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Fifty primary ACL repairs using the Marshall multiple suture technique were analyzed. The average age at surgery was 23 years (range, 15 to 56), with 76% under the age of 30. The average followup was 61.3 months (range, 48 to 86). The average time from injury to surgery was 7 days (range, 1 to 18). Eighty percent of the injuries were sports-related with football and skiing predominating. Thirty-eight percent were "isolated" ACL tears, and 62% had associated injuries. There was a 46% incidence of meniscal tear with 59% of the meniscal tears being repaired. The postoperative evaluation included a multifactorial analysis correlating 43 variables including subjective, objective, radiographic, and KT-1000 data. The Hospital for Special Surgery Knee Diagnostic Score, a clinical objective score based on the postoperative Lachman and pivot shift examination, a KT-1000 arthrometer data score, and an overall combined assessment score were determined. The results showed 59% excellent, 18% good, 14% fair, and 8% poor. The Lachman test was diagnostic in all cases. The quality of ACL tissue at repair was rated excellent or good in 62% of the cases. Four patterns of ACL tears were distinguished by the location of the tear. Football injury, younger age, increased peroperative pivot shift, midsubstance Type IV tear, and return of full motion correlated with poor postoperative results. Increasing age, tight jointedness, Type I tears, and a 5 degrees flexion contracture correlated with good postoperative results.

One hundred two patients underwent an arthrotomy for the primary repair of an acute ACL tear with or without an associated collateral ligament injury. The mean age was 23 years. Forty-seven patients (46%) had meniscal injuries. Meniscal injuries were found in 41% of Group I patients (isolated ACL injuries) and in 54% of Group II patients (injured ACL/collateral ligaments). Twenty-eight medial and 22 lateral meniscal tears were noted. Twenty-six of the 50 meniscal tears (52%) were sutured in an attempt to repair the menisci. Of these, 20 of the medial (71%), and 6 of the lateral (27%) meniscal injuries were sutured. No patients in this series required a total meniscectomy. A thorough evaluation of the menisci is mandatory in knees with an acutely injured ACL.

Rupture of the ACL is an extremely common sports injury and its incidence is currently rising.3,4,28 Various mechanisms of injury have been described as causing ACL injuries.3, 4, s, 28 Rupture of the patellar tendon, on the other hand, is rare. In the Kannus and Jozsa 12 study of 891 tendon ruptures, less than 6% of the injuries involved the patellar tendon. Clinicians agree that this injury occurs predominantly in the under-40 age group because in later life ruptures of the extensor mechanism typically involve the quadriceps tendon. Patellar tendon ruptures are associated with intratendinous degenerative changes (e.g., jumper's knee) (Refs. 10, 14, 25; G. J. Lane et al., unpublished data, 1994).In 1980, Baker reported a case in which a 24-year-old basketball player simultaneously ruptured the ACL, medial collateral ligament (MCL), and patellar tendon. In 1991, Rae and Davies 23 published what they considered to be the first report of the same injury combination in a 25-year-old trampoline gymnast. Rupture of the patellar tendon and the ACL without involvement of the MCL (Cases 2 and 3) has not, to our knowledge, been reported previously.We analyzed six cases collected from different centers. The treatment modes have varied widely. In each case, both the preoperative assessment and subsequent surgery were performed by at least one of the authors. We made a special effort to clarify the exact mechanism of injury in each case based on the patient's recollection, and we conducted interviews of bystanders, when possible. We more accurately scrutinized one of the injuries, which occurred during a professional football game, by using frame-toframe analysis of the existing videotape. CASE HISTORIESCase 1 A 36-year-old recreational soccer player injured his knee jumping for the ball (Table 1). On landing, he heard two pops as his knee collapsed under him. He had a positive Lachman test and a grade 3 opening on valgus stress on examination.During the operation, surgeons were surprised to find a midsubstance tear of the patellar tendon. Primary repair of the patellar tendon, as well as medial and lateral meniscal repairs, distal reattachment of the MCL, and ACL reconstruction with a prosthetic ligament were performed during the same procedure.After surgery, a hinge brace that limited motion was applied to the knee for 8 weeks. Rehabilitation was then intensified. At followup, 18 months after surgery, the athlete had full knee extension and good return of quadriceps muscle strength. Knee flexion had diminished by 15° and radiographs showed a 20% shortening of the patellar tendon. Results of the Lachman and pivot shift tests were negative.Case 2 A 15-year-old high school athlete injured her right knee during a long jump (Fig. 1). She heard a pop when she landed and subsequently was unable to walk. She was taken to the nearest hospital, where a patellar tendon rupture was diagnosed and a primary repair was performed. After surgery, the leg was immobilized in a long leg cast for 6 weeks.

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Bilateral rupture of the infrapatellar tendons is a rare event in an otherwise healthy athletic individual. The event is usually quite severe and diagnosis can be readily made on a clinical examination. In the case presented here, predisposing factors consisted of an underlying patella alta and a long history of repetitive trauma to the knee. Prompt diagnosis and surgical repair will lead to a good functional result.

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