A 45-year-old man presented to our clinic with a left knee injury that had occurred a few days before while skiing. He had been immobilized in a brace at the local medical office.\nClinical examination showed marked swelling of the knee joint, with pain at passive mobilization and restricted active motion: 40° of active flexion and an inability to actively extend the knee. Weight-bearing was hardly possible. There was an obvious gap at the level of the insertion of the patellar tendon on the lower pole of the patella. Testing of the MCL compared to the healthy side showed >10 mm widening of the medial joint line with valgus stress in 30° of flexion as well as in full extension. There was no clinical evidence of instability of the other knee ligaments.\nThe X-ray of the injured knee showed a superior migration of the patella compared to its usual position (). An MRI-scan confirmed the clinical suspicion of a complete tear of the MCL next to its proximal insertion on the medial femoral condyle, as well as a complete rupture of the patellar tendon at the level of its insertion on the lower pole of the patella. There were no lesions of the cruciate ligaments and menisci ().\nThe medical history revealed lower back pain due to a herniated disc, which had been treated conservatively. The patient also reported some pain episodes at the level of the left patellar tendon while jogging in the past. No specific treatment was prescribed for these pains.\nOur patient was operated on under epidural anesthesia 5 days after his accident. Clinical examination under anaesthesia confirmed once again the complete instability of the MCL with valgus stress without laxity in the other plains of motion.\nAt first, we approached the patellar tendon through an anterior longitudinal midline incision. After debridement of the tendinous tissue at the level of the tear, a Krackow-stitch was placed in the patellar tendon distally to its tear. The two loops of this stitch were passed through two bony tunnels in the patella and sutured to each other at the proximal pole of the patella. At the level of the tear, the transosseous reinsertion was reinforced by a running suture of a 3/0 wire. As there was a history of pain at the patellar tendon, we decided to reinforce the reinsertion of the tendon with an allograft of fascia lata, which was sutured directly to the tendinous tissue with absorbable stitches.\nThe tear of the MCL was approached via an oblique medial incision. At first we performed a direct suture which was reinforced with an autograft of the homolateral semitendinosus tendon. The semitendinosus was isolated with an open stripper, taking care to preserve its distal insertion on the tibia. After suturing it to the MCL, the autograft was fixed proximally with a staple at the level of the medial femoral condyle and distally with a direct suture to its original insertion in order to obtain a double-loop reinforcement. The staple fixation was done in a position of 30° knee flexion and slight varus.\nPostoperatively the knee was immobilized in 10° of flexion in a synthetic plaster cast with partial weight-bearing allowed. After 3 weeks the knee was placed in a brace with progressive flexion: 30° the first week, 60° the second week, and 90° the last week. After 6 weeks the brace was removed and complete flexion allowed. A rehabilitation programme with progressive mobilization, proprioceptive training, and muscle strengthening exercises was started.\nClinical control 3 months after the operation showed a limitation of flexion of 20° compared to the other side. There was no swelling of the knee but evident atrophy of the quadriceps muscle without limitation of active extension. Mediolateral stability testing showed no residual valgus instability. A bilateral X-ray of the knee showed normal height of the patella.\nAt 6 months, full motion was recovered and the patient had returned to normal daily life and recreational sports activities (cycling, fitness). Due to discomfort at the level of the medial femoral condyle, the staple fixing the semitendinosus autograft was removed at 9 months. After this removal, no medial instability occurred. At final follow-up 18 months after the injury, the patient was symptom-free and he had returned to skiing, protecting his knee with a brace.
A 36-year-old female jumped from a four-foot high deck landing flatly on both feet. She felt a pop in the right knee and experienced extreme pain and inability to bear weight on the limb. She sought emergency medical attention where radiographs revealed a joint effusion, and a wavy appearance to the tendon []. There was no patellar elevation, fracture or malalignment. Clinically the patient was believed to have an ACL tear. The patient was treated with a knee brace and instructed to follow-up with an orthopedic surgeon and obtain an MR examination of the knee.\nThe MR examination of the right knee was obtained 10 days later and demonstrated abnormal increased T2 signal in the midsubstance of the ACL and abnormal orientation of the ligament consistent with a complete ACL disruption []. Bone contusions in the posterior medial and lateral tibial plateaus as well as the lateral femoral condyle were present. The patellar tendon was abnormal in morphology and signal. The tendon had an abnormal wavy contour at the junction of the middle and distal thirds of the tendon and had abnormally increased signal on T2-weighted images. The axial images demonstrated near complete disruption of the patellar tendon with only a few intact fibers.\nOrthopedic follow-up visit was delayed for nearly 2 months. At the time of presentation she had persistent pain, instability, and very limited range of motion. She had a positive Lachman test of the right knee. Although the patient had tenderness over the patellar tendon, there was no palpable tendon defect and she was able to hold a straight leg raise with minimal extensor lag. The patient was diagnosed with a complete ACL tear and high-grade partial patellar tendon tear. Physical therapy was instituted to help prevent postoperative fibrosis. A delayed ACL reconstruction was schedule 8 weeks later.\nA diagnostic arthrogram at the time of surgery confirmed a complete midsubstance ACL tear. The ACL was reconstructed with an ipsilateral hamstring autograft. The patellar tendon was not directly inspected at the time of surgery and was treated clinically as a partial patellar tendon tear. The patient's postoperative course was complicated by complex regional pain syndrome requiring multiple nerve block injections. A year following the initial injury, the patient had continued stiffness, difficulty with walking and had developed quadriceps muscle atrophy.