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 longterm 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.

sgood-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).3-9 These are
usually performed as open procedures. Recently,

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: luithderek@yahoo.co.uk
2016 by the Arthroscopy Association of North America
2212-6287/15651/$36.00
http://dx.doi.org/10.1016/j.eats.2015.10.023

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).

Technique
The 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. 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 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 proximallateral 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

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T. H. LUI

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.

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 proximallateral portal (Fig 4). The knee is exed 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

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 longterm 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

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.

ENDOSCOPY AND OSGOOD-SCHLATTER DISEASE

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 distalmedial 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.

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 resection of the ossicle at the deep surface of the patellar
tendon and debridement of the tibial tuberosity deep to

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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 sufcient 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 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 insufcient 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.

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T. H. LUI

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 proximallateral portal is the viewing
portal. (B) An inamed
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 identied 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 dened with
an arthroscopic probe and a
small dissector. (D) The
ossicle is resected with an
arthroscopic acromionizer.
(PT, patellar tendon.)

ENDOSCOPY AND OSGOOD-SCHLATTER DISEASE

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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.

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