Abnormal Femoral Origin of the Anterior Cruciate Ligament Associated with Osteochondritis Dissecans of the Medial Femoral Condyle

doi:10.4236/ss.2013.410093

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Surgical Science, 2013, 4, 474-476

http://dx.doi.org/10.4236/ss.2013.410093 Published Online October 2013 (http://www.scirp.org/journal/ss)

Abnormal Femoral Origin of the Anterior Cruciate

Ligament Associated with Osteochondritis Dissecans of the

Medial Femoral Condyle*

Massimiliano Salvi#, Francesco Caputo, Giuseppe Piu, Marco Sanna, Cristina Sanna

Department of Prosthetic and Sports Surgery, Sant’Elena Private Hospital, Kinetika Group, Quartu Sant’Elena, Cagliari, Italy

Email: #[email protected]

Received September 27, 2013; revised October 20, 2013; accepted October 27, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

We report a case of abnormal meniscal-like anterior cruciate ligament (ACL), inserting at the 9 o’clock position just

beside the cartilage of the lateral femoral condyle, in a stable knee associated with osteochondritis dissecans (OCD) of

the medial femoral condyle.

Keywords: Congenital Anomaly; Abnormal Anterior Cruciate Ligament; Femoral Attachment; Osteochondritis

Dissecans

1. Introduction

Abnormal femoral or tibial attachments of the ACL are

very rare. To our knowledge, there have been only two

reported cases of abnormal femoral origin of the ACL,

one combined with a discoid lateral meniscus [1] and one

isolated [2]; two reported cases of abnormal tibial at-

tachment of the ACL [3] and one reported case of OCD

of the medial femoral condyle associated with ACL and

lateral meniscus hypoplasia [4].

We report a case of abnormal femoral origin of the

ACL associated with OCD of the medial femoral

condyle.

2. Case Report

A 17-year-old male presen ted to our clinic with on e-year

history of swelling, pain and locking in his right knee,

during daily activities and mild recreational sports activ-

ity, with no history of trauma. The patient was 170 cm

tall and weighed 58 Kg.

The left knee was asymptomatic. The right knee was

swollen, and two large loose bodies were palpable at the

suprapatellar pouch. The knee was locked in 15˚ of flex-

ion, and the active range of motion was from 15˚ to full

flexion.

Clinical lower limb alignment was normal. Both knees

were stable in anterior and posterior drawer tests, varus

and valgus stress tests, Lachman test and pivot shift test.

Plain radiographs revealed OCD of the medial femoral

condyle at the classical site and two loose bodies. Mag-

netic resonance imaging showed apparent normal cruci-

ate ligaments, normal menisci and cartilage of the lateral

and patello-femoral compartments, a large OCD of the

medial femoral condyle and three loose bodies (Figure

1).

The patient was scheduled for arthroscopic evaluation

and treatment of OCD and loose bodies removal.

Figure 1. Gradient echo STIR magnetic resonance image

showing a large osteochondritis dissecans of the medial

femoral condyle and a loose body.

*Conflict of interest: The Authors declare that they have no conflict o

interest.

#Corresponding author.

M. SALVI ET AL. 475

Arthroscopy was performed using the standard anter-

olateral and anteromedial portals and revealed no menis-

cus anomalies or tears and no cartilage damage of the

lateral femoral condyle, sulcus and patellae.

A large (2 × 4 cm) OCD of the medial femoral condyle

and five loose bodies, two of which were locatedin the

posteromedial compartment, were found.

The morphology of the ACL was surprisingly clearly

abnormal. A flat meniscal-like ACL, inserting just beside

the cartilage of the lateral femoral condyle at the 9

o’clock position over the whole length of the shallow-

deep direction was found (Figures 2(a)-(c)).The tibial

attachment of the ACL appeared to be normal.

Loose bodies were removed through the standard por-

tals and a posteromedial portal, and the OCD was treated

by microfractures. The abnormal femoral insertion of the

ACL was left untreated. The patient was recommended

to abstain from weight bearing activity and use two

crutches for six weeks.

Six months postoperatively, the patient had no pain,

swelling or limitation to the range of motion, and here

turned to his normal lifestyle.

3. Discussion

OCD of the medial or lateral femoral condyles combined

with malformation of the menisci [5,6] or associated with

congenital hypoplasia of the ACL and lateral meniscus

(a) (b)

(c)

Figure 2. (a), (b) Arthroscopic view of the right knee from a

standard anterolateral portal, and a meniscal-shaped ab-

normal attachment of the anterior cruciate ligament, just

beside the cartilage of the lateral femoral condyle. (c) The

anterior cruciate ligament inserts over the whole length of

the intercondylar notch in a shallow-deep direction at the 9

o’clock position. ACL: Anterior Cruciate Ligament; LFC:

Lateral Femoral Condyle; TP: Tibial Plateau; LM: Lateral

Meniscus.

[4] have been previously reported in the literatu re.

However, abnormal femoral or tibial attachments of

the ACL are very rare.

Calpur et al. in 2004 [3] described two cases of unre-

ported abnormally wide triangu lar-shaped tibial insertion

of the ACL, causing painful anterior notch impingement.

To our knowledge, abnormal femoral origin of the

ACL has been previously reported only in two cases,

although neither of them was associated with OCD.

The first case was reported by Hoffmann in 1997 [1].

He found an abnormal femoral origin of the ALC, which

is very similar to that of described in our case, and com-

bined with a complete discoid lateral meniscus in a 3-

year-old child.

In that case, the femoral insertion was found very an-

terior in the intercondylar notch at the 10 o’clock posi-

tion, just beside the articular cartilage of the lateral

femoral condyle. Although the anomaly was completely

asymptomatic, after the discoid lateral meniscus was

resected into a normal-shaped lateral meniscus, the ante-

rior part of the femoral insertion of the ACL was also

resected, without causing instability at one-year follow-

up.

In our case, the femoral insertion of the ACL was

more horizontal, at a 9 o’clock position, compared with

that described by Hoffmann. However, we did not resect

the anterior portion of the ACL.

The second case was reported by Sarsilmaz and Gelal

in 2011 [2].

They found an isolated congenital anomaly of the

femoral insertion of the ACL in which the posterolateral

bundle attached separately to an intraarticular large ac-

cessory ossicle, causing pain but not instability.

To our knowledge, this is the first reported congenital

abnormal femoral origin of the ACL associated with

OCD of the medial femoral condyle.

However, because this type of abnormal femoral at-

tachment of the ACL does not compromise ligament

function, we be li e ve that it should not be trea te d.

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M. SALVI ET AL.

476

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