KNEE

Fixation of chondral fracture of the weight-bearing areaof the lateral femoral condyle in an adolescent

Chung Ming Chan • Joseph J. King III •

Kevin W. Farmer

Received: 30 August 2013 / Accepted: 28 December 2013

� Springer-Verlag Berlin Heidelberg 2014

Abstract Purely chondral fractures of the distal femur

associated with patellar dislocation are uncommon, and

treatment varies from fixation to debridement and marrow

stimulation techniques. The unusual case reported here

involves an adolescent who underwent fixation of a purely

chondral fracture involving a large weight-bearing portion

of the lateral femoral condyle. Chondral fracture healing

was confirmed on follow-up magnetic resonance imaging

and arthroscopic examination. This case suggests that fix-

ation of purely chondral fractures can be successful in

weight-bearing areas of the knee.

Level of evidence V.

Keywords Chondral fracture � Adolescent �Bioabsorbable � Lateral femoral condyle

Introduction

The association of acute patella dislocations with osteo-

chondral or chondral fractures is well known [6, 7, 10, 12,

13, 15]. Osteochondral fractures are the more common of

the two, and fixation has become the treatment of choice

when possible. Fixation of isolated partial or full-thickness

chondral fractures has yet to become standard treatment

due to the limited healing potential of articular cartilage.

The sites of the fractures associated with patellar disloca-

tion are most commonly the lateral femoral trochlea and

the medial patella [12, 13]. This report is of an adolescent

who underwent successful fixation of a large chondral

fragment of nearly the entire weight-bearing portion of the

lateral femoral condyle resulting from a patellar disloca-

tion. It represents the third case in the literature of a purely

chondral fracture involving the weight-bearing surface of

the lateral femoral condyle.

The patient’s parents gave written informed consent to

the submission of this case report.

Case report

A 12-year-old male with a history of patellar dislocations

presented to the orthopaedic clinic hours after twisting his

left knee. He had pivoted on his left knee and felt it buckle.

On examination, he had a large knee effusion, tenderness

over the medial patella and lateral distal femur, and limited

range of motion of the knee. Plain radiographs of the knee

did not reveal any bony injury. Magnetic resonance imaging

(MRI) of the knee revealed a large area of chondral

delamination in the central weight-bearing portion of the

lateral femoral condyle, with the displaced chondral frag-

ment adjacent to the medial aspect of the patella (Fig. 1).

Surgery was performed 7 days after injury. Diagnostic

arthroscopy revealed a full-thickness chondral injury of

nearly the entire weight-bearing surface of the lateral

femoral condyle. There was no injury to the menisci or

cruciate ligaments. A lateral arthrotomy was performed,

and the chondral fragment was retrieved. It was approxi-

mately 4 cm 9 2.2 cm (Fig. 2) and was purely chondral

with no attached bone on the non-articular side. The donor

site was sharply demarcated, matched the chondral frag-

ment well, and had a base of subchondral bone without

evidence of bony injury.

C. M. Chan (&) � J. J. King III � K. W. Farmer (&)

Department of Orthopaedics and Rehabilitation, University

of Florida, 3450 Hull Road, Gainesville, FL 32607, USA

e-mail: chancm@ortho.ufl.edu

K. W. Farmer

e-mail: farmekw@ortho.ufl.edu

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2833-0

Repair of the chondral fracture was performed owing to

the size and location of the defect. The donor site was

debrided down to bleeding subchondral bone, and drill

holes were made. Bioabsorbable suture anchors (Micro

SutureTak, Arthrex, Naples, Florida, USA) were inserted

into the corners of the defect, and braided 2–0 absorbable

suture (Vicryl, Ethicon, Somerville, New Jersey, USA) was

passed through the fragment to reduce and secure the

corners of the fragment. The chondral fragment was then

transfixed by five 1.5-mm-diameter polylactide bone

fixation nails (SmartNail�, Conmed Linvatec, Largo,

Florida, USA). The heads of these nails were countersunk

to minimize prominence. The medial patellofemoral liga-

ment (MPFL) was then repaired and imbricated.

The patient’s knee was immobilized in a hinged brace,

and range of motion from 0 to 30� of flexion was permitted.

The maximum flexion permitted was increased by 15�every 2 weeks. No weight bearing was permitted for

6 weeks. Partial weight bearing was permitted at 6 weeks,

and he was weight bearing fully by 8 weeks.

Fig. 1 a Sagittal plane MRI image showing portion of the lateral femoral condyle (marked by arrow) affected by chondral delamination. b Axial

MRI image showing the chondral fragment (marked by arrowhead) lying medial to the patella

Fig. 2 Chondral fragment retrieved from knee, measuring approxi-

mately 4 cm in AP diameterFig. 3 MRI image at 4 months post-surgery showing chondral

fracture fragment fixed with bioabsorbable pins

Knee Surg Sports Traumatol Arthrosc

123

The patient sustained a minor reinjury in the left knee

4 months post-surgery and underwent knee MRI. No dis-

placement of the fixed chondral fragment or any evidence

of fissuring between the fragment and the subchondral bone

was noted (Fig. 3).

On follow-up, the patient did not have knee pain, but

did have patellar instability and subsequently underwent

an MPFL reconstruction. This was performed about

11.5 months after the initial procedure, and arthroscopic

evaluation of the prior chondral fracture was performed.

The chondral fragment was found to be stable on exami-

nation and appeared nearly identical to the adjacent areas

of healthy cartilage (Fig. 4).

Discussion

The most important finding of this report is that successful

fixation can be achieved in chondral fractures involving

high-stress areas such as the weight-bearing portion of the

femoral condyles. Osteochondral and chondral fractures

sustained during acute patella dislocations result from

shearing or impaction between the patella and the lateral

femoral trochlear groove in slight knee flexion. The ante-

roproximal margin of the lateral femoral condyle is the

most common site of femoral injury, with the weight-

bearing surface of the lateral femoral condyle being less

common [10, 13]. Few reports in the literature specifically

address osteochondral fractures here [1, 5, 16], and only

one report of two cases addresses chondral fractures on the

weight-bearing surface of the lateral femoral condyle [4].

Chondral fractures are distinct from the more common

osteochondral fractures [3]. They can be a challenge to

diagnose with MRI or arthroscopy often being necessary

for diagnosis. Management is also challenging, with the

lack of a bony component making fixation difficult and the

limited healing potential of articular cartilage leading to

concerns for healing following fixation [12, 13].

Good clinical results of fixation of purely chondral frag-

ments of the femur have been documented with a variety

of implants. These include bioabsorbable pins [4, 8, 14],

suture [9], metal screws [2], bioabsorbable screws [2], and

fibrin sealant [4]. Bioabsorbable pins have been found in the

rabbit osteochondral fracture model to achieve acceptable

rates of osseous union [11] and do not require removal or

cause secondary damage once degraded. Histologic evi-

dence of healing of such chondral fragments has also been

documented [8, 9]. In our patient, a combination of bioab-

sorbable transfixing pins and suture anchors was chosen for

fixation of the chondral fragment. This combination of fix-

ation has not been reported before in the literature, but was

utilized due to the large size of the fragment and to reduce

the risk of prominent hardware. This case demonstrates that

adequate fixation of large chondral fragments on the weight-

bearing surface of the lateral femoral condyle can be

successful.

Conclusion

Fixation of purely chondral fractures of the weight-bearing

portion of the femoral condyles can be successful in

obtaining good clinical outcomes and chondral healing.

The use of bioabsorbable nails and suture anchors is a

suitable strategy in achieving stable fixation in such frac-

tures and should be considered in the management of these

uncommon injuries.

References

1. Callewier A, Monsaert A, Lamraski G (2009) Lateral femoral

condyle osteochondral fracture combined to patellar dislocation:

a case report. Orthop Traumatol Surg Res 95:85–88

2. Frank RM, Wilson JB, Slabaugh MA, Usaf M, Smith T, Bush-

Joseph CA (2009) Isolated chondral fragment of the lateral

femoral trochlea in an adolescent: surgical technique and case

report. J Orthop 6(4):2

3. Gilley JS, Gelman MI, Edson M, Metcalf RW (1981) Chondral

fractures of the knee. Radiology 138:51–54

4. Maletius W, Lundberg M (1994) Refixation of large chondral

fragments on the weight-bearing area of the knee joint: a report of

two cases. Arthroscopy 10:630–633

Fig. 4 Arthroscopic images of

lateral femoral condyle at

11.5 months after chondral

fracture fixation

Knee Surg Sports Traumatol Arthrosc

123

5. Mashoof AA, Scholl MD, Lahav A, Greis PE, Burks RT (2005)

Osteochondral injury to the mid-lateral weight bearing portion of

the lateral femoral condyle associated with patellar dislocation.

Arthroscopy 21:228–232

6. Mayer G, Seidlein H (1998) Chondral and osteochondral frac-

tures of the knee joint—treatment and results. Arch Orthop

Trauma Surg 107:154–157

7. Milgram JE (1943) Tangential osteochondral fracture of the

patella. J Bone Joint Surg Am 27:271–280

8. Nakamura N, Horibe S, Iwahashi T, Kawano K, Shino K, Yos-

hikawa H (2004) Healing of a chondral fragment of the knee in an

adolescent after internal fixation. A case report. J Bone Joint Surg

Am 86:2741–2746

9. Noh JH, Song SJ, Bae JY, Roh YH, Kim W, Yang BG (2012)

Fixation of a chondral fragment of the knee in an adult. JBJS

Case Connect 2(e83):1–5

10. Nomura E, Inoue M, Kurimura M (2003) Chondral and osteo-

chondral injuries associated with acute patellar dislocation.

Arthroscopy 19:717–721

11. Plaga BR, Royster RM, Donigian AM, Wright GB, Caskey PM

(1992) Fixation of osteochondral fracture in rabbit knees. A

comparison of Kirschner wires, fibrin sealant, and polydioxanone

pins. J Bone Joint Surg Br 74:292–296

12. Rorabeck CH, Bobechko WP (1976) Acute dislocation of

the patella with osteochondral fracture. J Bone Joint Surg Br

58:237–240

13. Stanitski CL, Paletta GA (1998) Articular cartilage injury with

acute patellar dislocation in adolescents: arthroscopic and radio-

graphic correlation. Am J Sports Med 26:52–55

14. Uchida R, Toritsuka Y, Yoneda K, Hamada M, Ohzono K,

Horibe S (2012) Chondral fragment of the lateral femoral

trochlea of the knee in adolescents. Knee 19:719–723

15. Virolainen H, Visuri T, Kuusela T (1993) Acute dislocation of the

patella: MR Findings. Radiology 189:243–246

16. Walsh SJ, Boyle MJ, Moranti V (2008) Large osteochondral

fractures of the lateral femoral condyle in the adolescent: out-

come of bioabsorbable pin fixation. J Bone Joint Surg Am

90:1473–1478

Knee Surg Sports Traumatol Arthrosc

123