A boy who was 13 years old presented to the emergency room with pain and difficulty in walking after a break (sudden deceleration) during a football match. The patient's height and weight were 1.62 m and 59 kg, respectively. Physical examination indicated pain when trying to fully extend either knees, bilateral pain on palpation, swelling over the anterior tibial tuberosity, joint effusion, and inability to walk. Ligament manoeuvres were negative (bilateral Lachman test). This patient has a previous history of Osgood-Schlatter disease in both knees. He suffered from anterior knee pain the year before. This pain forced him to stop sport activities and to undergo different treatments. He was treated with resting from contact-sport activities, physical therapy, and as a last resort, some injections (he was treated in a different hospital, and the patient cannot specify which drug was administered). Anteroposterior and lateral radiographs of both knees evidenced a bilateral tibial tuberosity avulsion fracture (Figure 1). The fractures of both knees were classified as Ogden type IIIA in the left knee and type IB in the right knee. Surgical treatment was proposed (open reduction and internal fixation with screws), and the patient underwent surgery 24 hours after the trauma. Under spinal anesthesia and in a supine position, an anterior approach was performed in both knees. Intravenous tranexamic acid was used in this case to avoid the use of bilateral tourniquet. After dissection and haematoma drainage, we cleaned the fracture site and reduced the distal fragment fracture under radiological control (Figure 2). The left knee (Ogden type IIIA) was internally fixed with 2 cannulated screws of 4.5 mm with a washer (Asniss III, Stryker, Selzach, Switzerland). The right one (type IB) was fixed with one cannulated screw and a washer. We reinforce fixation of both patellar tendons with one suture anchor (Iconix 2.3 mm, Stryker, Mahwah, NJ, USA) (Figure 3).
On the basis of the patient's weight, type of fracture, and bilateral occurrence, immobilization was indicated for 3 weeks using a bilateral knee brace. Physical therapy was started with passive range of motion (ROM) exercises, and after a 3-week-period, loading and quadriceps strengthening exercises were allowed. At 8 weeks, full loading and active ROM exercises were performed. At 12 weeks after surgery, the patient had already achieved full ROM (0 -140 ) and regained bilateral knee extension strength.
Approximately 20 weeks after the surgery, the patient was able to perform physical activities without limitations at the same level as before the injury. Return to play was allowed at 6 months postoperative. A nonsymptomatic hypertrophic scar was developed, but the patient has no limitations during sport activities. By now, there has been no need for hardware removal (Figure 4).