A 32-year-old male visited our clinic with a major complaint of severe pain in the right knee that started to occur when he managed to stop running over the second base that he had run toward while playing baseball. The right leg that was planted on the second base at the time of injury produced a crackling sound when the knee was flexed with a valgus force applied and severe swelling of the right knee, range of motion (ROM) restriction due to pain, and approximately 40° of extension lag were present. Simple plain radiography showed patella alta on the lateral view (), but other abnormal findings, such as a fracture, were not observed. Magnetic resonance imaging (MRI) was performed to identify if there is an accompanying injury, which revealed a complete tear of the patellar tendon and complete tears of the ACL and the medial collateral ligament (MCL) at the femoral attachment sites, and increased signal intensity in the lateral meniscus led us to suspect an injury to the meniscus ().\nAt 6 days after injury, primary suture repair of the patellar tendon with ACL reconstruction was carried out. The patellar tendon repair preceded the ACL reconstruction. Initially, a 10cm longitudinal skin incision extending from the middle of the patella through the center of the patellar tendon to the tibial tuberosity was made to expose the ruptured patellar tendon. The patellar tendon was completely torn in the midsubstance, the torn end had a frayed mop-end appearance, and the tear extended to the medial retinaculum (). Taking consideration into the shape of the torn end and the distally narrowing anatomical shape of the patellar tendon, the torn end was longitudinally divided into three equal sections, and three core sutures of the patellar tendon were determined. The center of the distal end was repaired with a Fiberwire (Arthrex, Naples, FL, USA) suture using the Krackow method. Two longitudinal bone tunnels were created in the patella using a 2.0-mm Kirschner wire. A suture was passed through the tunnel and pullout repair with the proximal end was performed on the anterosuperior patella with the knee in 45° flexion. The proximal end was sutured with two Fiberwire sutures at medial 1/3 and lateral 1/3 points using the Krackow method. A bone tunnel parallel to the tibial tuberosity was created, through which the sutures were passed and pullout suture with the distal torn end was done. At the torn ends, end-to-end anastomosis was performed additionally (. Subsequently, an anterolateral portal, an anteromedial portal, and an accessory far medial portal for anatomical ACL reconstruction were created through the skin incision. An arthroscope was introduced into the joint. The presence of a transverse tear in the posterior horn of the lateral meniscus that was not clearly identifiable on MRI was confirmed. It was repaired using an all inside technique with two PDS (polydioxanone monofilament; Ethicon Inc., Somerville, NJ, USA) sutures. A complete tear of the ACL at the femoral attachment site was confirmed, and reconstruction was done using an Achilles tendon allograft to avoid a donor site injury (). For anatomical ACL reconstruction, a femoral tunnel was created at the center of the femoral attachment of the ACL using the transportal technique and a tibial tunnel was made at the center of the tibial attachment site using Pinn-ACL tibial guide (Linvatec, Largo, FL, USA). With the calcaneal fragment of the Achilles tendon allograft placed toward the femur, the graft was fixated to the femur using a metal interference screw and to the tibia using a bioabsorbable interference screw with the knee in 20° flexion, and a metal staple was used for additional fixation. Following ACL reconstruction, a primary suture for the medial retinaculum and the patellar tendon sheath was carried out. The complete tear of the MCL at the femoral attachment site was conservatively treated: after 2 weeks of splint immobilization, rehabilitation therapy was administered so that the range of flexion could be gradually increased.\nFor the 14 postoperative days, the patient was treated with compression dressing, application of ice, and elevation of the leg with a long leg splint applied, to reduce swelling. From day 1 after surgery, quadriceps strengthening exercises were recommended. From the second postoperative week, the long leg splint was replaced with a limited motion knee brace and the patient was encouraged to perform flexion exercises within pain-free ranges. The range of flexion was gradually increased to 30° at the 2nd postoperative week, to 60° at the 4th postoperative week, and to 90° at the 6th postoperative week. Weight bearing ambulation was not allowed until 6 weeks after surgery due to the meniscal repair.\nMRI scan at 6 month after surgery showed well-maintained continuity of the ACL and patellar tendon and no abnormal findings in other soft tissue, such as the meniscus (). At 1-year postoperative follow-up, 0°-140° of flexion was possible, and no changes were detected in the Lachman and pivot shift tests. The Lysholm score was satisfactorily high (94 points). Other than discomfort in the knee after long or knee-straining activities, no complication was reported.
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.