Concomitant Rupture of the Anterior Cruciate Ligament and the Patellar Tendon in a High-Level Athlete: A Case Report

Introduction

Anterior cruciate ligament (ACL) rupture is commonly encountered in competitive athletes [13,16]. Management depends on the patient: young, active patients and athletes commonly undergo surgical reconstruction [9,25]. Return to play rates have been reported from 75% to 83% in athletes undergoing ACL reconstruction [1,3,25], although not all (44%-55%) return to preinjury levels of play [2,3].

Patellar tendon rupture is most common in the third and fourth decades of life and relatively rare in young athletes [14,28]. Acute surgical repair of the patellar tendon is the treatment standard in patients of all activity levels [17]. Reported return to play rate after patellar tendon repair in athletes is 89%, with 81% returning to preinjury competition levels [12].

Concomitant rupture of the ACL and patellar tendon is extremely uncommon. In the young athlete, management typically consists of a patellar tendon repair and ACL reconstruction, although no consensus exists on optimal surgical staging and timing. In the current literature, patients with this injury combination were managed with either a single-stage combination ACL reconstruction and patellar tendon repair or a 2-stage surgical approach of patellar tendon repair followed by ACL reconstruction [23]. A single-stage approach provides the benefit of a single surgical and anesthetic event and period of rehabilitation, with a faster return to play time [11,23]. Concerns with single-stage surgery and combined rehabilitation with patellar tendon repair (requiring a period of knee immobilization) and ACL reconstruction (typically requiring immediate postoperative range of motion [ROM]) include postoperative arthrofibrosis [10,23]. This risk can be mitigated by a 2-stage surgical approach: the patellar tendon repair, followed by ACL reconstruction once adequate ROM has been achieved. Studies reporting outcomes of these approaches consist of case reports and small meta-analyses. A systematic review by Meheux et al [23] found the 1-stage method was associated with greater risk of complications, with 25% of patients (2 of 8) experiencing residual stiffness and 1 requiring arthroscopic lysis of adhesions, vs none (0/10) with a 2-stage approach. There was no reported difference in return to preinjury level of activity between the surgical methods. Given the rarity of these injuries in athletes, established complication rates, return to play time, and return to prior level of play rates have not been established.

We are not aware of case reports documenting 2-stage surgical treatment of this injury pattern in a Division 1 or professional athlete who has returned to competitive play [29]. This case report presents a Division 1 collegiate football player who sustained simultaneous ACL and patellar tendon rupture treated with a 2-stage surgical approach of primary patellar tendon repair and ACL reconstruction and who returned to competitive college football 11 months postinjury.

Case Report

This case was reviewed by the Institutional Review Board (IRB) of the University of Minnesota. The patient was a 20-year-old male defensive lineman who sustained a concomitant ACL and patellar tendon rupture during a Division 1 collegiate football game. He described a “popping” sensation in his right knee as he planted his right foot and was contacted by an opposing player. Examination in the locker room noted 2B Lachman testing, patella alta, and inability to perform straight leg raise. Day-of-injury magnetic resonance imaging (MRI) revealed a complete midsubstance rupture of the right ACL, femoral-side low-grade tear of the medial collateral ligament (MCL), and delaminating midsubstance tear of the right patellar tendon (Fig. 1). Treatment options, including surgical timing and staging and the risks and benefits of operative intervention, were discussed with the patient and family the following day. It was decided that he would undergo a 2-stage approach of primary, acute patellar tendon repair and non-operative MCL treatment in a hinged brace, followed by ACL reconstruction with hamstring autograft.

Fig. 1.

MRI imaging demonstrating delaminated patellar tendon tear and complete ACL rupture: (a) demonstrates axial view of overlapping medial and lateral patellar tendon limbs, (b) demonstrates patellar sided avulsion of the medial patellar tendon limb, and (c) demonstrates patellar sided avulsion of the lateral patellar tendon limb and complete ACL rupture.

Four days postinjury, the patient underwent open right patellar tendon repair performed through a standard anterior midline approach. The patellar tendon was found to be completely torn in a delaminated fashion, with the medial aspect avulsed from the inferior pole of the patella and the lateral half torn from the tibial insertion (Fig. 2a). The medial and lateral retinaculum was also noted to be torn. The medial and lateral tendon flaps were sutured in a Krackow manner with #2 nonabsorbable suture (FiberWire, Arthrex) (Fig. 2b). The medial limb was repaired to the patella through 2 vertical transosseous bone tunnels; the lateral limb was repaired to the tibial insertion with a 4.5-mm biocomposite anchor (SwiveLock, Arthrex) (Fig. 2c). The soft tissue was closed in a layered fashion, and the knee was placed in a hinged knee brace locked in extension.

Fig. 2.

Intraoperative images of the delaminated patellar tendon tear: (a) showing medial aspect avulsed from inferior pole of the patella and the lateral half torn from the tibial insertion, (b) demonstrating Krackow suturing of the medial and lateral tendon limbs and reapproximating to the patellar origin and tibial insertion, and (c) highlighting final patellar tendon repair with transosseous repair to the patella medially and biocomposite anchor fixation to the tibia laterally.

Postoperative protocol consisted of immediate weight bearing as tolerated in a knee brace locked in extension with isometric quad strengthening followed by progressive ROM in a hinged knee brace starting at postoperative week 3. Ambulation out of the knee brace and gentle quadriceps strengthening were initiated at 6 weeks after surgery. At 10 weeks, physical examination noted full straight leg raise without lag, full knee extension, flexion to greater than 115°, and stability to varus and valgus stress at 0° and 30° of knee flexion. The Lachman test remained a 2B with a 1+ pivot shift. At this time, MCL healing, knee ROM, and soft tissue swelling were deemed adequate to move forward with ACL reconstruction. Hamstring tendon autograft was selected over the patellar tendon and quadriceps tendon (involving the extensor mechanism), given his patellar tendon injury. The addition of a lateral extraarticular tenodesis (LET) was considered but not performed after discussion with the patient.

The patient underwent hamstring autograft all-inside ACL reconstruction 11 weeks after the patellar tendon repair. Intraoperatively, examination under anesthesia and diagnostic arthroscopy revealed 0° to 130° of knee flexion, no laxity to valgus stress, grade 3 rupture of the ACL (Fig. 3a), a small radial tear at the midbody of the lateral meniscus within the white-white zone, and a vertical tear of the undersurface of the posterior horn of the lateral meniscus (Fig. 3b). A quadrupled semitendinosus autograft was harvested and prepared in the standard fashion with a final diameter of 10 mm and length of 75 mm. Blind-ended, 10-mm diameter tibial and femoral tunnels were reamed in a retrograde manner to a depth of 25 mm on the femoral side and 30 mm on the tibial side (FlipCutter 3, Arthrex). At that time, the midbody lateral meniscus tear was treated with a partial meniscectomy, and the posterior horn tear was repaired with 2 all-inside, all-suture devices placed in a vertical mattress fashion (FiberStitch, Arthrex) (Fig. 3c). The hamstring graft was then passed into the femoral and tibial tunnels and fixed with tensionable suspensory fixation over metallic buttons on both the femoral and tibial sides (TightRope RT button and TightRope ABS button, Arthrex) (Fig. 3d). The knee was cycled, and final tensioning was performed with the knee in full extension. Intraoperative examination documented a stable knee with a negative Lachman test and no pivot shift. Incisions were closed in a layered fashion, and a knee immobilizer was placed.

Fig. 3.

Intraoperative arthroscopy images of the right knee: (a) showing femoral-sided ACL rupture, (b) shows the lateral compartment demonstrating small midbody radial tear and posterior horn vertical tear of the lateral meniscus, (c) shows the lateral meniscus after midbody partial meniscectomy and posterior horn all-inside repair, and (d) highlights final intraoperative images of hamstring autograft ACL reconstruction.

The patient was allowed immediate weightbearing as tolerated; the knee immobilizer was discontinued 1 week postsurgery, when weightbearing as tolerated out of the brace and ROM of the knee as tolerated were initiated. The patient began a 5-phase ACL rehabilitation protocol set by our institution (Supplemental Figure 1) involving protection and early mobilization in the first 2 weeks, followed by ROM and lower-extremity biomechanics in weeks 3 to 8. Phases 3 to 5 focus on improvement of cardiovascular fitness, proprioception, balance, core stability, and strength and are completed by 18 weeks or upon attainment of return of quadriceps girth, normal walking speed and distance, normal stair climbing, and performance of 20 2-leg squats and 1 single-leg squat. At 3 months after ACL reconstruction, 0° to 128° of knee flexion with a negative Lachman test were achieved, and a return-to-run protocol was started. At 6 months, the patient began a return to sports (RTS) protocol, consisting of regular moderate-intensity workouts with the incorporation of plyometric, agility, cutting, and sports drills, as well as continued proprioception, core stability, and strength development. Ultimately, he was cleared to return to full participation at 8 months after ACL reconstruction and 11 months after patellar tendon repair.

The patient returned to collegiate football regular season competitive game play 11 months and 3 weeks after the initial injury, appearing in all of the remaining regular season games. During the initial return, he sustained a retear of the lateral meniscus requiring arthroscopic partial lateral meniscectomy, 9 months after ACL reconstruction. At final follow-up 20 months after initial injury, he had a Single Assessment Numeric Evaluation (SANE) score of 90, was participating in full-contact college football practice without restrictions, and had played more than 20 snaps during his team’s regular season opener.

Discussion

This case report presents the staged surgical approach and postoperative rehabilitation used to manage concomitant ACL and patellar tendon rupture in a Division 1 collegiate football defensive lineman. Studies on concomitant ACL and patellar tendon rupture are quite scarce, and most are case reports. Even fewer reports document RTS in high-level athletes after these injuries. Both 1-stage and 2-stage approaches have been described as successful, with excellent postoperative range of motion, functional scores, satisfactory MRI findings, and return to pre-injury levels of activity [8,23]. The 1-stage approach has been associated with increased complications including knee instability, patella baja, arthrofibrosis, infection, and patellofemoral crepitus [6,7,10,18,23].

A 1-stage approach may allow for the shorter rehabilitation time afforded by a single operation. Usually, the knee is immobilized in full extension for at least 2 weeks after surgery [6,7,10,11,18,26]. However, Selva-Sarzo and Nebot-Sanchis [27] described an adapted rehabilitation protocol with accelerated ROM that was implemented for a professional handball player after a 1-stage surgery; he returned to play without complications 13 months after the procedure. Case reports of the 2-stage technique commonly made use of knee immobilization typically lasting 4 to 6 weeks after patellar tendon repair, followed by progressive knee ROM before ACL reconstruction [7,15,18,21,29]. Matthews et al [20] performed a systematic review of 22 combined patellar tendon and ACL injuries, reporting no differences in RTS times between 1-stage and 2-stage approaches, finding 1 case of arthrofibrosis in the 1-stage group and 1 superficial wound infection and 1 case of patella baja in the 2-stage group.

Our patient recovered rapidly compared with other athletes with this injury combination, with RTS times reportedly ranging from 8 to 22 months (average, 12.3 months) [5–8,10,11,15,22,23]. Furthermore, some case reports do not report on RTS [7,18,21], which may reflect either a failure to RTS or to do so within the follow-up period. In the context of isolated ACL injuries, our patient returned faster than many, as the average time to RTS in competitive athletes after primary ACL reconstruction has been reported to range from 8.7 to 12.4 months [4,19,24]. Despite the idea that a 2-stage approach requires longer rehabilitation, this case suggests that timely RTS might be achieved with this method when paired with an intentional rehabilitation protocol. Delayed ROM of the knee (3 weeks in this case), followed by quadriceps strengthening, ambulation, progressive ranging of the knee between surgeries, and phasic ACL rehabilitation, appears to have been effective. This approach is similar to others reported in the literature [7,15,18,21,29]. We acknowledge the limitations of a single case and emphasize that further studies are needed to determine the best treatment approach.

Concomitant ACL and patellar tendon rupture are rare injuries in high-level athletes. Additional data are necessary to make conclusions on the advantages and disadvantages of various surgical approaches, rehabilitation methods, and RTS times in athletes presenting with this combined injury. This case report suggests that a 2-stage approach of patellar tendon repair followed by ACL reconstruction may be an acceptable treatment for athletes sustaining this injury, given that our patient returned to the same level of competition less than a year after injury. Additional case reports on outcomes for high-level athletes and their RTS times will help elucidate the optimal treatments for these patients.