A 24-year-old male patient with a BMI of 35 kg/m2 (height 185 cm; weight 120 kg) who presented to the emergency department with severe bilateral knee pain and inability to walk. The mechanism of injury was sport-related. While playing basketball, the patient jumped and eccentrically loaded his left knee followed by a popping sound. While trying to maintain his balance by putting his weight on the contralateral leg, he heard a second popping sound, then experienced severe bilateral knee pain, and was not able to stand. His past medical history was unremarkable, and he had no history of steroid or fluoroquinolone intake. He is an active person and plays basketball on weekly basis. He had no history of prodromal knee pain prior to his injury. Clinical examination revealed a palpable gap in the suprapatellar region and loss of knee extension bilaterally. Magnetic resonance imaging (MRI) confirmed the diagnosis, which was bilateral quadriceps tendons rupture (Figure 1).
A day after his diagnosis with SBQTR, he was taken to the operating room for surgical repair. We approached both knees through standard anterior midline incisions. Intraoperatively, we identified both tears at the osteotendinous junction. We debrided all the frayed tissue and then repaired both tendons surgically using number 5 FiberWire  sutures (Arthrex, Naples, Florida) in a Whipstitch fashion. The free ends of the sutures were passed through three drilled holes in each patella using a 2.5 mm drill in a vertical orientation. These 3 holes were drilled using an anterior cruciate ligament (ACL) tibial tunnel guide which is used during this aspect of the procedure to manoeuvre the drill more accurately to the desired endpoint. Using the tunnel guide decreases the risk of violating the articular surface, reduces the number of passes required to obtain an optimal position, minimizes injury to the patellar tendon, and eliminates the additional step of retrieving sutures through drill holes. The drill is then replaced with a Beath pin. The inner limb of each suture is passed through the central tunnel, and then the outer limb is passed through the outer tunnels. All free limbs of the suture on both ends of the tendon were tied with the knee in full extension. We also found a complete retinacular tear in the left knee and only a small longitudinal split in the right knee and both were repaired using a number 1 absorbable suture.
Postoperatively, both knees were protected in a knee immobilizer. The patient was allowed to bear weight as tolerated in full extension with the aid of crutches on both lower extremities. He started physiotherapy at 4 weeks to regain his knee range of motion (ROM) and quadriceps muscle strength. At the two-year follow-up, he had full quadriceps muscle strength with no extension lag (Figure 2), and his ROM was from 0 to 120 degrees bilaterally (Figure 3). At this point, the patient already resumed all his sport activities including playing basketball without limitations.