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 ).
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.