosity and ossicle proximal to the tubercle. (B) Magnetic resonance imaging (sagittal, T2-weighted image) shows that the tubercle and ossicle are at the anterior aspect of the patellar tendon.
Technique
The patient is positioned supine. A pneumatic thigh tourniquet is applied to provide a bloodless operative field. A 4.0-mm 30° arthroscope (Dyonics; Smith & Nephew, Andover, MA) is used for this procedure. A proximal-lateral portal is made on the proximal-lateral side of the bony prominence at the tibial tuberosity. A distal-medial portal is made on the distal-medial side of the bony prominence. It is important to place the portals away from the prominence to avoid the formation of a painful scar over the bony prominence (Fig 2). A plane is developed anterior to the bony prominence by means of a hemostat. This is the working area for the endoscopy. The proximal-lateral portal is the viewing portal. An inflamed pretibial bursa, if present, can be resected by a 4.5-mm arthroscopic shaver (Smith & Nephew) through the distal-medial portal (Fig 3). The arthroscope is then switched to the distal-medial portal. The anterior surface of the patellar tendon is identified and traced distally. The anterior surface of the tendon is probed to identify the avulsed ossicle, which is embedded at the distal part of the patellar tendon. The thin layer of tendinous tissue over the ossicle is resected with an arthroscopic shaver through the proximal-lateral portal. The borders of the ossicle, especially its deep margin, can be defined with an arthroscopic probe and a small dissector (Kokubun dissector; Mizuho Medical, Tokyo, Japan). It is important to define the borders of the ossicle before resection to prevent resection of the surrounding normal tendinous tissue. The ossicle is resected with a 5.5-mm arthroscopic acromionizer (Smith & Nephew) through the proximal-lateral portal (Fig 4). The knee is flexed during the resection. This can increase tension on the patellar tendon and immobilize the ossicle to facilitate the resection. Caution should be taken to preserve the normal tendinous tissue. After resection of the ossicle, the patellar tendon is traced distally to the tibial tuberosity. The prominent tuberosity is resected with preservation of the patellar tendon insertion. This is performed by starting the bone shaving from the proximal end of the prominence, which is distal to the tibial insertion of the patellar tendon. The acromionizer faces distally during the procedure, with the sheath protecting the tendon from damage (Fig 5). After completion of the procedure, the patellar tendon is examined for any abnormality (Video 1). If there is a through-and-through tear of the tendon after resection of the ossicle, endoscopic-assisted repair of the tendon can be performed.10
Fig 2.
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. The proximal-lateral portal (PLP) and distal-medial portal (DMP) are located at the proximal-lateral and distal-medial aspects of the tibial tuberosity (TT), respectively. These can avoid formation of painful surgical scars over the patellar tendon. Moreover, a sufficient working space can be obtained and instrument crowding can be avoided.
Fig 3.
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. (A) A plane is developed anterior to the bony prominence. This is the working area for the endoscopy. The proximal-lateral portal is the viewing portal. (B) An inflamed pretibial bursa (PB), if present, can be resected with an arthroscopic shaver through the distal-medial portal.
Fig 4.
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. The distal-medial portal is the viewing portal. (A) The avulsed ossicle can be identified at the distal part of the patellar tendon. (B) The thin layer of tendinous tissue over the ossicle (OS) is resected with an arthroscopic shaver through the proximal-lateral portal. (C) The dimensions of the ossicle, especially its deep margin, can be defined with an arthroscopic probe and a small dissector. (D) The ossicle is resected with an arthroscopic acromionizer. (PT, patellar tendon.)
Fig 5.
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. The distal-medial portal is the viewing portal. (A) After resection of the ossicle, the patellar tendon is traced distally to the tibial tuberosity (TT). The prominent tuberosity is resected with preservation of the patellar tendon (PT) insertion. This is performed by starting the bone shaving from the proximal end of the prominence with the acromionizer facing distally. (B) A postoperative radiograph shows that the ossicle and prominent tibial tuberosity have been resected.
Discussion
Traction apophysitis of the tibial insertion of the patellar tendon (Osgood-Schlatter disease) usually presents in adolescent male patients aged 10 to 14 years, with an incidence of 25% to 33% in bilateral knees.4 Traditionally, it is believed to be self-limiting, with resolution of symptoms in about 90% of cases with or without some form of treatment.4 However, the long-term outcomes have not always been favorable.11, 12 Symptoms can persist into adulthood. Resection of the ossicle and debridement of the tibial tuberosity are indicated if the pain cannot be resolved with conservative treatment. However, the surgeon should make sure that the symptoms are due to Osgood-Schlatter disease. There should be radiographic and clinical evidence of Osgood-Schlatter disease with symptoms localized to the prominent tibial tuberosity region.7, 8 Surgery is contraindicated for a patient with diffuse anterior knee pain, which can be due to other disease entities such as chondromalacia patellae.6
Open resection of the ossicle and debridement of the tubercle are performed through an anterior incision with a split–patellar tendon approach.7, 8, 9 Repair of the patellar tendon and postoperative immobilization are needed.7, 8, 9 Delayed resolution of pain and swelling at the surgical site after open surgical procedures has been reported.6 The resultant surgical scar over the tendon can be painful with kneeling.7, 8, 9, 13 Modifications with an anterolateral incision and reflection of the patellar tendon have been proposed to reduce this risk.5 Endoscopic approaches have been reported with the advantage of avoidance of painful surgical scars because the portal incisions are located away from the patellar tendon.4 Sports activity may be allowed earlier because the patellar tendon is not violated.3 Moreover, other intra-articular knee pathology can also be addressed arthroscopically.
Previous reports have focused on endoscopic resection of the ossicle at the deep surface of the patellar tendon and debridement of the tibial tuberosity deep to the tendon.3, 4, 6 The knee is extended to relax the patellar tendon and improve the working space deep to the tendon.3, 4, 6 Standard knee arthroscopy portals have been used, with the advantage of arthroscopic examination of the knee joint through the same portals.3, 4 However, this approach has the disadvantage of violation of the infrapatellar fat pad and risk of damage to the anterior horn of the meniscus or intermeniscal ligament during resection of the ossicle.3, 4 A direct bursoscopic approach has been proposed to minimize infrapatellar fat pad violation.6 However, additional portals are needed to examine the knee joint. Moreover, the working space can be limited, and the portals should be made away from the tendon borders to obtain a sufficient working space and avoid instrument crowding.6
This report, in contrast to the previous reports, focuses on the lesions anterior to the patellar tendon. The location of the lesions cannot be accurately determined by radiographs. Magnetic resonance imaging provides important information for surgical planning. The relation among the ossicle, the prominence of the tibial tuberosity, and the patellar tendon can be studied. This can determine the location of the portals and whether the working space should be developed anterior or posterior to the tendon. Any associated knee joint pathology should also be noted, and this will determine whether knee arthroscopy is indicated.
The described endoscopic procedure is indicated in the case of symptomatic Osgood-Schlatter disease with the avulsed ossicle anterior to the patellar tendon. It has the advantage of small surgical scars located away from the bony prominence. This can provide a better cosmetic result and less risk of painful surgical scars. The major risk is damage to the patellar tendon insertion. This is a technically demanding procedure and should be reserved for arthroscopists familiar with endoscopic surgery.
During the procedure, the knee is flexed to increase tension on the patellar tendon. This can stabilize the ossicle and facilitate the resection. The surgeon should start debridement of the tubercle from the point just distal to the patellar tendon insertion and work downward with the acromionizer distally. This can avoid accidental avulsion of the patellar tendon insertion. Intraoperative fluoroscopy is recommended to ensure completeness of resection because insufficient ossicle removal and excision of the osseous prominence may fail to resolve the clinical symptoms.7, 9
Endoscopic resection of the ossicle and debridement of the tibial tuberosity comprise a feasible surgical choice for unresolved Osgood-Schlatter lesions. Preoperative magnetic resonance imaging provides important information for surgical planning.
Footnotes
The author reports that he has no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. The proximal-lateral portal and distal-medial portal are located at the proximal-lateral and distal-medial aspects of the tibial tuberosity, respectively. In step 1, the proximal-lateral portal is the viewing portal. The inflamed pretibial bursa is resected with an arthroscopic shaver through the distal-medial portal. In step 2, the distal-medial portal is the viewing portal and the proximal-lateral portal is the working portal. The thin layer of tendinous tissue over the ossicle is resected. The dimensions of the ossicle, especially its deep margin, are defined with a small dissector. The ossicle is resected with an arthroscopic acromionizer. In step 3, after resection of the ossicle, the patellar tendon is traced distally to the tibial tuberosity. The prominent tuberosity is resected with preservation of the patellar tendon insertion. This is performed by starting the bone shaving from the proximal end of the prominence with the acromionizer facing distally.
References
- 1.Schrouff I., Magotteaux J., Gillet P. How I treat… Osgood-Schlatter disease. Rev Med Liege. 2015;70:159–162. [in French] [PubMed] [Google Scholar]
- 2.Narayan N., Mitchell P.D., Latimer M.D. Complete resolution of the symptoms of refractory Osgood-Schlatter disease following percutaneous fixation of the tibial tuberosity. BMJ Case Rep. 2015 doi: 10.1136/bcr-2014-206734. Available at http://casereports.bmj.com. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Beyzadeoglu T., Inan M., Bekler H., Altintas F. Arthroscopic excision of an ununited ossicle due to Osgood-Schlatter disease. Arthroscopy. 2008;24:1081–1083. doi: 10.1016/j.arthro.2007.03.010. [DOI] [PubMed] [Google Scholar]
- 4.DeBerardino T.M., Branstetter J.G., Owens B.D. Arthroscopic treatment of unresolved Osgood-Schlatter lesions. Arthroscopy. 2007;23:1127.e1–1127.e3. doi: 10.1016/j.arthro.2006.12.004. [DOI] [PubMed] [Google Scholar]
- 5.El-Husseini T.F., Abdelgawad A.A. Results of surgical treatment of unresolved Osgood-Schlatter disease in adults. J Knee Surg. 2010;23:103–107. doi: 10.1055/s-0030-1267474. [DOI] [PubMed] [Google Scholar]
- 6.Eun S.S., Lee S.A., Kumar R. Direct bursoscopic ossicle resection in young and active patients with unresolved Osgood-Schlatter disease. Arthroscopy. 2015;31:416–421. doi: 10.1016/j.arthro.2014.08.031. [DOI] [PubMed] [Google Scholar]
- 7.Pihlajamäki H.K., Visuri T.I. Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men. Surgical technique. J Bone Joint Surg Am. 2010;92:258–264. doi: 10.2106/JBJS.J.00450. (suppl 1, pt 2) [DOI] [PubMed] [Google Scholar]
- 8.Pihlajamäki H.K., Mattila V.M., Parviainen M., Kiuru M.J., Visuri T.I. Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men. J Bone Joint Surg Am. 2009;91:2350–2358. doi: 10.2106/JBJS.H.01796. [DOI] [PubMed] [Google Scholar]
- 9.Weiss J.M., Jordan S.S., Andersen J.S., Lee M., Kocher M. Surgical treatment of unresolved Osgood-Schlatter disease. Ossicle resection with tibial tubercleplasty. Pediatr Orthop. 2007;27:844–847. doi: 10.1097/BPO.0b013e318155849b. [DOI] [PubMed] [Google Scholar]
- 10.Lui TH. Endoscopic resection of avulsed fragment of tibial tuberosity and endoscopic-assisted repair of patellar tendon. Arthrosc Tech. 2015;3:e851–e854. doi: 10.1016/j.eats.2015.08.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kaya D.O., Toprak U., Baltaci G., Yosmaoglu B., Ozer H. Long-term functional and sonographic outcomes in Osgood-Schlatter disease. Knee Surg Sports Traumatol Arthrosc. 2013;21:1131–1139. doi: 10.1007/s00167-012-2116-1. [DOI] [PubMed] [Google Scholar]
- 12.Cakmak S., Tekin L., Akarsu S. Long-term outcome of Osgood-Schlatter disease: Not always favorable. Rheumatol Int. 2014;34:135–136. doi: 10.1007/s00296-012-2592-0. [DOI] [PubMed] [Google Scholar]
- 13.Flowers M.J., Bhadreshwar D.R. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop. 1995;15:292–296. doi: 10.1097/01241398-199505000-00005. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Arthroscopic excision of the ossicle and debridement of the tibial tuberosity in the left knee. The patient is positioned supine. The proximal-lateral portal and distal-medial portal are located at the proximal-lateral and distal-medial aspects of the tibial tuberosity, respectively. In step 1, the proximal-lateral portal is the viewing portal. The inflamed pretibial bursa is resected with an arthroscopic shaver through the distal-medial portal. In step 2, the distal-medial portal is the viewing portal and the proximal-lateral portal is the working portal. The thin layer of tendinous tissue over the ossicle is resected. The dimensions of the ossicle, especially its deep margin, are defined with a small dissector. The ossicle is resected with an arthroscopic acromionizer. In step 3, after resection of the ossicle, the patellar tendon is traced distally to the tibial tuberosity. The prominent tuberosity is resected with preservation of the patellar tendon insertion. This is performed by starting the bone shaving from the proximal end of the prominence with the acromionizer facing distally.