Simultaneous Rupture of the Anterior Cruciate Ligament and the Patellar Tendon

Abstract

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are associated with intratendinous degenerative changes (e.g., jumper's knee) (Refs. 10, 14, 25; G. J. Lane et al., unpublished data, 1994).In 1980, Baker reported a case in which a 24-year-old basketball player simultaneously ruptured the ACL, medial collateral ligament (MCL), and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.

Intra-articular knee injuries in patients with knee extensor mechanism ruptures

“…The incidence of meniscal tears in patients with acute ACL ruptures have been reported between 16 and 82% [4][5][6]. There have been several documented case reports of patellar tendon ruptures with ACL ruptures [7,8]. One case report found in the literature described a simultaneous rupture of the patellar tendon combined with a MCL tear and an ACL rupture [9].…”

A complex knee injury in a rugby league player

“…A careful clinical examination is important when the injuries are suspected to have occurred individually, as the combined injury was missed in several of the previous case reports. [1][2][3]5 In the eight cases reported previously 1-3,5 the mechanism of injury was not well described. In our case, it is possible that all structures were damaged at one of two points in the tackle or that the PT was injured separately to the ACL and MCL.…”

Acute Concomitant Anterior Cruciate Ligament and Patellar Tendon Tears in a Non-dislocated Knee

“…Simultaneous ACL and PT tears have been described largely in a limited number of case reports with the largest series of six patients published by Levakos et al[4–8] Five of these individuals had other associated injuries including medial collateral ligament (MCL) or meniscal tears. The most common reported location of PT rupture was the middle third of the tendon followed by the proximal patellar attachment.…”

“…[3] Acute concomitant rupture of the ACL and the patellar tendon (PT) in a non-dislocated knee, however, is extremely rare and thus far limited mostly to case reports in the orthopedic literature. [4–8] To our knowledge, this injury pattern has not been reported in the radiology literature and the imaging features have not been fully described. The purpose of our case report is to introduce this combined injury to the radiology community and emphasize the role imaging plays to avoid misdiagnosis.…”