Arthroscopic Resection of Symptomatic Tibial Tubercle Ossicles for Recalcitrant Osgood-Schlatter Disease Using a 2-Portal Technique

Abstract

Arthroscopic resection of symptomatic unfused tibial tubercle ossicles causing chronic anterior knee pain due to recalcitrant Osgood-Schlatter disease has been shown to be a reproducible arthroscopic technique. Although a number of other surgical techniques have been described, including ossicle excision and tubercle-plasty, drilling of the tibial tubercle, bone peg insertion to induce fusion, open excision of loose fragments, direct bursoscopic ossicle resection, and closing-wedge tubercle osteotomy, with varied outcomes, this technique offers a minimally invasive approach with low risk. Complications including injury to the patellar tendon and scarring of the anterior fat pad have been previously reported, but this approach can be performed with minimal fat pad debridement and direct visualization of the patellar tendon during all resections. This article presents a technique for arthroscopic resection and debridement of unfused ossicles in patients with chronic anterior knee pain due to Osgood-Schlatter disease by use of minimally invasive arthroscopic techniques that are used in standard knee arthroscopy and should be familiar to most arthroscopists.

Fig 1

Plain radiographic lateral view left knee showing retained unfused ossicle (red arrow) at tibial tuberosity consistent with Osgood-Schlatter disease.

Fig 2

Sagittal T1 magnetic resonance image of left knee showing retained unfused ossicle (arrow) at patellar tendon insertion consistent with Osgood-Schlatter disease.

Fig 3

Sagittal T2 magnetic resonance image of left knee showing retained unfused ossicle (arrow) at patellar tendon insertion consistent with Osgood-Schlatter disease.

Fig 4

Axial T2 magnetic resonance image of left knee showing retained unfused ossicle (arrow) at patellar tendon insertion consistent with Osgood-Schlatter disease.

Fig 5

Operative positioning during arthroscopic resection of ossicles in left knee with Osgood-Schlatter disease using 2-portal technique, with anteromedial portal for arthroscopic viewing and anterolateral portal for instrumentation. The portals have been switched from the initial diagnostic arthroscopy, with the anterolateral portal used for arthroscopic viewing and the anteromedial portal used for instrumentation.

Fig 6

Needle localization of superior tip of ossicle using fluoroscopic imaging with lateral view. The needle can be simultaneously visualized arthroscopically to confirm its location.

Fig 7

Identification of tibial tubercle ossicle during arthroscopic resection for recalcitrant Osgood-Schlatter disease in left knee using 2-portal technique. Viewing is performed through an anteromedial portal using a 70° arthroscope after arthroscopic shaver and radiofrequency electrode debridement, then looking inferiorly and lateral to the intact and protected patellar tendon (blue arrow). An anterolateral working portal is used to excise the ossicle (red arrow) with an arthroscopic burr (orange arrow) after skeletonization of the ossicle with a shaver and radiofrequency electrode directed away from the patellar tendon.

Fig 8

Arthroscopic burr beginning resection of Osgood-Schlatter disease ossicle in left knee with arthroscopic viewing through anteromedial portal and instrumentation through anterolateral portal. An arthroscopic 3.5-mm burr and unhooded burr are used to completely resect the retained tibial tubercle ossicle. The patellar tendon is visualized during resection to ensure that the tendon remains undamaged.

Fig 9

Arthroscopic post-resection image showing eradication of retained tibial tubercle ossicle with intact patellar tendon. Arthroscopic image of left knee with arthroscopic viewing through anteromedial portal and instrumentation through anterolateral portal.

Fig 10

Post-resection lateral fluoroscopic image confirming complete elimination of tibial tubercle ossicle in knee with Osgood-Schlatter disease.