Concomitant Patellar Tendon Tear (PTT) with Cruciate and/ Collateral ligament injury (Multi- Ligamentous Knee Injury –MLKI) and new pathoanatomical -Ganga PTT classification aids to strategize treatment options

Published:October 31, 2022DOI:


      • The complex multi-ligament knee injury needs a systematic approach.
      • Patellar tendon tear associated with MLKI, restoration of extensor apparatus precedes other ligament reconstructions.
      • Further, longer and supervised rehabilitation is needed for adequate recovery.



      Concomitant patellar tendon (PT) tear with cruciate or multi-ligament knee injuries (MLKI) following high-velocity injury requires a systematic approach.


      The study is a retrospective case series of patients (2008–2019) with concomitant PT ligament injury with cruciate or collateral ligament injury (MLKI), including bony avulsion injuries. Isolated cruciate and MLKI without patellar tendon tears are excluded. N = 32 patients (1 female and 31 male) are divided into two groups, Group 1 (11 patients) with PT tear and ACL tear and group 2 (21 patients) with PT tear and MLKIs. Patients were taken up for a single stage in types 1,2,3 and staged repair with reconstruction for types 4,5 of our new classification. All the patients are followed up regularly, and IKDC and Lyshom's score and objective radiological stress x-rays taken at each follow-up


      Incidence of PTT combined injuries among all knee ligament injuries is 0.57%. The mean age was 35.09+/-11.96 SD(group1) and 36.55+/-11.89 SD(group2). The average follow-up was 34.45 months +/- 12.86SD (group 1) and 35.3 months +/- 15.75 SD (group2). Mean post-operative Lysholm score and IKDC score of group 1 and group 2 improvement was statistically significant p-value <=0.01. The mean post-operative ROM of the two groups were 132.73 (SD 6.46) (Group 1) and 111.75 (15.75) (Group 2) and was a statistically significant p-value <0.01. Residual lag of 30° seen in all patients improved by 3rd month in group 1 and 6th month in group 2. Knee stiffness is seen in 2 patients and superficial infection in 2 patients.


      PTT combined injuries are rare and occurs due to direct impact injuries. Single-stage PT repair with ACL reconstruction gives adequate stability, and extensor lag is eminent and needs supervised rehabilitation. PT with MLKI is a challenging scenario that can be performed in single-stage/multiple stages, depending on the injuries, surgical expertise, and institutional facilities. Newer simplified classification aids surgeons in planning a treatment strategy.



      MLKI (Multi-Ligament Knee Injury), ACL (Anterior Cruciate Ligament), ACLR (Anterior Cruciate Ligament Recontruction), PTT (Patellar Tendon Tear), MCL (Medial Collateral Ligament), LCL (Lateral Collateral Ligament), PCL (Posterior Collateral Ligament), IKDC (International Knee Documentation Committee), RTA (Road Traffic Accidents), ROM (Range of movements)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Al-Khalifa F.K.
        • Alhamam N.M.
        • Uddin F.Z.
        • Aljawder A.A.
        • Abubaris R.K.
        Hameed R Clinical outcomes following anterior cruciate ligament reconstruction utilising hamstring tendon autografts.
        Saudi J Sports Med. 2014; 14: 89
        • Clayton R.A.E.
        • Court-Brown C.M.
        The epidemiology of musculoskeletal tendinous and ligamentous injuries.
        Injury. 2008; 39: 1338-1344
        • McKinney B.
        • Cherney S.
        • Penna J.
        Intra-articular knee injuries in patients with knee extensor mechanism ruptures.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 633-638
        • Baker B.E.
        O'Donoghue's triad plus patellar tendon rupture.
        N Y State J Med. 1980; 80: 1436-1437
        • Futch L.A.
        • Garth W.P.
        • Folsom G.J.
        • Ogard W.K.
        Acute rupture of the anterior cruciate ligament and patellar tendon in a collegiate athlete.
        Arthroscopy. 2007; 23 (112): e1-e4
        • Wissman R.D.
        • Vonfischer N.
        • Kempf K.
        Acute Concomitant anterior cruciate ligament and patellar tendon tears in a non-dislocated knee.
        J Clin Imaging Sci. 2012; 2: 3
        • Brunkhorst J.
        • Johnson D.L.
        Multiligamentous knee injury concomitant with a patellar tendon rupture.
        Orthopaedics. 2015; 38: 45-48
        • Ismailidis P.
        • Kernen R.
        • Egloff C.
        • Nüesch C.
        • Mündermann A.
        • Müller S.A.
        Clinical and biomechanical outcomes of one-stage treatment of a simultaneous ipsilateral patellar tendon and ACL tear combined with a tibial plateau fracture: a case study.
        Case Rep Orthop. 2020; 5793948
        • Louka J.G.
        • Pourre D.
        Simultaneous bilateral rupture of the patellar tendon and medial collateral ligament: a case report and literature review.
        Case Rep Orthop. 2020; 8862600
        • Quinn M.
        • Lemme N.
        • Anna King D.O.
        • Tabaddor R.R.
        Simultaneous rupture of the anterior cruciate ligament, medial collateral ligament and patellar tendon: a case series, review of the literature, and proposed treatment algorithm.
        Int J Sports Exerc Med. 2019; 5: 144
        • Cucchi D.
        • Aliprandi A.
        • Nocerino E.
        • Randelli P.
        Early combined arthroscopic treatment for simultaneous ruptures of the patellar tendon, and the anterior cruciate ligament leads to good radiological results and patient satisfaction.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1164-1173
        • Kim D.H.
        • Lee G.C.
        • Park S.H.
        Acute simultaneous ruptures of the anterior cruciate ligament and patellar tendon.
        Knee Surg Relat Res. 2014; 26: 56-60
        • Tsarouhas A.
        • Iosifidis M.
        • Kotzamitelos D.
        • Traios S.
        Combined rupture of the patellar tendon, anterior cruciate ligament and lateral.
        Hippokratia. 2011; 15: 178-180
        • Capogna B.
        • Strauss E.
        • Konda S.
        • Dayan A.
        • Alaia M.
        Distal patellar tendon avulsion in association with high-energy knee trauma: a case series and review of the literature.
        Knee. 2017; 24: 468-476
        • Sundararajan S.R.
        • Sambandam B.
        • Rajagopalakrishnan R.
        • Rajasekaran S.
        Comparison of KD3-M and KD3-L multiligamentous knee injuries and analysis of predictive factors that influence the outcomes of single-stage reconstruction in KD3 injuries.
        Orthop J Sports Med. 2018; 19 (62325967118794367)
        • Koukoulias N.E.
        • Koumis P.
        • Papadopoulos A.
        • Kyparlis D.
        • Papastergiou S.G.
        Acute, simultaneous tear of patellar tendon and ACL: possible mechanism of injury and rationality of the two-stage surgical treatment.
        BMJ Case Rep. 2011; 4 (bcr0520114178)
        • Levakos Y.
        • Sherman M.F.
        • Shelbourne K.D.
        • Trakru S.
        • Bonamo J.R.
        Simultaneous rupture of the anterior cruciate ligament and the patellar tendon. Six case reports.
        Am J Sports Med. 1996; 24: 498-503
        • Chow F.Y.
        • Wun Y.C.
        • Chow YY.
        Simultaneous rupture of the patellar tendon and the anterior cruciate ligament: a case report and literature review.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 1017-1020
        • Costa-Paz M.
        • Muscolo D.L.
        • Makino A.
        • Ayerza M.A.
        Simultaneous acute rupture of the patellar tendon and the anterior cruciate ligament.
        Arthroscopy. 2005; 21: 1143
        • Chiba K.
        • Takahashi T.
        • Hino K.
        • et al.
        Surgical treatment of simultaneous rupture of the anterior cruciate ligament and the patellar tendon.
        J Knee Surg. 2013; 26 (Suppl-4): S40
        • Schenck R.
        Classification of knee dislocations.
        Oper Tech Sports Med. 2003; 11: 193-198
        • Gilmore J.H.
        • Clayton-Smith Z.J.
        • Aguilar M.
        • Pneumaticos S.G.
        • Giannoudis PV.
        Reconstruction techniques and clinical results of patellar tendon rupture evidence today.
        Knee. 2015; 22: 148-155
        • Halinen J.
        • Lindahl J.
        • Hirvensalo E.
        • Santavirta S.
        Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomised study.
        Am J Sports Med. 2006; 34: 1134-1140
        • Stannard J.P.
        • Black B.S.
        • Azbell C.
        • Volgas D.A.
        Posteromedial corner injury in knee dislocations.
        J Knee Surg. 2012; 25: 429-434
        • Chiang A.S.
        • Shin S.S.
        • Jazrawi L.M.
        • Rose D.J.
        Simultaneous ipsilateral ruptures of the anterior cruciate ligament and patellar tendon: a case report.
        Bull Hosp Jt Dis. 2005; 62: 134-136
        • Gülabi D.
        • Erdem M.
        • Bulut G.
        • Sağlam F.
        Neglected patellar tendon rupture with anterior cruciate ligament rupture and medial collateral ligament partial rupture.
        Acta Orthop Traumatol Turc. 2014; 48: 231-235
        • Levy B.A.
        • Dajani K.A.
        • Morgan J.A.
        • Shah J.P.
        • Dahm D.L.
        • Stuart M.J.
        Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multi-ligament-injured knee.
        Am J Sports Med. 2010; 38: 804-809
        • Ng Jimmy W.G.
        • Myint Y.
        • Ali F.M.
        Management of multi-ligament knee injuries.
        EFORT Open Rev. 2020; 5: 145-155
        • Stannard J.P.
        • Brown S.L.
        • Farris R.C.
        • McGwin G.
        • Volgas D.A.
        The posterolateral corner of the knee: repair versus reconstruction.
        Am J Sports Med. 2005; 33: 881-888
        • Sundararajan SR
        • Srikanth KP
        • Rajasekaran S
        Neglected patellar tendon ruptures: a simple modified reconstruction using hamstrings tendon graft.
        Int Orthop. 2013; 37: 2159-2164
        • Sundararajan SR
        • D’souza Terrence
        • Ramakanth Rajagopalakrishnan
        • Rajasekaran SR
        Management of Multiligament knee injuries (MLKI`s) with concomitant fractures and neurovascular injuries- A descriptive review.
        Asian Journal of Arthroscopy. 2020; 5: 9-13