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 30-year-old male presented with severe pain and inability to move his right knee following injury in a RTA. The mechanism of injury was a direct force on his flexed knee while riding pillion on a bike, followed by a twisting valgus knee injury with foot landing on the ground. He was brought to the emergency and evaluated for the injury. On clinical examination, abrasions were noted over the anterior aspect of the knee ( and ). A subtle dip was noted on the patellar tendon region and patient was unable to move his knee. Due to severe pain, further clinical examination was not possible. Radiographs revealed patella Alta ( and ). An urgent MRI was done to evaluate all the injuries of the knee. MRI confirmed the presence of patellar tendon injury along with ACL tear and Grade 1 medial collateral ligament sprain ( and ).\nThe patient was planned for immediate extensor mechanism repair, followed by ACL reconstruction at a later date. Under anesthesia, Lachman’s test and anterior Drawer’s test were found to be positive. A longitudinal incision skirting around the abrasion was made over the right knee. Intraoperatively, the patellar tendon and extensor retinaculum were found torn (). The patellar tendon was torn at its mid portion and was attached end to end using prolene 1-0 (). The extensor retinaculum was repaired using Vicryl 1-0. Following closure, the limb was immobilized in a slab. A cylindrical cast was applied after suture removal and kept for a further period of 3 weeks, during which the patient was taught isometric quadriceps exercises. The cast was removed at 5 weeks post repair and knee were mobilized using continuous passive motion and active assisted exercises. Once active full extension with flexion up to 120° was attained by the patient, arthroscopic ACL reconstruction using hamstring graft was done at 6 weeks. The ipsilateral hamstrings graft was harvested and prepared ( and ). The tunnels were drilled using the transtibial technique. The femoral side was fixed using cross pins and tibial side using bioabsorbable screw. Postoperatively patient underwent routine post ACL reconstruction physiotherapy followed at our institute. In the immediate post-operative period, a hinged brace was provided with flexion permitted up to 90° and closed chain exercises were initiated. This was followed by partial weight bearing at 4 weeks, and open chain exercises were started after 3 months. At 6 months post injury, the patient has regained full function of the knee including complete active extension and flexion up to 120°, with full weight bearing and stability ( and ).