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Patellar tendon thickness seen as strong predictor for tears
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BOSTON — According to a presentation at the American Orthopaedic Society for Sports Medicine Annual Meeting, partial patellar tendon tears are located either posterior or posteromedial in the proximal patellar tenon. Patellar tendon thickness was the most sensitive metric for partial patellar tendon tears, with thickness of more than 8.8 mm being a strong predictor of surgical intervention.
“Make sure you look for [partial patellar tendon tears] when you have an athlete who seems to have jumper’s knee that just doesn’t seem to get better,” Charles A. Popkin, MD, said during his presentation.
Popkin and colleagues identified 112 athletic patients who underwent knee MRI. Of these patients, 85 patients had history and physical examination that showed recalcitrant patellar tendonitis or had a suspicion of a partial patellar tendon tear. There were 27 patients who underwent MRI for other pathology and were age-matched controls. Patellar tendon tear size, thickness and location in relation to the entire patellar tendon were assessed with MRI scans. The tendon size and tear distributions were evaluated with descriptive statistics. Pearson correlation, univariate and logistic regressions were used to find associations between tendon geometry and tear sizes. Patient-reported outcomes and tear geometry measures were compared with t-tests.
Results showed 56 patients had partial patellar tendon tears. Investigators noted 91% of the partial patellar tendon tears involved the posterior and posteromedial regions of the proximal patellar tendon. Patients with partial patellar tendon tears had mean tendon thickness of 10 mm vs 5.9 mm in athletic patients without partial patellar tendon tears. There was a significant association between patellar tendon thickness and partial patellar tendon tear.
According to logistic regression analysis results, patients with patellar tendon thickness of more than 7.45 mm had a greater chance of partial patellar tendon tears. There were 11 patients who underwent surgery for partial patellar tendon tears. All of these patients had tear sizes on axial images greater than 50% of tendon thickness. A patellar tendon thickness of greater than 8.8 mm and a tear size greater than 55% was associated with surgical intervention. There were five patients who underwent surgery and were not able to return to sport at the same level. None of the patients had surgery for tear thickness of less than 4.5 mm. – by Monica Jaramillo
Reference:
Golman M, et al. Abstract 63. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 11-14, 2019; Boston.
Disclosure: Popkin reports no relevant financial disclosures.
Perspective
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Seth L. Sherman, MD
There remains controversy regarding the indications for surgical repair of partial thickness patella tendon tears (PPTT) in athletes. Evidence-based recommendations would be critically important to better identify the challenging subset of patients who may not respond to conservative measures.
Golman and colleagues performed an age-matched case-control study to investigate the relationship between patella tendon thickness and tear size as predictors of response to non-surgical intervention. They reviewed MRIs for 85 patients with symptomatic patella tendinopathy or partial tears and 27 age-matched controls. They identified 56 patients with partial patella tendon tears and 11/56 (19.6%) who failed conservative treatment and required surgery. The researchers found that 91% of PPTTs involved the posterior and posteromedial region of the proximal patellar tendon. On axial MRI imaging, patients with PPTT had mean tendon thickness of 10 mm compared to 5.9 mm for athletes with no PPTT, including healthy controls (P<.0001). There was a significant correlation between patellar tendon thickness and PPTT size (R=0.85, P<.0001). Athletes with greater than a 55 % tear thickness on axial MRI imaging or with a tear measuring more than 4.5 mm on axial cuts were less likely to respond to nonoperative treatment.
Strengths of this study include relatively large number of patients for a fairly uncommon diagnosis and somewhat rare surgical procedure and standardized imaging protocol for all subjects. Weaknesses include inherent limitations related to retrospective data review and lack of treatment group randomization.
Overall, this study helps clinicians risk stratify to identify the subset of patients with PPTT who may not respond to conservative care. Athletes with thick tendons are at higher risk for tear and those with larger tears are at highest risk of requiring surgery. This is important information for prognosis and to guide treatment recommendations. Multicenter study with prospective and/or randomized study design would be a helpful next step. Development of a classification system for PPTT and an evidence-based treatment algorithm is the ultimate goal of this line of work.
Orthopedic surgery
Redwood City, California
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