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 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 ).