SURGERY OR NOT? Surgery is reserved for cases where conservative treatment, including injections (corticosteroids or PRP) and progressive reloading programs, have consistently failed (usually after 6 to 12 months of optimal care or depending on the ski season—spring is preferable in order to allow for a gradual recovery without the constraints of skiing).
The indication for surgery is primarily functional and symptomatic:
Failure of Conservative Treatment: Persistent chronic pain (Phase 3 or 4 of the Cook and Purdam classification) 15 ,despite a well-conducted rehabilitation program (optimal loading) lasting at least 6 months, often extended to 9-12 months.
Severe functional impact: Inability to return to previous athletic level and significant impact on activities of daily living.
Exclusion of differential diagnoses: Confirmation by imaging (MRI, ultrasound) that it is indeed tendinosis of the lower pole of the patellar, and not a cartilage lesion, patellofemoral pathology, or Osgood-Schlatter disease.
The different surgical procedures are:
Debridement and excision (open technique or arthroscopy), in which the area of degenerative tendon tissue (the neo-matrix) is removed, often located on the posterior and proximal side of the tendon (against the lower pole of the patella). Tenotomy and drilling, which involves making a longitudinal incision in the tendon to stimulate an inflammatory response and neovascularization, thereby promoting healing. Then, drilling small tunnels in the bone of the lower pole of the patella allows blood and stem cells to flow to the injured osteotendinous junction, which is supposed to improve repair (localized microfracture effect). Tendon stripping to cut small nerves (neo-innervation) and neovessels that are often associated with chronic pain. In all these cases, PBM must be used immediately after surgery (daily from day 1 to day 5, then 2 to 3 times a week depending on rehabilitation). This type of treatment promotes microcirculation and fibroblast formation and stimulates stem cells.
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