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. 2024 Dec 18;145(1):61. doi: 10.1007/s00402-024-05676-w

Simultaneous patellar tendon and anterior cruciate ligament rupture: a systematic review, meta-analysis and algorithmic approach

Petros Ismailidis 1,2,3,8,✉,#, Georgios Neopoulos 1,#, Christian Egloff 1,9, Annegret Mündermann 1,3,5, Florian S Halbeisen 8, Corina Nüesch 1,3,5,6, Christian Appenzeller-Herzog 4, Sebastian A Müller 2,7,10
PMCID: PMC11655589  PMID: 39694972

Abstract

Introduction

Isolated patellar tendon (PT) or anterior cruciate ligament (ACL) ruptures are common injuries, yet the co-occurrence of both presents a rare challenge for clinicians. The objectives of the study are to document diagnostic and therapeutic approaches, outcomes, and complications of combined PT and ACL injuries and to develop an algorithm to guide clinicians in decision-making.

Methods

The systematic review und metanalysis was conducted according to the PRISMA guidelines. Studies reporting on simultaneous PT and ACL ruptures were included. Meta-analysis was performed to compare different diagnostic modalities and treatment strategies.

Results

Thirty-six studies reporting on 56 Patients were included. 88% of patients had a concomitant injury (apart from PT and ACL) to the ipsilateral knee. Part of the diagnosis was missed in 23% of the cases. Performance of MRI significantly reduced the risk of missing a part of the injury (5% with MRI vs 69% without MRI, p < 0.001). Surgical treatment was used only for the PT in 21% of the cases and for the PT and ACL in 77% of the cases (48% one-stage, 52% two-stage surgical treatment).

Conclusion

Combined ACL and PT rupture is rare, and recognizing its full extent is crucial for successful management. Performing an MRI in PT rupture from high-energy trauma and diagnostic arthroscopy/arthrotomy when MRI is not done is essential. PT ruptures should be treated surgically. For ACL rupture, conservative and operative treatment, one- or two-stage surgery are possible based on the patient's profile and concomitant injuries. Based on the limited available literature, this systematic review provides a diagnostic and therapeutic algorithm to assist in clinical decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00402-024-05676-w.

Keywords: Patellar tendon, Anterior cruciate ligament, Combined knee injury, Concomitant knee injuries

Introduction

Isolated patella tendon (PT) or anterior cruciate ligament (ACL) ruptures are common injuries [13, 18, 52]. The management of these injuries is well described in the literature. However, the combination of these two injuries is a rare entity and the literature is mostly limited to case reports. When confronted with this combination of serious injuries, the clinician is faced with several challenges regarding the diagnosis, acute treatment, and rehabilitation.

The first challenge is to correctly diagnose this rare injury. McKinney et al. [41] performed magnetic resonance imaging (MRI) in patients with PT rupture and reported a high incidence of concomitant injuries of the ipsilateral knee, especially to the ACL. Therefore, using the most accurate diagnostic instruments and not overlooking any part of the diagnosis is the first challenging step, before establishing a treatment plan.

Appropriate treatment—surgical or conservative—and timing of surgery are the next major challenges. In general, PT ruptures are treated surgically as soon as possible in order to reconstruct the extensor mechanism, avoid quadriceps muscle atrophy, contractions, and scar formations [19, 63]. Regarding ACL, both surgical and conservative treatment are possible depending on the patient profile [17]. Choosing the surgical treatment for both raises the question of timing [12]. Two-stage surgery could reduce the time between injury and surgical management and minimize the risk of knee stiffness [7, 42]. One-stage surgery, on the other hand, has the advantage of requiring only one intervention, a shorter total period of rehabilitation, and a faster return to previous activity [14, 15, 23, 28].

Postoperatively, the rehabilitation regimen used, especially when choosing a one-stage surgery, is a major challenge because the most commonly used rehabilitation regimens for PT and ACL are contradictory. For instance, after PT surgery, the knee motion is restricted to avoid stressing the PT reconstruction, whereas after ACL injury, early attainment of full range of motion (ROM) is encouraged to avoid postoperative stiffness [58].

Because these combined injuries are rare and always present in an acute setting, decisions must often be made under pressure. An individualized treatment plan based on the injury and the patient profile is required. Since the literature on this topic consists mostly of case reports and small case series, and a comprehensive overview of the literature for guidance in decision making is missing, it is difficult to make the best, evidence-based decision. Therefore, a diagnostic and therapeutic algorithm would be very helpful for clinicians to develop their treatment strategy and could lead to clear and successful decisions. Therefore, the primary objective of this systematic review and meta-analysis was to report the diagnostic and therapeutic approaches, outcomes and complications described in the literature. The secondary objective was to develop a diagnostic and therapeutic algorithm specifically designed for this combination injury.

Materials and methods

This study was performed according to the PRISMA guidelines [45] for systematic reviews and meta-analysis. A systematic literature search was performed in Embase (via embase.com), Scopus (via scopus.com), Medline (via Ovid) and SportDiscus (via EBSCOhost) from inception to December 4, 2019, and updated on December 7, 2022. References and citing literature from records included from the primary database search were collected by backward and forward citation tracking from TheLens (via citationchaser) and Scopus and screened for eligibility as described below. The protocol was registered in PROSPERO on April 28, 2020 (registration number CRD42020161853). The detailed search strategy is available as Supplementary Material 1. All retrieved references were exported to EndNote 20 (Clarivate, USA) and deduplicated using the Bramer method [6].

Inclusion criteria were human-based studies reporting on simultaneous rupture of the PT and the ACL. Conference abstracts were not included. No further restrictions were placed on study design, publication date, surgical approach, and sex. Exclusion criteria were the reporting of a knee dislocation (because knee dislocations have a different injury mechanism, risks and treatment concept than ACL and PT injuries [34]), patient age younger than 15 years (because injuries in patients with open physis have a different treatment concept than adults [4]) and publication language other than English, German, French, Spanish, Turkish or Greek (to ensure that we have a member in the research team being a proficient user of the language).

The titles and abstracts of the initially retrieved references were screened for potential inclusion. Studies that potentially met the inclusion criteria were included in the full-text screening, which was performed by two authors (PI and SM). A third author was consulted (GN) in case of disagreement on fulfillment of the eligibility criteria. References and citing literature from records included from the primary database search were collected by backward and forward citation tracking from TheLens (via citationchaser [25]) and Scopus and screened for eligibility as described above.

Quality assessment

The Joanna Briggs Institute (JBI) critical appraisal tool for case reports and case series [41] was used to assess the quality of the included studies, as all of them were case reports or case series. The tool consists of 8 questions for case reports and 10 questions for case series. Each question has four possible responses: “yes”, “no”, “unclear”, or “not applicable”. Answering “no” to any of the questions negatively affects the overall quality of the case report or case series.

Data extraction

Data from the full texts were extracted and entered into a standardized form by two reviewers (PI and SM). Any discrepancies were resolved by consultation with a third reviewer (GN). Extracted information on study characteristics included the authors and year of publication, country in which the study was conducted, type of study, number of patients, and language in which the study was written. In addition, information on patient characteristics (age, sex, health status, pre-injury knee-specific, activity level with Tegner score if available), mechanism of injury, diagnostic methods, anatomical location of the rupture of the PT (proximal, middle third, distal) and the ACL (proximal, middle third, distal), and accompanying injuries of the ipsilateral and contralateral knee were documented. Finally, information on the part of whether the diagnosis was missed before entering the operating room (in case of missed diagnosis), the treatment, the rehabilitation protocol, the results, the complications and the additional surgeries (if necessary) were documented.

Outcomes

The main outcomes of this systematic review and meta-analysis were, first, the incidence of missed diagnosis of the combined PT and ACL ruptures and the association of this incidence with the diagnostic tests used; second, the incidence and type of concomitant knee injuries other than the PT and ACL; third the complication rates and outcomes of both conservative and surgical treatment of the ACL rupture; and last, the incidence, complication rates, and outcomes of one-stage and two-stage surgical treatment of both PT and ACL.

Secondary outcomes were the anatomical location of PT rupture and its correlation with the mechanism of injury; the surgical technique (arthroscopic or open) in one-stage surgical treatment of the PT and ACL; and the rehabilitation regimens regarding ROM restrictions, weight bearing, and the incidence and timing of return to sport.

Statistical analysis

Continuous variables were described as means and standard deviations or medians and ranges when possible. Categorical variables were reported as absolute and relative frequencies.

Meta-analysis

A meta-analysis was performed to provide a comprehensive comparison between one-stage surgery and two-stage surgery, as well as between missed diagnosis and non-missed diagnosis in terms of patient-reported outcomes (PROMs) and complications. We performed both logistic and linear mixed effects modeling to evaluate the relationships between our predictors and the response variables. For binary outcomes (complications, return to sports, and MRI), logistic mixed-effects models were used, whereas continuous outcomes (postoperative vs. preoperative Lysholm, IKDC) were analyzed using a linear mixed-effects model. Both models included random intercepts to account for the non-independence of measures within a study. All statistical analyses were performed using the R statistical software (Version 4.2.2, The R Foundation for Statistical Computing, Vienna, Austria).

Results

Study selection and methodological assessment

2969 publications were identified from the initial literature search after removing the duplicates. 311 were identified after citation and reference chasing. After the screening process, 36 publications met the eligibility criteria. The detailed overview of the screening process is presented as a PRISMA flowchart (Fig. 1) [45]. Most included studies were case reports (27 studies), four were case series, three were case reports with literature review and two were case series with literature review. The results of the assessment of the methodological quality of all included studies are presented in Supplementary Material 2.

Fig. 1.

Fig. 1

Flow-chart of the study selection process according to the PRISMA 2020 statement: an updated guideline for reporting systematic reviews – available as Additional Material 1

Extracted information

A total number of 56 patients (46 men and 10 women, median age 30 years, range 15–62 years) were evaluated. Median follow-up was 12 months (range 2–72 months). An overview of the included studies with extracted information on number of patients, study type, patient demographics, activity level and follow-up time is presented in Table 1.

Table 1.

Overview of the included studies including extracted information regarding number of patients, study type, patient demographics, activity level (Tegner Score*), mechanism of injury (namely*) and follow-up time

References Number of Patients Study type Age (years) Gender Activity level (Tegner Score*) Mechanism of injury (namely*) Follow-up, months
Baker [3] 1 Case report 24 m n/a Basketball (ER stress in a flexed knee) n/a
Brunkhorst [7] 1 Case report 27 m n/a Soccer (R stress) n/a
Chiang [10] 1 Case report 30 m n/a Basketball (R stress) 12
Chiba [11] 1 Case report 36 m n/a Baseball (unclear stress on a flexed knee) 31
Chow [12] 1 Case report 23 m n/a Basketball (while jumping, no direct impact) 21
Costa-Paz [14] 3 Case series# 31 m n/a Motorcycle acc 48
31 m Recreational soccer player Soccer (R stress, impact) 36
50 m nm Bicycle acc 24
Cucchi [15] 2 Case report# 35 m n/a Ski (IR stress) 12
44 m n/a Ski (R stress) 12
Futch [23] 1 Case report 19 m n/a Football (deceleration with fixed foot and flexed knee) n/a
Kim [30] 1 Case report 32 m n/a Baseball (fixed foot, valgus stress on flexed knee) 12
Koukoulias [31] 1 Case report 47 m n/a Unclear 36
McCormack [40] 1 Case report 26 m Pro football player Football (R stress with fixed foot) n/a
Rae [50] 1 Case report 25 w n/a Trampoline (forced flexion on extended knee) 24
Levakos [33] 6 Case series 36 m Recreational soccer player Soccer (landing) 18
15 w School athlete Long jump (landing) 72
33 m n/a Ski (landing) 72
20 m College football athlete Football (R stress on a fixed foot) n/a
23 m n/a Motorcycle acc 12
23 m Pro football player Football (R stress on a fixed foot) 6
Mariani [37] 3 Case series 45 M Competitive skier Ski (Valgus and ER stress) 7.5
19 w Pro modern dancer Trampoline (Valgus and ER stress 9
18 w n/a Wake board (Valgus and ER stress) 12
Shillington [55] 1 Case report 23 m State level rugby leave Rugby (Single leg stance and impact with 3 defenders or valgus and hyperflexion stress) 7.5
Tsarouhas [56] 1 Case report 38 m Recreational martial arts Martial arts (Impact and Valgus stress) 11
Wissman [61] 1 Case report 36 w n/a nm (fall from height and landed on both feet) n/a
Gülabi [24] 1 Case report 30 m Recreational soccer player Soccer (deceleration with foot fixed and knee flexed) 12
Capogna [9] 6 Case series 40 m n/a Bicycle struck by motorcycle 2 (lost to follow-up)
57 m n/a Struck by a car 3 (lost to follow-up)
36 m n/a Struck by motorcycle 7
62 m n/a nm (jumping to avoid a ball on the street) 4
20 m n/a Trampoline (R stress) 6
20 w n/a Trampoline (while landing) 9
Achkoun [1] 1 Case report 22 m n/a Soccer (R stress of lower leg with blocked foot) 6
Schmidt-Wiethoff [53] 1 Case report 28 w n/a Ski (ER and valgus stress) 5
Vega [59] 1 Case report 31 m n/a Soccer (R stress) 6
Perez [46] 1 Case report 21 m n/a Soccer (by landing, without able to describe the exact mechanism) 18
Mathews [39] 1 Case report# 41 m n/a Motocross (landing on foot with flexed knee) 36
Lobo [36] 1 Case report 30 m n/a Traffic acc. (Direct blow on the knee and valgus stress) 6
Ismailidis [29] 1 Case report 40 w n/a Ski (R stress, no direct impact) 24
Quinn [49] 3 Case series# 20 m Collegiate football athlete Football (flexed knee, fixed leg, varus stress) 12
15 m School football player Football (tackled) 12
17 m Lacrosse player Football (ER and valgus stress, direct contact) 15
Boublik [5] 3 Case series nm m National football league player (10) Football (tackled) n/a
nm m National football league player (10) Football (R stress, direct blow) n/a
nm m National football league player (10) Football (Non contact injury, no other info) n/a
Verma [60] 2 Case report 20 m nm Traffic acc 18
34 m nm (4) Traffic acc 12
Ansari [2] 1 Case report 37 m Recreational soccer player Football (Leg twisted beneath him) 36
Pointinger [48] 1 Case report 25 m n/a nm (ER and valgus stress on flexed knee) 3
Perwanger [47] 1 Case report 37 m n/a Ski (high velocity, hyperflexion, R stress) 6.5
Xie [62] 1 Case report 46 m n/a Traffic acc. (Translation and valgus of proximal tibia with flexed knee and eccentric quadriceps contracture) 12
A.De Rousiers [16] 1 Case report# 39 w Recreational sportswoman (climbing, swimming, running) Climbing (R stress after hyperextension landing) 18
Selva-Sarzo [54] 1 Case report 28 m Pro handball player Handball (IR and valgus after landing) 24
Zhong Li [35] 1 Case report 18 w n/a Long jump (sprained knee) 12

BMI body mass index (kilogram/meter2), SD standard deviation, n/a Not available, *: If available, #: with a review of the literature, R rotational, ER external rotation, IR internal rotation, acc accident

Mechanism of injury

Regarding the mechanism of injury, 77% (43 of 56) of patients had a sports-related injury, while 18% (10 of 56) had an injury resulting from a traffic accident. 41% of patients (23 of 56) described a rotational stress on the knee (either internal or external) in addition to a varus or valgus stress in a partially flexed knee [1, 3, 5, 7, 9, 10, 1416, 29, 33, 37, 40, 47, 48, 53, 54]. In addition, 30% of patients (17 of 56) clearly demonstrated rapid deceleration and consequent quadriceps contraction in a flexed knee [3, 9, 12, 16, 23, 24, 37, 39, 46, 47, 50, 54, 61]. The data collected are shown in Table 1.

Diagnostic modalities

Regarding the diagnostic modalities used, radiography and clinical examination were performed in all cases, sonography in 4%, and a MRI in 71% (40 of 56) of patients (Table 2) [1, 5, 7, 911, 1416, 23, 24, 30, 33, 3537, 39, 46, 47, 53, 55, 6062].

Table 2.

Detailed information on the diagnosis, the concomitant injuries, the performance of MRI as well as the part of the diagnosis missed clinically and after applying the radiological diagnosis, prior to entering the operating room

References Number of Patients MRI Location of PT rupture Location of ACL rupture Concomitant injuries Missed clinically (namely) Missed prior to operation (namely)
Baker [3] 1 nm n/a Mid-substance MCL, MM n/a n/a
Brunkhorst [7] 1 Yes n/a n/a MCL, LM No No
Chiang [10] 1 Yes Mid-substance Mid-substance LM No No
Chiba [11] 1 Yes Proximal Distal MCL No No

Chow

[12]

1 No Proximal n/a MM, LM Yes (MM, LM) Yes (MM, LM)
Costa-Paz [14] 3 Yes Mid-substance n/a MCL No No
Yes Mid-substance n/a MCL Yes (PT) No
Yes n/a n/a LM Yes (ACL, LM) No
Cucchi [15] 2 Yes n/a n/a MCL, MM Yes (ACL, MM) Yes (MM)
Yes n/a n/a MCL, LCL No No
Futch [23] 1 Yes Mid-substance Mid-substance MM, LM No No
Kim [30] 1 Yes Mid-substance Proximal MCL, LM No No
Koukoulias [31] 1 No Mid-substance n/a MCL, MM,LM, chondral defect medial femoral condyle Yes (ACL, MM, LM, chondral defect medial femoral condyle) Yes (ACL, MM, LM, chondral defect medial femoral condyle)
McCormack [40] 1 No Mid-substance Proximal MM, medial and lateral patellar retinaculum Yes (MM, medial and lateral patellar retinaculum) Yes (MM, medial and lateral patellar retinaculum)
Rae [50] 1 No Mid-substance n/a MCL Yes (PT) Yes (PT)
Levakos [33] 6 No Mid-substance n/a MCL, MM, LM Yes (PT) Yes (PT)
No Mid-substance n/a No Yes (ACL) Yes (ACL)
No Mid-substance n/a MM, LM Yes (PT, MM, LM) Yes (PT)
Yes Mid-substance n/a MCL, LM No No
No Proximal n/a MCL, MM, LM Yes (ACL, MCL, MM, LM) Yes (ACL, MCL, MM, LM)
Yes Mid-substance Mid-substance MCL No No
Mariani [37] 3 Yes Mid-substance n/a MCL, MM No No
Yes Mid-substance n/a MCL, MM, LM No No
Yes nm n/a MCL, MM No No
Shillington [55] 1 Yes nm n/a MCL, MM No No
Tsarouhas [56] 1 No proximal n/a MCL, LM Yes (ACL, MCL, LM) Yes (ACL, MCL, LM)
Wissman [61] 1 Yes Mid-substance Mid-substance No Yes (PT) No
Gülabi [24] 1 Yes Mid-substance Mid-substance MCL No No
Capogna [9] 6 Yes Distal n/a MCL, MM, lateral tibia plateau fracture, partial tear of biceps femoris No No
Yes Distal n/a MCL, MM, PCL No No
No Distal n/a MCL, posterolateral tibia plateau fracture No No
Yes Distal n/a MCL, MM, LM, PCL, posterolateral tibia plateau fracture, avulsion of iliotibial band No No
Yes Distal n/a MCL No No
Nm Distal n/a MCL No No
Achkoun [1] 1 Yes nm n/a No No No
Schmidt-Wiethoff [53] 1 Yes Mid-substance n/a MCL, MM No No
Vega [59] 1 Yes Mid-substance n/a No No No
Perez [46] 1 Yes Proximal n/a No No No
Mathews [39] 1 Yes nm n/a MM Yes (PT, MM) No
Lobo [36] 1 Yes Mid-substance n/a MCL No No
Ismailidis [29] 1 No Mid-substance Proximal MM, LM, tibia plateau fracture Yes (ACL, PT, MM, LM) Yes (ACL, MM, LM)
Quinn [49] 3 Yes Proximal Proximal MCL No No
Yes n/a n/a MCL, MM, LM No No
Yes Distal n/a MCL, LM, medial capsule and retinaculum Yes (ACL, LM) No
Boublik [5] 3 Yes n/a n/a LM n/a No
Yes n/a n/a Chondral defect in trochlea n/a No
Yes n/a n/a No n/a No
Verma [60] 2 Yes Proximal n/a MCL, LM Yes (ACL, PT, MCL, LM No
Yes Proximal n/a MCL, LM Yes (ACL, PT, MCL, LM) No
Ansari [2] 1 No n/a n/a No Yes (ACL) Yes (ACL)
Pointinger [48] 1 No n/a n/a MCL, LM, PCL, pes anserinus lesion, chondral fragment lateral femoral condyle Yes (PT, pes anserinus lesion) No
Perwanger [47] 1 Yes Mid-substance Mid-substance LM No No
Xie [62] 1 Yes n/a n/a MCL, tibia plateau fracture Yes (MCL) No
De Rousiers [16] 1 Yes n/a n/a MCL Yes (ACL, PT, MCL) No
Selva-Sarzo [54] 1 nm n/a n/a MCL, MM n/a No
Zhong Li [35] 1 Yes n/a n/a MCL, MM, LM Yes (LM, MM) Yes (MM)

MRI magnetic resonance imaging, PT patellar tendon, ACL anterior cruciate ligament, PCL posterior cruciate ligament, MCL medial collateral ligament, LCL lateral collateral ligament, MM medial meniscus, LM lateral meniscus, n/a not available

Localization of the PT and ACL rupture

The most frequently reported rupture was a mid-substance rupture of the PT (59% of patients) [10, 14, 23, 24, 2931, 33, 36, 37, 40, 47, 50, 53, 61], whereas a distal PT rupture occured in 19% of cases, where the location of the rupture was reported. It should be noted, however, that in a considerable proportion of cases (34% of patients) there was no information on the location of the rupture. For ACL rupture, the anatomical location of the rupture was not reported in most cases, with 79% of cases lacking information. 58% of cases reporting the location of the ACL rupture, presented with a mid-substance and 33% with a proximal ACL rupture. (Table 2).

Accompanying injuries

88% of patients had a concomitant injury (apart from PT and ACL) to the ipsilateral knee, with 68% having a medial collateral ligament (MCL) rupture, 39% a medial meniscus lesion, and 41% a lateral meniscus lesion (Table 2).

Missed diagnosis

The diagnosis of the PT, ACL rupture, or concomitant injuries was clinically missed in 20% (11 out of 56), 21% (12 of 56), and 30% (17 of 56) of patients, respectively, at the initial examination. PT was missed in 5% (3 of 56), ACL in 11% (6 of 56), and concomitant injuries in 14% (8 of 56) of patients prior to admission to the operating room, even after radiologic diagnosis. Overall, patients entered the operating room with a part of the diagnosis missing in 23% (13 out of 56) cases. Except for two patients in whom a medial meniscus injury was overlooked even after performing MRI [15, 35], all other patients in whom part of the diagnosis was missed did not undergo an MRI [2, 12, 29, 31, 33, 40, 49, 55]. Hence all combined injuries of PT and ACL were depicted on the MRI performed. Detailed information about the diagnosis and the missed part of the diagnosis is shown in Table 2.

Treatment approach: surgical or conservative

Regarding the treatment approach, surgery was chosen in 77% (43 of 56) of cases for both PT and ACL [1, 2, 5, 7, 911, 14, 15, 23, 24, 2931, 33, 3537, 39, 40, 46, 47, 5356, 60], with arthroscopic reconstruction of the ACL accounting for 72% of these cases. Conversely, in 21% (12 of 56) of cases, surgical treatment was chosen for the PT and conservative treatment for the ACL rupture [3, 9, 12, 16, 33, 48, 50, 62]. Only one patient was treated surgically for the ACL and conservatively for the PT rupture [61]. As for the concomitant lesions, the MCL and medial meniscus were treated surgically in the majority of patients (55% of them with MCL and 68% of them with medial meniscus rupture, respectively). Suture and partial meniscectomy were chosen for lateral meniscus lesions in approximately equal numbers, 43% and 35%, respectively (Table 4). Detailed information on the treatment strategies of the individual studies regarding the PT, ACL, and concomitant injuries can be found in Table 3.

Table 4.

Statistical analysis of the group receiving an MRI and the group not receiving an MRI as part of the diagnostics, with regards to missing a part of the diagnosis and presenting complications

Group Diagnosis missed Complications

With mri

N = 40

5% (2/40) 6/40 (15.4%)

No mri

N = 16

69% (11/16) 5/16 (31.2%)

P Value

Test performed

 < 0.001 0.343

Table 3.

Treatment strategies of the individual studies regarding the patellar tendon, anterior cruciate ligaments and concomitant injuries

References Number of patients Management Surgical timing (interval in weeks if two-stage) Treatment ACL (technique) Treatment PT Treatment concomitant injuries
Baker [3] 1

PT op

ACL cons

nr nr Suture + wire

MCL: suture

MM: partial meniscectomy

Brunkhorst [7] 1 PT, ACL op Two-stage (nm) Arthroscopic (n/a) Suture + transosseus suture

MCL: n/a

LM: suture

Chiang [10] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, hamstrings) Suture + transosseus suture LM: partial removal and fixation of the rest with meniscal arrows
Chiba [11] 1 PT, ACL op Two-stage (28) Arthroscopic (not clear, semitendinosus) Suture + transosseus suture MCL: suture
Chow [12] 1

PT op

ACL cons

nr nr Suture + wire

MM: suture

LM: partial meniscectomy

Costa-Paz [14] 3 PT, ACL op Two-stage (5) Arthroscopic (autograft contralateral, BPTB) Suture MCL: suture
PT, ACL op One-stage Arthroscopic (not clear, quadriceps) Suture MCL: suture
PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) suture LM: partial meniscectomy
Cucchi [15] 2 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + wire

MCL: suture

MM: suture

PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + wire
Futch [23] 1 PT, ACL op One-stage Open (allograft BPTB) Suture + allograft PT MM: suture
Kim [30] 1 PT, ACL op One-stage Arthroscopic (allograft, achilles tendon) Suture + transosseus suture

MCL: cons

LM: suture

Koukoulias [31] 1 PT, ACL op Two-stage (24) nm (autograft ipsilateral, hamstrings) Suture + wire

MCL: cons

MM: cons

LM: partial meniscectomy

McCormack [40] 1 PT, ACL op Two-stage (12) Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + transosseus suture

MM: suture

LM: partial meniscectomy

Rae [50] 1

PT op

ACL cons

nr nr Suture MCL: suture
Levakos [33] 6 PT, ACL op One-stage n/a (synthetic) Suture

MCL: suture

MM: suture

LM: suture

PT, ACL op Two-stage (156) n/a (autograft ipsilateral, iliotibial band) Suture n/a
PT, ACL op One-stage n/a (autograft ipsilateral, semitendinosus) Suture

MM: suture

LM: partial meniscectomy

PT op

ACL cons

nr nr Suture

MCL: suture

LM: cons

PT op

ACL cons

nr nr Suture Missed
PT, ACL op Two-stage (12) n/a (allograft, n/a) Suture n/a
Mariani [37] 3 PT, ACL op Two-stage (6) Arthroscopic (autograft ipsilateral, hamstrings) Suture

MCL: suture

MM: suture

PT, ACL op Two-stage (13) nm (autograft ipsilateral, hamstrings) Suture + wire

MCL: suture

MM: suture

LM: suture

PT, ACL op Two-stage (10) Arthroscopic (autograft ipsilateral, hamstrings) Suture

MCL: suture

MM: suture

Shillington [55] 1 PT, ACL op Two-stage (14) Arthroscopic (autograft contralateral, hamstrings) Suture + transosseus suture

MCL: suture

MM: cons

Tsarouhas [56] 1 PT, ACL op Two-stage (12) Arthroscopic (autograft ipsilateral, hamstrings) Suture + transosseus suture

MCL: cons

LM: partial meniscectomy

Wissman [61] 1

PT cons

ACL op

nr Arthroscopic (autograft ipsilateral, hamstrings) nr nr
Gülabi [24] 1 PT, ACL op One-stage Arthroscopic (autograft contralateral, gracilis and semitendinosus) Suture + transosseus suture + semitendinosus and gracilis augmentation in figure of 8 style MCL: cons
Capogna [9] 6

PT op

ACL cons

nr nr suture anchor fixation

MCL: cons

Tibia fracture: cons

PT op

ACL cons

nr nr suture anchor fixation

MCL: suture

MM: suture

PT op

ACL cons

nr nr nm

MCL: suture

Tibia fracture: ORIF

Femur fracture: cons

PT op

ACL cons

nr nr Suture anchor fixation

MCL: suture

MM: partial meniscectomy and suture

LM: suture

PCL: cons

Tibia fracture: cons

Iliotibial band: suture anchor

PT, ACL op Two-stage (12) Arthroscopic (autograft ipsilateral, BPTB) Suture anchor fixation MCL: suture
PT, ACL op Two-stage (16) Arthroscopic (autograft ipsilateral, hamstrings) Suture anchor fixation MCL: cons
Achkoun [1] 1 PT, ACL op Two-stage (n/a) Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + wire nr
Schmidt-Wiethoff [53] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis) Suture + wire

MCL: suture

MM: suture

Vega [59] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + semitendinosus autograft augmentation (contralateral) nr
Perez [46] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Anchor + semitendinosus and gracillis autograft augmentation (contralateral) nr
Mathews [39] 1 PT, ACL op One-stage Arthroscopic (autograft contralateral, hamstrings) Suture MM: suture
Lobo [36] 1 PT, ACL op Two-stage (6) Arthroscopic (autograft ipsilateral, hamstrings) Suture + transosseus suture MCL: cons
Ismailidis [29] 1 PT, ACL op One-stage Open (refixation, direct repair) Suture + wire

MM: suture

LM: suture

Tibia fracture: ORIF

Quinn [49] 3 PT, ACL op Two-stage (12) Arthroscopic (allograft, BPTB) Suture + transosseus suture MCL: suture
PT, ACL op Two-stage (12) Arthroscopic (autograft ipsilateral, quadriceps) Suture

MCL: internal brace

MM: suture

LM: cons

PT, ACL op Two-stage (24) Arthroscopic (allograft, semitendinosus) Suture + transosseus suture

MCL: suture

LM: partial meniscectomy

Boublik [5] 3 PT, ACL op One-stage nm (autograft, contralateral, BPTB) n/a LM: nm
PT, ACL op One-stage n/a (allograft, n/a) n/a nr
PT, ACL op Two-stage (4) n/a n/a nr
Verma [60] 2 PT, ACL op One-stage Arthroscopic (autograft contralateral, hamstrings) Suture + transosseus suture

MCL: autograft

LM: partial meniscectomy

PT, ACL op One-stage Arthroscopic (autograft contralateral, hamstrings) Suture + transosseus suture

MCL: autograft

LM: partial meniscectomy

Ansari [2] 1 PT, ACL op Two-stage (104) Arthroscopic (autograft ipsilateral, semitendinosus) Suture nr
Pointinger [48] 1

PT op

ACL cons

Two-stage (ACL plastic in the future) nr Suture

MCL: suture

LM: partial meniscectomy

PCL: resected initial

Chondral fragment: removed

Retinaculum: suture

Perwanger [47] 1 PT, ACL op Two-stage (14) Arthroscopic (autograft ipsilateral, semitendinosus) Suture + transosseus suture

LM: suture

ALL: reconstruction

Xie [62] 1

PT op

ACL cons

nr nr Suture + wire

MCL: suture

Tibia fracture: cons

De Rousiers [16] 1

PT op

ACL cons

nr nr Suture MCL: reinsertion distal
Selva-Sarzo [54] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and semitendinosus) Suture + wire + semitendinosus and gracilis autograft augmentation (contralateral)

MCL: cons

MM: partial meniscectomy

Zhong Li [35] 1 PT, ACL op One-stage Arthroscopic (autograft ipsilateral, gracilis and peroneus longus) Suture

MCL: autograft (semitendinosus)

MM: suture

LM: suture

op. operation, cons. conservative, nr non-relevant, PT patellar tendon, ACL anterior cruciate ligament, PCL posterior cruciate ligament, MCL medial collateral ligament, LCL lateral collateral ligament, MM medial meniscus, LM lateral meniscus, BPTB bone-patellar tendon-bone, ORIF open reduction, internal fixation, ALL anterolateral ligament, n/a not available

Timing of surgery: one versus two-stage

Regarding the timing of surgery, when both the PT and ACL are treated surgically, there is an almost equal distribution of studies favoring one-stage (48%, 21 of 44 patients) and two-stage surgery (52%, 23 of 44 patients) approaches. The median interval for two-stage surgery was 12 weeks (range 4–104 weeks). Table 3 shows the reported treatment strategies.

Rehabilitation protocols

Depending on the treatment strategy, different rehabilitation protocols were followed.

One-stage treatment: A cast was used in 95% of cases. All studies reporting on weight-bearing used partial or no weight-bearing for a median duration of 6 weeks (range 2–8 weeks), whereas 38% did not report on weight-bearing. ROM restrictions were used in all patients for whom ROM was reported, while no information was available in 19%.

Two-stage treatment or surgical treatment of PT alone: A cast was used in 60% of cases. 40% of patients were reported to have followed a partial or no weight bearing for a median of 5 weeks (range 2–6 weeks), while 53% lacked information on weight bearing. Of the studies that reported ROM regimens, ROM restrictions were used in 85% of patients. In 40% of the patients, no information on ROM was provided.

Complications and additional procedures

Regarding complications, 20% of the patients (11 of 56) had a documented complication. The most common complications were arthrofibrosis and patella baja, each observed in 7% of patients, while infection (either deep or superficial) and complex regional pain syndrome (CRPS) was observed in 4% and 2% of patients, respectively. A total of 14 additional procedures were required in 12 patients (21%). Removal of the wire used to secure the PT suture was performed in six cases, arthroscopy in five cases (2 for synovectomy, 1 for debridement of scar tissue and resection of suture and 2 for removal of the wire and diagnostic purposes), and revision for infection in two cases. Arthrolysis, fasciocutaneous flap coverage, closed manipulation, and arthroscopy with debridement of the scar tissue and resection of suture material were each performed in one case each.

Statistical analysis and meta-analysis

When comparing patients with and without missed diagnoses prior to entering the operating room, there were some interesting findings.

Importance of MRI

Performing MRI as part of the diagnostic workup is clearly the key to not missing part of the diagnosis. In the group where MRI was performed, only 5% had part of the diagnosis missed, while in the group where MRI was not performed, in 69% of cases part of the diagnosis was missed (p < 0.001, Table 4). In the MRI group, only minor injuries (meniscal lesions) were missed.

“Missed diagnosis vs. non-missed diagnosis”

Interestingly the “missed diagnosis” group had only slightly more complications than the “non-missed diagnosis” group (23% vs. 19%, p = 0.676), with markedly different groups sizes however. The clinical scores of the two groups were also comparable. The statistical results and clinical scores are shown in Table 5.

Table 5.

Statistical analysis comparing the patients, where a part of the diagnosis was missed prior to entering the operating room (“missed diagnosis) to those where no part of the diagnosis was missed (“non-missed”)

Group Complications Return to sports (patients returning to sports/total patients with reported return to sports as outcome/no data reported) IKDC score Lysholm score

Missed diagnosis

N = 13

23% (3/13) 44% (6/8/5) 78.3 (SD 16.5) (Reported in 2/13) 89.5 (SD 6.4) (Reported in 2/13)

Non missed diagnosis

N = 43

19% (8/43) 40% (17/20/23)

85.91

(SD 11.4)

(Reported in 12/43)

Lysholm: 88.4

(SD 11.9)

(Reported in 17/43)

P value 0.676 0.567 0.129 0.394

IKDC International Knee Documentation Committee, SD Standard Deviation

One-stage versus two-stage

When comparing patients who underwent one-stage surgery with those who underwent two-stage surgery, the complication rate was higher in the one-stage group, however statistically not significant (9% vs. 19%, p = 0.88). Conversely, 12/14 patients (86%) return to sport after “one-stage” surgery, while 7/9 (78%) after “two-stage” surgery, without a statistically significant difference between them (p = 0.88). The statistical results as well as the clinical scores are presented in Table 6. It is important to mention than the data was only available in a portion of the studies, as indicated in Table 6

Table 6.

Statistical analysis of patients receiving a surgical treatment of both the ACL and PT, separated on the group of one stage and two stage treatment

Group Complications Return to sports (patients returning to sports/total patients with reported return to sports as outcome/no data given) Lysholm IKDC

One-stage

N = 21

19% (4/21) 86% (12/14/7)

86.30

(SD 14.67)

83.23

(SD 15.62)

Two-stage

N = 23

9% (2/23) 78% (7/9/14)

92.5

(SD 4.41)

87.43

(SD 5.84)

P value P = 0.88 P = 0.88 0.376 0.939

IKDC International knee documentation committee, SD Standard deviation

Discussion

The primary aim of this study was to report the diagnostic and therapeutic approaches, outcomes and complications of combined PT and ACL injury. The secondary aim was to develop a diagnostic and therapeutic algorithm.

Missed diagnosis

The most important finding of this study is that part of the diagnosis was missed in 23% of cases. This percentage drops dramatically if an MRI is performed no case missing a tear of the ACL nor the PT. Only a meniscal tear was missed on the MRI in 5% of the cases, not substantially changing the treatment approach. As shown in this review, the management of such complicated injuries requires an in-depth examination of the injuries, and therefore only a complete diagnosis allows for a structured treatment plan. Therefore, establishing the correct diagnosis prior to entering the operating room seems to be the key to successful treatment. This is particularly important because many surgeons still consider a rupture of the PT to be a “clinical diagnosis”, supported at most by sonography. Therefore, as shown in this review, MRI is often not performed and part of the diagnosis could be missed. Interestingly, in patients with missed diagnosis, complications were only slightly higher and clinical outcomes were not worse. However, it is important to note that the groups sizes were markedly different and the p value (p = 0.676) indicates that this difference is not statistically significant. This finding should be interpreted with caution as the lack of statistical significance does not confirm the absence of a difference but rather that the study might be underpowered to detect a difference. Moreover, this result is probably related to the small number of reported cases and should not be used as an argument to avoid acquiring a full diagnosis prior to the operation.

The available literature supports the findings of this review that associated injuries are very common in cases of PT rupture. McKinney et al. [41] reported an 18% incidence of ACL rupture detected in routine MRI in patients with already clinically diagnosed PT rupture following a low energy trauma (non-contact sports, walking or activities of daily living, fall from standing and chronic PT ruptures), and 38% incidence after a high energy trauma. While PT can be easily diagnosed clinically and/or with a sonography most of the times, the same does not apply for an ACL rupture and for the rest concomitant injuries (MCL, meniscal injuries). Therefore, an MRI should be performed in all high-energy injuries with PT rupture. In the case of low energy trauma with inconclusive clinical examination or when an MRI is not available, a diagnostic arthroscopy or direct visual examination should be performed during surgical treatment to avoid missing part of the diagnosis.

Treatment concepts

Operative versus conservative treatment

The management of this rare injury is controversial in the available literature. There is a clear consensus for immediate surgical reconstruction of the PT rupture [3, 10, 12, 14, 23, 33, 38, 50], in order to restore the extensor mechanism, avoid any atrophy or contraction of the quadriceps muscle, and also avoid scar formation of the PT. In the setting of the combination injury, our review revealed that a surgical treatment was chosen in 77% of the cases, whereas 21% of cases opted for surgical treatment of the PT rupture and conservative treatment for the ACL rupture.

The indication for surgical treatment of the ACL must be decided individually according to the patient’s profile [17]. If the patient’s profile indicates that surgical treatment of the ACL might not be necessary, one can wait until the completion of PT rehabilitation and then decide on the need for ACL reconstruction according to the current guidelines based on the degree of knee instability and activity level.

In the presence of a repairable meniscal injury (e.g., bucket handle tear), a stable ACL is required, otherwise the risk of meniscal repair failure is unacceptable [51]. Similarly, the ACL should be treated surgically in patients participating in high-level pivot-shift sports [20, 32, 44]. In these cases where surgical treatment of the ACL is indicated, the timing of surgery as well as the methods are controversial.

One-stage versus two-stage surgical treatment

In cases of repairable large meniscal lesions, where meniscus repair is indicated, two-stage surgery with a long interval is not a reasonable option due to the high risk of meniscal repair failure in the absence of an ACL [51]. In these cases, one-stage treatment should be favored. In the rest of the cases one or two-stage treatment is an option. Arguments in favor of two-stage surgery are the reduction of the risk of arthrofibrosis and the postoperative ROM deficit observed in one-stage surgery [10, 23]. On the other hand, one-stage surgery offers the obvious advantage of fewer surgeries and shorter rehabilitation time as well as satisfactory outcomes [14, 15, 55]. However, one-stage treatment makes the rehabilitation more difficult because of the conflicting rehabilitation protocols after PT repair (protected, limited, gradually increasing ROM) compared to after ACL reconstruction (early ROM encouraged).

In a systematic review published in 2018, Meheux et al. [42] found a significantly higher complication rate with no significant difference in return to preinjury activity level. Our review is consistent with that review in terms of the complication rates, with 19% reported in the one-stage group and 9% in the two-stage group, however without a statistical significant different. This may be due to the presence of inflammation, swelling, and the ROM deficit at the time of ACL reconstruction, which would also explain arthrofibrosis being the most common complication reported. In summary, both one-stage and two-stage surgeries are reasonable options and can be chosen on an individual basis.

Surgical ACL treatment: reconstruction versus repair

Arthroscopic ACL reconstruction with autograft (hamstring or PT) is the gold standard for ACL treatment [20]. However, in the specific setting of combined ACL and PT injuries, additional questions arise. A PT autograft is obviously not an option, and an ipsilateral hamstring autograft, especially in cases of concomitant MCL rupture, would be an additional trauma and further weaken the knee. Therefore, an acute repair of proximal Type I ACL ruptures [57] may be a good option. Such repairs have yielded satisfactory results [8, 26, 43], and although not established for standard ACL treatment, they offer obvious advantages in combined ACL and PT injuries. A repair was only performed in one case of the ones included in this review [29]. An allograft would be an alternative option. The data from our review do not allow for a statistical comparison of repair versus autograft versus allograft reconstruction, as only 5% of the cases treated by one-stage surgery had a repair and 14% had an allograft.

Rehabilitation regimens

Rehabilitation regimens after PT rupture differ from those after ACL rupture. The ACL requires an early ROM and an accelerated rehabilitation, whereas PT demands a period of immobilization and restricted ROM [19, 29, 38]. This is an important argument for surgeons for choosing the two-stage approach. On the contrary, with the one-stage surgery, encouraging an early postoperative ROM is crucial to prevent arthrofibrosis. A gradual increase in ROM with non-weight bearing for 6 weeks is supported, taking into account the strength of the PT repair. According to two studies included in our review, rehabilitation alone should not preclude a one-stage approach, as a combined regimen is feasible for this combined injury [22, 29]. However, due to the lack of documented data in the available literature regarding the timing of return to the previous activity level and, of course, the uniqueness of each possible combination of injury, the rehabilitation regimen should be decided on an individual basis.

Injury mechanism

The most common mechanism of injury described is a sudden anterior translation of the tibia, which explains the rupture of the ACL, followed by a quadriceps contraction in a slightly flexed knee and fixed foot. The stress on the extensor mechanism and especially on the PT is greater in a partially flexed position, explaining the rupture of the PT [64]. The reported valgus stress in addition to rotational stress also explains why MCL rupture and medial or lateral meniscus rupture were the most common concomitant injuries.

Anatomical location of the PT rupture

An interesting finding relates to the anatomical location of the PT rupture. Most studies described a mid-substance rupture [10, 14, 23, 24, 2931, 33, 3638, 47, 50, 53, 61]. Distal avulsion has been associated with a high-energy trauma, most notably demonstrated by Quinn et al. [49]. Therefore, the need to look for concomitant injuries in case of a distal PT rupture is even more important.

Diagnostic and therapeutic algorithm

Taking into account all of the above, it is a challenge for the treating physician to make the correct decisions under time pressure. To assist, a diagnostic and therapeutic algorithm was developed based on the results of this review, summarizing all the points discussed above (Fig. 2).

Fig. 2.

Fig. 2

Diagnostic and therapeutic algorithm of simultaneus ACL and PT injuries based on the results of the systematic review and metaanalysis (see also Additional Files)

Strengths and limitations

The state-of-the-art review methodology, allowed for the inclusion of all available literature and the best possible data synthesis. However, this study has several limitations. First, the available literature is limited to case reports and case series with a maximum of six patients. The small sample size, consisting of only 56 patients limits the findings and their significance and may lead to an unknown selection bias due to the uneven quality and scope of the included studies. Secondly, despite efforts to synthesize available data comprehensively, the heterogeneity in study design and the data quality among the included studies posed challenges in achieving robust statistical significance. In addition, while our meta-analysis could provide valuable insights into the importance of MRI in the diagnosis of concomitant patella tendon and ACL ruptures, a significant concern is the possibility of publication bias because studies that report missed diagnoses are more likely to be published due to the perceived importance and clinical implications of these findings. Furthermore, the lack of documented data regarding the time of return to the previous activity level and the lack of postoperative or posttraumatic clinical and functional scores is an important drawback, meaning that conclusions should be drawn with caution. Finally, while the algorithm proposed in this study reflects the authors’ insights gained from a thorough analysis of the existing literature, its application remains contingent on individual surgeon preferences rather than being strictly evidence-based. Moreover, it is recognized that no algorithm could cover the full range of the possible concomitant injuries. Therefore decisions regarding management, especially for less common injuries, necessitate a personalized, case-by-case approach guided by both surgeon preference and patient-specific considerations.

Conclusion

Combined ACL and PT rupture is a rare injury. Other concomitant injuries are common. Recognizing the full extent of this injury is key to successful management. It is important to perform an MRI in patients with PT rupture resulting from a high-energy trauma and a diagnostic arthroscopy / arthrotomy in cases where an MRI was not performed. PT ruptures should be treated surgically. For ACL rupture, conservative and operative treatment, one- or two-stage surgeries are possible depending on the patient’s profile and presence of other concomitant injuries. This systematic review provides a diagnostic and therapeutic algorithm to make the best possible, evidence-based decisions in this difficult injury setting.

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

Ethical review and approval were waived for this study because unlike primary research, no new personal, sensitive or confidential information was collected from participants. Only publicly available documents were used for the systematic review.

Informed consent

Due to the nature of the study, no “Informed Consent” was necessary.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Conceptualization: Petros Ismailidis, Georgios Neopoulos, and Sebastian A. Müller; Methodology: Petros Ismailidis, Georgios Neopoulos; Sebastian A. Müller; Data curation: Petros Ismailidis, Georgios Neopoulos, and Sebastian A. Müller; Writing—Original draft preparation: Petros Ismailidis and Georgios Neopoulos; Writing—Review and editing: Sebastian A. Müller, Christian Egloff, Annegret Mündermann, and Corina Nüesch; Statistical analysis: Florian Halbeisen, Corina Nüesch; Supervision: Sebastian A. Müller; Project administration: Petros Ismailidis and Georgios Neopoulos. All authors have read and agreed to the published version of the manuscript.

Funding

Open access funding provided by University of Basel. This research was conducted without any external funding.

Declaration

Conflict of Interest

The authors declare that they have no conflict of interest.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Petros Ismailidis and Georgios Neopoulos have contributed equally to the work.

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