髌腱病（髌腱炎，跳高者膝，蹲走者膝)：诊断和治疗新进展：2016年美国骨科医师协会杂志JAAOS

髌腱病（髌腱炎）：诊断和治疗新进展：2016年美国骨科医师协会杂志J Am Acad Orthop Surg

作者：David Figueroa, Francisco Figueroa, Rafael Calvo.

作者单位: the Knee Unit, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.

译者：陶可（北京大学人民医院骨关节科）

典型病例介绍：青年男性，30岁，1年前因需要进行深蹲训练，导致膝关节胫骨结节处明显疼痛，曾贴服膏药及热敷治疗，效果良好，但后期症状反复，在深蹲或屈膝动作较大时，如上楼时仍出现膝前疼痛不适，平路行走时无任何不适。核磁共振检查结果显示：明显的髌腱区长T2和T1信号改变，提示炎性改变（如图黄色箭头标注）。

髌腱是髌骨下极连接胫骨结节的重要肌腱，是带动下肢小腿活动的力臂，如果不恰当的反复劳损，如反复蹦跳、下蹲行走、深蹲站立等，都会引起其发生无菌性炎症反应，症状主要是反复或持续性疼痛，伸直膝关节无力，甚至出现站立、上下楼梯或行走困难等，所以一定要重视。髌腱炎多见于运动员、军人及爱好运动者。可在运动中、运动后出现明显的膝前髌骨下极及周围疼痛，按压疼痛加重。

治疗一般采用限制或避免引起疼痛加重的动作，如蹦跳、下蹲或上下楼梯，消炎止疼药外用和口服以及配合持续热敷(40度左右热水袋，半小时)，同时配合运动康复锻炼(偏心锻炼、股四头肌锻炼等)往往效果较佳，必要时可佩戴功能护膝。保守治疗6-8周可基本缓解疼痛不适。严格保守效果不理想时，应结合膝关节核磁共振仔细阅片分析，决定进一步手术治疗(推荐一年做100台以上的有经验的关节镜专家进行微创治疗)。

Patellar tendonitis (jumper’s knee): 髌腱炎（跳高者膝，蹲走者膝）

Front view: 前面观

lateral view: 侧面观

quadriceps tenden: 股四头肌腱

patella: 髌骨

most common site for patellar tendonitis: 髌腱炎最常见的部位(红色区域标记的位置)

Patellar tendon: 髌腱

Physical therapy exercises for Patellar tendonitis: 髌腱炎的物理治疗练习

Quad isometric : 股四头肌等距锻炼，即：股四头肌腱收缩，小腿向前而非向上伸展。

eccentric exercises: 偏心练习，即：单腿负重站立，另一侧下肢伸直，做蹲起练习。

knee extension: 膝关节伸展练习，即：双脚踝缠绕弹力带，一侧下肢做向前伸展/伸膝动作。

plyometric exercises: 增强式练习，即：屈髋屈膝90度下蹲，脚尖着地，做向上弹跳练习。

膝关节功能护膝

Patellar Tendinopathy: Diagnosis and Treatment

Abstract

Patellar tendinopathy is a common cause of pain in athletes‘ knees. Historically, it has been related to jumping sports, such as volleyball and basketball. Repetitive jumping generates a considerable load of energy in the extensor mechanism, leading to symptoms. The main pathophysiologic phenomenon in patellar tendinopathy is tendinosis, which is a degenerative disorder rather than an inflammatory disorder; therefore, the other popular term for this disease, tendinitis, is not appropriate. The nonsurgical treatment of patellar tendinopathy is focused on eccentric exercises and often has good results. Other experimental options, with variable levels of evidence, are available for recalcitrant cases. Surgical treatment is indicated for cases that are refractory to nonsurgical treatment. Open or arthroscopic surgery can be performed; the two methods are comparable, but arthroscopic surgery results in a faster recovery time.

髌腱病是运动员膝盖疼痛的常见原因。从历史上看，它与排球和篮球等跳跃运动有关。重复跳跃会在伸肌机制中产生相当大的能量负荷，从而导致症状。髌腱病的主要病理生理现象是肌腱变性，这是一种退行性疾病，而不是炎症性疾病；因此，这种疾病的另一个流行术语，肌腱炎，是不合适的。髌腱病的非手术治疗以离心运动为主，常有较好的疗效。其他具有不同证据水平的治疗选择可用于顽固性案例。手术治疗适用于非手术治疗无效的病例。可以进行开放式或关节镜手术；这两种方法具有可比性，但关节镜手术的恢复时间更快。

A, Histologic specimen of a patellar tendon showing connective tissue with increased cellularity and stromal mucoid degeneration (diamond; hematoxylineosin stain, magnification×200). B, Histologic specimen showing areas of vascular proliferation (arrows; hematoxylin-eosin stain, magnification×400). (Courtesy of Mauricio Oyarzo, MD, Santiago, Chile.)

A，髌腱组织学标本显示结缔组织细胞增多和间质粘液变性（菱形；苏木精染色，放大倍数×200）。B，显示血管增生区域的组织学标本（箭头；苏木精-伊红染色，放大倍数×400）。（由智利圣地亚哥医学博士Mauricio Oyarzo提供。）

Clinical photograph demonstrating the decline squat test.

显示下蹲试验的临床照片。

Sonogram showing zones of lower echogenicity (arrow), typically in the posterior portion of the patellar tendon adjacent to the inferior pole of the patella.

超声图显示低回声区（箭头），通常位于邻近髌骨下极的髌腱后方。

Sagittal T1-weighted magnetic resonance image showing increased signal in the posterior region of the proximal patellar tendon and the inferior pole of the patella, with tendon thickening (arrow).

矢状面T1加权磁共振图像显示髌骨近端肌腱后方和髌骨下极的信号增加，肌腱增厚（箭头）。

表格1 髌腱病的严重程度分类15

分级 描述

I级 只在运动后疼痛

II级 运动开始时疼痛，热身后消失，疲劳时再次出现

III级 休息和活动时持续疼痛

IV级 髌腱完全断裂

表2 髌腱病的鉴别诊断

髌股关节疼痛综合征

髌下脂肪垫综合征（炎性水肿或炎性浸润）

半月板撕裂

软骨病变（软骨剥脱OCD，软骨损伤，退变等）

牵涉痛（髋关节疾病，会引起20-75%的膝关节疼痛，需认真排除）

Intraoperative photograph depicting the open surgical technique. The inferior pole of the patella is perforated using a drill to produce a bleeding bed that promotes repair.

开放式手术技术的术中照片。使用钻头对髌骨的下极进行穿孔以产生出血灶促进修复。

Arthroscopic view showing the inferior pole of the patella after the débridement of degenerative tissue.

关节镜下显示髌骨下极退变组织清创后。

Nonsurgical Treatment

非手术治疗

Eccentric Exercises

Eccentric exercises have been proposed to increase the remodeling process of the collagen fibers in the patellar tendon. This process causes the musculoskeletal unit to adapt to protect itself from the stress related to physical activity. Excellent results have been reported in athletes and nonathletic patients. Findings suggest that eccentric exercises have positive effects with no adverse reactions.16 A recent systematic review concluded that eccentric exercises are the only treatment of patellar tendinopathy that has the support of high-level evidence.17 Therefore, we advocate the use of eccentric exercises as the initial treatment for most patients with patellar tendinopathy, especially when the disorder is in the early stages.

偏心练习

已经提出偏心运动来增加髌腱中胶原纤维的重塑过程。这个过程使肌肉骨骼单位适应以保护自己免受与体育活动相关的压力。据报道，在运动员和非运动员患者中取得了优异的疗效。研究结果表明，偏心运动具有积极作用，没有不良反应。16最近的一项系统评价得出结论，偏心运动是唯一有高水平证据支持的髌腱病治疗方法。17因此，我们提倡使用偏心运动作为大多数髌腱病患者的初始治疗，尤其是当疾病处于早期阶段时。

Several different types of eccentric patellar tendon loading exercises are available. In a systematic review, Visnes and Bahr18 concluded that the ability to specify which protocol component is responsible for the positive effects in patellar tendinopathy is limited. The available studies, which are small and of variable quality, indicate that the treatment program should include a decline board, should be performed with some level of discomfort, and should include the removal of athletes from sports activity.19-25

有几种不同类型的偏心髌腱负荷练习可供选择。在一项系统评价中，Visnes和Bahr 18得出结论，指定哪个方案组成条目对髌腱病产生积极影响的能力有限。现有的研究规模小且质量参差不齐，表明治疗计划应包括倾斜木板，应在一定程度不适感的情况下进行，并应包括将运动员从体育活动中移除。19-25

Extracorporeal Shock Wave Therapy

体外冲击波治疗

The utility of extracorporeal shock wave therapy (ESWT) for patellar tendinopathy is based on three theories. 26 The first theory is that pain relief is achieved by hyperstimulation analgesia, in which overstimulation of the painful area leads to a diminished transmission of signals to the brain stem. A second theory presumes that the mechanical load developed by ESWT stimulates tissue regeneration. The third theory asserts that ESWT destroys calcifications in tendons in the same way that lithotripsy destroys kidney stones. Today, ESWT is debated as a treatment option for patellar tendinopathy, although a recent systematic review concluded that it is a safe and promising treatment.27

体外冲击波治疗(ESWT)治疗髌腱病的效用基于三个理论。26第一个理论是，疼痛缓解是通过过度刺激镇痛来实现的，其中对疼痛区域的过度刺激会导致向脑干的信号传输减少。第二种理论假设ESWT产生的机械负荷会刺激组织再生。第三种理论认为，ESWT破坏肌腱钙化的方式与碎石术破坏肾结石的方式相同。今天，ESWT被认为是一种治疗髌腱病有争议的选择，尽管最近的系统评价得出结论认为它是一种安全且有希望的治疗方法。27

Wang et al28 conducted a randomized study that compared ESWT with physical therapy and NSAIDs and found substantial differences in pain, Victorian Institute of Sport Assessment scores, range of motion, functional improvement, overall outcomes, and sonographic vascularity during follow-up that favored the ESWT group. Another, more recent prospective randomized study did not find any benefit for using ESWT, however.29 Given the controversial evidence, more controlled studies are necessary before ESWT can be recommended, and it remains an experimental treatment for patellar tendinopathy.

Wang等28进行了一项随机研究，将ESWT与物理治疗和NSAIDs进行比较，发现在疼痛、Victorian运动评估评分、运动范围、功能改善、总体结果和随访期间的超声血管分布方面存在显着差异，支持选择ESWT治疗。然而，另一项更近期的前瞻性随机研究并未发现使用ESWT的任何益处。29鉴于存在争议的证据，在推荐ESWT之前需要进行更多的对照研究，并且它仍然是髌腱病的实验性治疗。

Injections

注射疗法

Steroids

激素/类固醇药物

We do not recommend steroid injections for the treatment of patellar tendinopathy. Three randomized studies failed to demonstrate long term relief with the use of steroid injections, which pose a potential risk of tendon rupture.30-32 In a randomized study of placebo versus steroid injection, Fredberg et al30 concluded that a steroid injection can normalize the lesions in patellar tendons that are found on ultrasonography and can have dramatic clinical effects over a short-term period, but have no effect in a 4-week to 6-month follow-up period.

我们不推荐使用类固醇注射治疗髌腱病。三项随机研究未能证明使用类固醇注射可以长期缓解症状，这会造成肌腱断裂的潜在风险。30-32在安慰剂与类固醇注射的随机研究中，Fredberg等30得出结论，类固醇注射可以使病变正常化在超声检查中发现的髌腱中，可以在短期内产生显着的临床效果，但在4周至6个月的随访期内没有效果。

Kongsgaard et al31 conducted a randomized study comparing steroid injections, eccentric training, and heavy slow resistance training for patellar tendinopathy. They concluded that all the therapies studied have good short-term effects; however, at long-term follow-up, only the eccentric training and resistance groups maintained the effects, with steroid injections having no beneficial effects at 6-month follow-up. Capasso et al32 compared the efficacy of steroids with aprotinin versus training protocols for management of patellar tendinopathy in athletes. The authors found that steroid treatment resulted in short-term improvement, but that improvement deteriorated by the 6-month follow-up.

Kongsgaard等31进行了一项随机研究，比较了类固醇注射、偏心训练和负重慢速阻力训练对髌腱病的影响。他们得出结论，所研究的所有疗法都具有良好的短期效果；然而，在长期随访中，只有离心训练组和阻力训练组保持了效果，类固醇注射在6个月的随访中没有任何有益效果。Capasso等32比较了类固醇与抑肽酶与训练方案对运动员髌腱病管理的疗效。作者发现类固醇治疗导致短期改善，但在6个月的随访中改善恶化。

Platelet-rich Plasma

富血小板血浆

Platelet-rich plasma (PRP) is thought to be capable of enhancing tissue repair because of its high concentration of growth factors. A recent systematic review showed that studies comparing PRP with other treatments had inconsistent results and that none of the studies showed marked differences between PRP and other treatments.33 Therefore, PRP is a promising therapy, but controlled studies are necessary to determine its true efficacy.

富含血小板的血浆(PRP)被认为能够增强组织修复，因为它含有高浓度的生长因子。最近的一项系统评价表明，将PRP与其他治疗方法进行比较的研究结果不一致，并且没有一项研究显示PRP与其他治疗方法之间存在显着差异。33因此，PRP是一种很有前途的治疗方法，但需要对照研究来确定其真正的疗效。

In a recent systematic review, Jeong et al34 reported that PRP seems to have a positive effect in treating patellar tendinopathy, but the available evidence is of low quality and, thus, this finding is not definitive. Furthermore, no standard protocol for obtaining PRP exists and the number of injections needed is variable. Some evidence shows that multiple injections are better than one injection, however.35,36 In contrast, Kaux et al37 found no benefit for successive injections compared with a single injection. Given the inconsistent results and the lack of uniform protocols for treatment of patellar tendinopathy with PRP, this treatment should be considered investigational.

在最近的系统评价中，Jeong等34报道PRP似乎对治疗髌腱病有积极作用，但现有证据质量低，因此这一发现不是确定性的。此外，不存在获得PRP的标准协议，所需的注射次数是可变的。然而，一些证据表明多次注射优于一次注射。35,36相比之下，Kaux等37发现与单次注射相比，连续注射没有任何好处。鉴于PRP治疗髌腱病的结果不一致和缺乏统一的方案，这种治疗应该被认为是研究性的（临床治疗尚不推荐）。

Cell-based Therapies

基于细胞的疗法

Limited data are available on the use of cell-based therapies for patellar tendinopathy. It is theorized that the addition of stem cells could improve the speed and quality of the repair process and autocrine and paracrine factors could enhance tissue healing and remodeling. Much of the research in this area involves nonrandomized cases studies or series and animal models of the disease.38

关于使用基于细胞的治疗髌腱病的数据有限。理论上，添加干细胞可以提高修复过程的速度和质量，而自分泌和旁分泌因子可以增强组织愈合和重塑。该领域的大部分研究涉及该疾病的非随机病例研究或系列和动物模型。38

Pascual-Garrido et al39 conducted a study in which eight patients with patellar tendinopathy in whom nonsurgical treatments had failed were injected with mononuclear bone marrow cells. At 5-year follow-up, seven patients stated that they were satisfied with the procedure and that they would be willing to undergo the same procedure again if the disease developed in the contralateral knee.

Pascual-Garrido等39进行了一项研究，其中8名非手术治疗失败的髌腱病患者被注射了单核骨髓细胞。在5年的随访中，7名患者表示他们对手术感到满意，如果对侧膝关节出现疾病，他们愿意再次接受相同的手术。

Clarke et al40 injected skin-derived tenocyte-like cells in 33 knees in a prospective randomized study of patients in whom nonsurgical treatments had failed. Faster and greater improvement in pain and function were observed in the group treated with the cells. Cell-based therapies for management of patellar tendinopathy are promising, but more evidence is needed to recommend them. Their use remains experimental, and patients being offered such treatments must be counseled regarding this experimental status.

在一项针对非手术治疗失败的患者的前瞻性随机研究中，Clarke等40在33个膝关节中注射了皮肤来源的肌腱样细胞。在用细胞治疗的组中观察到疼痛和功能的更快和更大的改善。用于治疗髌腱病的基于细胞的疗法是有希望的，但需要更多的证据来推荐它们。它们的使用仍然是实验性的，并且必须就这种实验状态向接受此类治疗的患者提供咨询。

Hyaluronic Acid

透明质酸

High–molecular-weight hyaluronic acid has been reported to have an anti-inflammatory effect in addition to promoting tendon healing at the bone-tendon interface and tissue regeneration.41 In a recent level IV study of 50 patients with patellar tendinopathy that did not respond to a minimum 2-month course of nonsurgical treatment, a mean of two injections of hyaluronic acid had positive effects on recovery.41 High quality evidence regarding this treatment is still lacking. More studies are needed to determine the efficacy of this treatment option, which remains at an investigational stage.

据报道，除了促进骨-肌腱界面的肌腱愈合和组织再生外，高分子量透明质酸还具有抗炎作用。41在最近一项对50名没有反应的髌腱病患者的IV级研究中对于至少2个月的非手术治疗疗程，平均两次注射透明质酸对康复有积极影响。41关于这种治疗的高质量证据仍然缺乏。需要更多的研究来确定这种治疗方案的有效性，该方案仍处于研究阶段。

Sclerosing Agents

硬化剂

Neovascularization is a phenomenon that is considered relevant in the pathophysiology of patellar tendinopathy, and it is present in 60% to 80%ofpatientswithpain.7 Therefore, sclerosing agents are used to inhibit vessel formation, collapse vessels that have already formed, and destroy the accompanying vasa nervorum, which has a denervating effect.

新生血管形成是一种被认为与髌腱病的病理生理学相关的现象，它存在于60%至80%的疼痛患者中。7因此，硬化剂用于抑制血管形成，使已形成的血管塌陷，并破坏伴随的血管神经形成，具有去神经作用。

In a level IV study, Alfredson and Ohberg42 reported a considerable reduction in pain during activity following an ultrasound-guided injection of a sclerosing agent (5 mg/mL polidocanol) to the paratenon, which indicates that sclerosing agents have the potential to manage pain. Hoksrud et al43 administered an ultrasound-guided injection of polidocanol (10 mg/mL) to the paratenon in patients with painful chronic patellar tendinopathy and found a substantial difference in the Victorian Institute of Sport Assessment-P score in the group treated with a sclerosing agent versus a placebo. However, in a subsequent study of the same group with a longer follow-up (44 months), more than one third of the group treated with sclerosing agents underwent surgery for pain.44 Therefore, the usefulness of sclerosing agents remains unclear, and the agents still are at an experimental stage.

在一项IV级研究中，Alfredson和Ohberg 42报告称，在超声引导下将硬化剂(5 mg/mL聚多卡醇)注射到肌腱组织旁后，活动期间的疼痛显着减轻，这表明硬化剂具有控制疼痛的潜力。Hoksrud等43对患有疼痛性慢性髌腱病患者的腱旁进行了超声引导下的聚多卡醇(10 mg/mL)注射，发现在使用硬化剂治疗的组中，维多利亚运动评估研究所的P评分存在显着差异与安慰剂相比。然而，在随后对同一组进行更长随访（44个月）的研究中，超过三分之一的硬化剂治疗组接受了疼痛手术。44因此，硬化剂的效用仍不清楚，并且代理仍处于试验阶段。

Other Injections

其他注射剂

Various other injections have been studied for the treatment of patellar tendinopathy. Aprotinin, autologous blood, dry injections, and high volume injections all have been used; however, studies of these treatment options are of low quality and the effects of these treatments remain unclear. Therefore, at this time, it is impossible to recommend their use for management of patellar tendinopathy. Thus, they remain experimental treatments.45

已经研究了各种其他注射剂用于治疗髌腱病。抑肽酶、自体血、干注射剂和大容量注射剂均已使用；然而，对这些治疗方案的研究质量低下，这些治疗的效果仍不清楚。因此，目前无法推荐将它们用于治疗髌腱病。因此，它们仍然是实验性治疗。45

Additional Treatments

其他治疗方式

Various other treatments have been examined in level I studies. Glyceryl trinitrate delivers nitric oxide, which has exhibited a role in fibroblast proliferation, collagen synthesis, and the contraction of collagen lattices. Macrophage angiogenic activity, which is important for wound healing, also depends on nitric oxide synthase, and nitric oxide synthase activity is upregulated in tendinopathy.46 Based on the positive effects of glyceryl trinitrate reported in three studies of other types of tendinopathy, 47-49 Steunebrink et al46 conducted a randomized study of patients with patellar tendinopathy comparing the use of a glyceryl trinitrate patch with that of a placebo patch. The authors did not find any difference in outcome between the two groups.

在I级研究中已经检查了各种其他治疗方法。三硝酸甘油酯提供一氧化氮，它在成纤维细胞增殖、胶原蛋白合成和胶原蛋白晶格收缩中发挥作用。对伤口愈合很重要的巨噬细胞血管生成活性也取决于一氧化氮合酶，而一氧化氮合酶活性在肌腱病中上调。46基于其他类型肌腱病的三项研究中报告的三硝酸甘油酯的积极作用，47-49 Steunebrink等46对髌腱病患者进行了一项随机研究，比较了使用硝酸甘油贴片和安慰剂贴片的情况。作者没有发现两组之间的结果有任何差异。

Low-intensity pulsed ultrasonography can stimulate in vitro collagen production from fibroblasts and may increase mechanical strength following the repair of acute tendon injuries. Stasinopoulos and Stasinopoulos21 and Warden et al50 each conducted a randomized study on the effectiveness of low-intensity pulsed ultrasonography and found that this modality provided no benefit compared with eccentric exercises for management of patellar tendinopathy. These findings are supported by an earlier study by Giombini et al51 that showed that hyperthermia was more effective than lowintensity pulsed ultrasonography for the treatment of patellar tendinopathy. All these modalities remain at an investigational stage and are not recommended for management of patellar tendinopathy.

低强度脉冲超声可以刺激成纤维细胞在体外产生胶原蛋白，并可以增加急性肌腱损伤修复后的机械强度。Stasinopoulos和Stasinopoulos 21以及Warden等50各自对低强度脉冲超声检查的有效性进行了一项随机研究，发现与偏心锻炼相比，这种方式在治疗髌腱病方面没有任何益处。这些发现得到Giombini等早期研究的支持51，该研究表明热疗比低强度脉冲超声治疗髌腱病更有效。所有这些方式仍处于研究阶段，不推荐用于治疗髌腱病。

Surgical Treatment

手术治疗

Although nonsurgical treatment is successful in most patients with patellar tendinopathy, approximately 10% of all patients do not respond to it and eventually require surgery.52 Several surgical techniques have been described, including open surgery and arthroscopic surgery.53 The goals of these techniques are tenotomy of the patellar tendon, excision of abnormal tissue, and induction of the repair process through stimulation of the inferior pole of the patella by drilling and marginal resection.

尽管大多数髌腱病患者的非手术治疗是成功的，但大约10%的患者对其没有反应并最终需要手术治疗。52已经描述了几种手术技术，包括开放手术和关节镜手术。53这些技术的目标是髌腱切断术，异常组织切除，通过钻孔和边缘切除刺激髌骨下极诱导修复过程。

Open Surgery

开放手术

A longitudinal incision is made from the inferior pole of the patella to the tibial tubercle. The paratenon is exposed and opened longitudinally to expose the patellar tendon. Through a longitudinal incision into the tendon, the posterior degenerative tissue is approached and débrided. The distal 5 mm of the patella are resected using a saw blade. Then, the inferior pole of the patella is perforated using a drill to produce a bleeding bed that promotes repair (Figure 5). Finally, the tendon and paratenon are closed with resorbable sutures.

从髌骨下极到胫骨结节做一个纵向切口。腱旁暴露并纵向打开以暴露髌腱。通过肌腱的纵向切口，接近并清除后部退行性组织。使用锯片切除髌骨远端5 mm。然后，使用钻头对髌骨下极进行穿孔，以形成促进修复的出血床（图 5）。最后，用可吸收缝线闭合肌腱和腱旁。

Arthroscopic Surgery

关节镜手术

The procedure starts with diagnostic arthroscopy to rule out intra-articular pathology. It is of particular importance to rule out patellar chondral lesions, which frequently are associated with patellar tendinopathy. The inferior pole of the patella is identified, and the adjacent synovial tissue is resected, exposing the degenerative tissue in the posterior zone of the proximal patellar tendon, which is resected until normal tendon fibers are observed (Figure 6). The distal 5 mm of the patella are resected using a burr. Finally, hemostasis is achieved, and articular lavage is performed.

该程序从诊断性关节镜检查开始，以排除关节内病变。排除经常与髌腱病变相关的髌骨软骨病变尤为重要。识别髌骨下极，切除邻近的滑膜组织，暴露髌骨近端肌腱后区的退变组织，直至观察到正常肌腱纤维（图6）。使用钻头切除髌骨远端5 mm。最后，实现止血，并进行关节灌洗。

We use the same rehabilitation protocol for open and arthroscopic surgery, consisting of full weight bearing and free range of motion as tolerated. When the wounds are healed at approximately 10 days postoperatively, the patients start a rehabilitation program that consists of pain management, the initiation of eccentric squats on an inclined board, and a strengthening program. Patients are allowed to return to sport when they have completed at least 3 months of supervised rehabilitation and are pain free during strengthening exercises.

我们对开放式和关节镜手术使用相同的康复方案，包括完全负重和可耐受的自由活动范围。当伤口在术后约10天愈合时，患者开始康复计划，包括疼痛管理、在斜板上开始偏心深蹲和加强计划。当患者完成至少3个月的监督康复并且在加强锻炼期间没有疼痛时，他们可以重返运动场。

Results

髌腱病治疗结果

Comparable results for open and arthroscopic surgery have been described in the literature. A recent systematic review reported that the mean rate of success for surgical treatment of patellar tendinopathy is 87% for open treatment and 91% for arthroscopic treatment.54 In the studies reviewed, the mean time to return to sports was 3.9 months for arthroscopic treatment and 8.3 months for open treatment. The average rate of return to sporting activities was 82.3% after arthroscopic surgery and 78.4% after open surgery.54 In patients who underwent open surgery with the resection of the inferior pole of the patella, clinical scores were better than in those who underwent the procedure without resection. However, no difference was observed in the rate of return to sport, and the time to return to sport was longer for the group treated with bony patellar resection. In patients treated with arthroscopic surgery, those who had resection of the inferior pole of the patella had better rates of return to sports than did those without resection of the inferior patellar pole, but there was no difference in clinical scores or the time to return to sports between the two groups.

文献中描述了开放手术和关节镜手术的可比结果。最近的一项系统评价报告说，髌腱病手术治疗的平均成功率为87%，开放治疗为87%，关节镜治疗为91%。54在回顾的研究中，关节镜治疗的平均恢复运动时间为3.9个月，开放治疗8.3个月。关节镜手术后恢复体育活动的平均率为82.3%，开放式手术后为78.4%。54接受开放式手术切除髌骨下极的患者，临床评分优于接受该手术的患者不切除。然而，恢复运动的比率没有观察到差异，并且接受骨性髌骨切除治疗的组恢复运动的时间更长。在接受关节镜手术治疗的患者中，切除髌骨下极的患者恢复运动的率高于未切除髌下极的患者，但临床评分或恢复时间无差异两组之间的运动。

No clear guidelines exist for the use of one technique over another. However, given that arthroscopic treatment has results comparable to those of open surgery but yields a faster return to sport, we recommend arthroscopic treatment of patellar tendinopathy as long as the surgeon has experience using this technique.

对于使用一种技术优于另一种技术，没有明确的指导方针。然而，鉴于关节镜治疗的效果与开放手术相当，但可以更快地恢复运动，只要外科医生有使用该技术的经验，我们建议对髌腱病进行关节镜治疗。

Summary

总结

Historically, patellar tendinopathy has been associated with jumping sports. The main pathophysiologic phenomenon of patellar tendinopathy is tendinosis, which is a degenerative disorder rather than an inflammatory disorder. Therefore, the popular term for this disease, tendinitis, is not appropriate. Nonsurgical treatment primarily consists of eccentric exercises, which often have good results. If a patient does not respond to these exercises in a 4- to 6-month period, other nonsurgical options may be attempted, but all of these options are in experimental stages. ESWT and injections of PRP or other agents are promising treatments, but more evidence is required before they can be recommended. For cases refractory to nonsurgical treatment, surgery is indicated and can be performed open or arthroscopically. The two methods are comparable, but arthroscopic treatment results in a faster return to sport.

从历史上看，髌腱病与跳跃运动有关。髌腱病的主要病理生理现象是肌腱变性，这是一种退行性疾病，而不是炎症性疾病。因此，这种疾病的流行术语，肌腱炎，是不合适的。非手术治疗主要包括偏心锻炼，通常有很好的效果。如果患者在4到6个月内对这些练习没有反应，则可以尝试其他非手术选择，但所有这些选择都处于实验阶段。ESWT和注射PRP或其他药物是有希望的治疗方法，但在推荐之前需要更多证据。对于非手术治疗难治的病例，手术是指征，可以切开或关节镜下进行。这两种方法具有可比性，但关节镜治疗可以更快地恢复运动。

文献出处：David Figueroa, Francisco Figueroa, Rafael Calvo. Patellar Tendinopathy: Diagnosis and Treatment. Review, J Am Acad Orthop Surg. 2016 Dec;24(12):e184-e192. doi: 10.5435/JAAOS-D-15-00703.

图片来源Google images。