The patient had been a professional basketball player from 18 to 25 years old and practiced competitive weightlifting until 30 years old. He admitted having taken a few cycles of oral and injectable steroids during the weightlifting competitive practice time. Currently, he is a bouncer and a recreational weightlifting practitioner. The patient assured not having taken steroids or any other supplements for the last three years. He reported no previous injuries to his knees and denied chronic knee pain. At the time of the trauma, the patient body type was athletic, weighing 120 kg and was 192 cm tall.
The X-rays showed cephalic patellar migration and small calcification avulsions of the inferior poles of both patellae. An isolated undisplaced spiral fracture of the left fibular neck was also identified (Fig. 1). Ultrasound confirmed total bilateral rupture of the patellar tendons. Intraoperatively we found both tendons torn in their substance near the inferior patellar poles, with some segments avulsed from the patellar insertion. Lateral and medial retinacula were disrupted bilaterally. An end-to-end primary Kessler-type tendon repair reinforced with intraosseous sutures was performed in both knees. We temporarily protected it with cerclage wiring, followed by immobilization with a leg cylinder cast. We chose a nonabsorbable monofilament loop suture that allowed a proper tendon suture tension, by its second passage through the middle of the loop (Fig. 2). The tension within stitches was carefully adjusted to avoid shortening of infrapatellar length, according to the patellae position. The ruptured retinacula were repaired with Vicryl sutures. The strength of the repair was tested by careful flexion of both knees (Fig. 3). Cerclage wiring was applied in a figure-of-eight tension band running around the superior pole of the patellae, passing in front of the tendon, fixed with a transverse screw through the tibia tubercle and tied at average 60  of knee flexion (Fig. 4).
The postoperative course was uneventful and radiographic control was satisfactory (Fig. 5). The cast immobilization was removed at the third postoperative day and the patient began ambulation with crutches using extension knee braces and full weight-bearing allowed as tolerated. At the 2rd postoperative week he began periodic removal of knee braces and a daily rehabilitation program, initially consisting in isometric muscle strengthening and knee flexion exercises restricted to 60 , complemented with peripatellar soft tissue massage. At the 4th week the patient could walk without crutches, had no pain and attained 40  of maximum bilateral active knee flexion. At the 6th week he had 60  of flexion and the knee braces were discontinued. At the 8th postoperative week, the cerclage wire was removed and the patient continued the daily physiotherapy program with progression to full knee flexion allowed and emphasis on muscle strengthening exercises. Stationary bicycle was introduced at the 9th week. Eleven weeks after surgery, the patient presented 100  maximum bilateral knee flexion and returned to work. On examination 5 months after surgery, the patient presented a satisfactory range of motion of both knees (135  flexion, 0  extension) good quadriceps strength and no signs of muscular atrophies or extensor lag (fig. 6). He denied any sense of instability or swelling, and therefore he returned to recreational sportive activities. He reported feeling that his knees were as strong as they were prior to the lesions and he was able to run, squat, and hop in place without difficulty.