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Endoscopic Management of Osgood-Schlatter Disease

Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.

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 thetibial tubercle) is a common causeof 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 tubercleand to reduce the tension in the quadri-

ceps muscle.3 However, resolution of symptoms may

take several years. A proportion of teenagers are pre-

vented 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 in-jections, cylinder casts, and infrapatellar straps has been

proposed for adults with continued symptoms.4 Surgical

treatment is indicated if they do not respond to con-

servative measures. The surgical options include exci-

sion of the ossicle together with reduction osteotomy or

debridement of the tibial tuberosity, drilling of the tu-

bercle, autogenous bone peg insertion through the tu-

bercle, or sequestrectomy (i.e., excision of the ununited

ossicles and free cartilaginous pieces).3-9 These are

usually performed as open procedures. Recently,

endoscopic resection of the ossicle and debridement ofthe 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).

TechniqueThe patient is positioned supine. A pneumatic thigh

tourniquet is applied to provide a bloodless operative

eld. A 4.0-mm 30 arthroscope (Dyonics; Smith &

Nephew, Andover, MA) is used for this procedure. Aproximal-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 por-

tals 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 inamed 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 identied

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 dened with an arthroscopic probe

and a small dissector (Kokubun dissector; Mizuho

Medical, Tokyo, Japan). It is important to dene the

From the Department of Orthopaedics and Traumatology, North District

Hospital, Sheung Shui, China.

The author reports that he has no conicts of interest in the authorship and

publication of this article.

Received July 13, 2015; accepted October 27, 2015.

Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin),

F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology,

North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR,

China. E-mail: [email protected]

2016 by the Arthroscopy Association of North America

2212-6287/15651/$36.00

http://dx.doi.org/10.1016/j.eats.2015.10.023

Arthroscopy Techniques, Vol 5, No 1 (February), 2016: pp e121-e125 e121
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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 exed during the

resection. This can increase tension on the patellartendon 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 tu-

berosity. 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

DiscussionTraction apophysitis of the tibial insertion of the

patellar tendon (Osgood-Schlatter disease) usually pre-

sents in adolescent male patients aged 10 to 14 year s,

with an incidence of 25% to 33% in bilateral knees.4

Traditionally, it is believed to be self-limiting, with res-

olution 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 areindicated if the pain cannot be resolved with conserva-

tive 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 toother disease entities such as

chondromalacia patellae.6

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 exion.

5. The completeness of resection should be conrmed by

intraoperative uoroscopy.

6. Caution should be paid to avoid damage to the patellar tendon

insertion.

MRI, magnetic resonance imaging.

Fig 1. (A) Lateral radio-

graph 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.

e122 T. H. LUI
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Open resection of the ossicle and debridement of the

tubercle are performed through an anterior incision

with a splitepatellar tendon approach.7-9 Repair of the

patellar tendon and postoperative immobilization are

needed.7-9 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.7-9,13 Modications with

an anterolateral incision and reection 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 resec-

tion 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 tendonand improve the working space deep to

the tendon.3,4,6 Standard knee arthroscopy portals have

been used, with the advantage of arthroscopic exami-

nation of the knee joint through the same portals.3,4

However, this approach has the disadvantage of viola-

tion of the infrapatellar fat pad and risk of damage to

the anterior horn of the meniscus or intermeniscal lig-ament during resection of the ossicle.3,4 A direct bur-

soscopic approach has been proposed to minimize

infrapatellar fat pad violation.6 However, additional

portals are needed to examine the knee joint. More-

over, the working space can be limited, and the portals

should be made away from the tendon borders to

obtain a sufcient working space and avoid instrument

crowding.6

This report, in contrast to the previous reports, fo-

cuses 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 rela-tion 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 pa-

thology 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 canprovide 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 exed 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 uoroscopy is recommended

to ensure completeness of resection because in-

sufcient 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. Preop-

erative magnetic resonance imaging provides important

information for surgical planning.

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 sufcient working space can be

obtained and instrument crowding can be avoided.

ENDOSCOPY AND OSGOOD-SCHLATTER DISEASE e123


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Fig 4. Arthroscopic exci-

sion 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 identied at the distal

part of the patellar tendon.

(B) The thin layer of tendi-

nous 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 dened with

an arthroscopic probe and a

small dissector. (D) The

ossicle is resected with an

arthroscopic acromionizer.

(PT, patellar tendon.)





The patient is positionedsupine. (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 inamed

pretibial bursa (PB), if pre-

sent, can be resected with

an arthroscopic shaver

through the distal-medial

portal.

e124 T. H. LUI


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The patient is positioned

supine. The distal-medial

portal is the viewing portal.

(A) After resection of theossicle, the patellar tendon

is traced distally to the tibial

tuberosity (TT). The promi-

nent tuberosity is resected

with preservation of the

patellar tendon (PT) inser-

tion. This is performed by

starting the bone shaving

from the proximal end of

the prominence with the

acromionizer facing distally.

(B) A postoperative radio-

graph shows that the ossicle

and prominent tibial tuber-

osity have been resected.

ENDOSCOPY AND OSGOOD-SCHLATTER DISEASE e125
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