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 15.5-year-old female teenager presented to the emergency room with acute right knee pain after she jumped from a scooter to brake going downhill at high speed. She reported feeling a “popping” in the knee and collapsed. Her knee became swollen, and she was unable to bear weight. The patient had a moderate knee effusion but was nevertheless able to extend the knee against gravity. No laxity during valgus stress testing was found, and the Lachmann test was negative. The foot was well perfused, and pulses were present. As the clinical vascular examination was entirely normal, we did not perform an arteriogram. Radiographs and MRI revealed a partial distal patellar tendon avulsion injury, a complete tear of the ACL, and associated bone bruises on the lateral femoral condyle, and also on the posterolateral tibial plateau (Figures –). The posterior cruciate ligament and the MCL were undamaged (Figures and ). The patient was taken to the operating room to repair the distal patellar tendon avulsion 14 days after her injury. The clinical exam under general anesthesia demonstrated a positive (grade 1) Lachman test, but no laxity during the valgus stress test. Considering the importance of the patellar tendon lesion, we avoided to perform a pivot shift test during general anesthesia. The surgical treatment focused therefore on stabilizing the patellar tendon/extensor mechanism. Surgical exploration demonstrated a partial distal patellar tendon bone avulsion injury; repair of the lesion was realized by osteosuture using suture anchors. At a 9-month follow-up (), the patient recovered a functional range of motion, with a mild 20° flexion restriction. She did not feel any anterolateral rotatory instability, and she could participate in light sports activities. Radiographs demonstrated a normal patellar height with a Caton-Deschamps index measured at 0.7; however, we noted an anterior static tibial translation of 9 mm.