Abstract
Lateral femoral condyle (LFC) impaction fractures are an increasingly recognized pathology occurring concomitantly with anterior cruciate ligament (ACL) rupture. These lesions are important to identify and treat because of the impact they have on knee instability, meniscal degeneration, a faster rate of progression to osteoarthritis, and increased chance of ACL graft rerupture. The technique presented is intended for use in large and deep LFC impaction fractures in conjunction with ACL reconstruction with bone−patellar tendon−bone autograft. It uses an open anterolateral arthrotomy and a subchondral cortical window to place autologous bone graft into the LFC from the bone−patellar tendon−bone tibial harvest site and tibial tunnel bone chips. This is performed to mitigate the risk of posttraumatic complications and to restore the native joint anatomy in a biologically sound, cost-effective manner.
Technique Video
Anterior cruciate ligament (ACL) tears are a common sports medicine injury seen by orthopaedic surgeons, and the vast majority of ACL tears result in some degree of trauma to the subchondral bone.1, 2, 3, 4 Of patients with ACL tears and bone lesions, up to 92% have been reported to have a subchondral impaction fracture; additionally, impaction most commonly affects the lateral femoral condyle (LFC), with a prevalence as high as an 51% among all ACL tears.2,5,6 This specific injury occurs in the setting of anterior tibial translation and tibial internal rotation (pivot-shift) when the anterior aspect of the extension surface of the LFC is impacted by the posterior edge of the lateral tibial plateau.7 Similar to the posterior humeral head impaction fracture that frequently accompanies anterior shoulder dislocations, LFC impaction fractures can be severe enough to resemble a “Hill-Sachs lesion” of the knee.6,7 Like Hill-Sachs lesions of the humeral head, knee LFC impaction fractures disrupt the bony geometry of the lateral compartment. Although the clinical significance of large LFC impaction fractures remains unknown, these lesions undoubtedly alter the biomechanics of the lateral compartment and may potentially lead to pain and/or instability.2,7, 8, 9 Compared with those without LFC impaction injuries, patients with an LFC impaction fracture have significantly lower 1-year postoperative International Knee Documentation Committee scores, increased rates of ACL graft failure, and greater rates of concomitant lateral meniscus injuries.7, 8, 9, 10 Although the optimal treatment of LFC impaction fractures remains unknown, the association between these injuries and inferior postoperative outcomes suggests that attempting to restore the natural convexity of the LFC may represent an opportunity to improve patient outcomes. This Technical Note describes the first author’s technique to address this challenging but frequent problem facing orthopaedic surgeons.
Indications
This technique is indicated for posttraumatic osteochondral impaction fractures of the LFC measuring greater than 2 mm in depth in cases in which the overlying cartilage remains intact and is associated with a concomitant ACL injury undergoing bone−patellar tendon−bone (BTB) autograft reconstruction (Fig 1, Video 1).
Fig 1.
Preoperative magnetic resonance imaging of the patient’s left knee was obtained due to suspicion of a complete rupture of the anterior cruciate ligament (ACL). This sagittal T2 view demonstrates the lateral femoral condyle (LFC) impaction fracture (orange star). The depth of the fracture measured 3.5 mm into the LFC. There is also visualization of significant bone edema (blue star) that is a concomitant finding of the LFC impaction fracture. Because of the size of the patient’s impaction fracture in the setting of a concomitant ACL tear, lack of cartilage damage, and plan for ACL reconstruction with bone−patellar tendon−bone autograft, a plan was made to perform an open reduction of the LFC impaction fracture using an open anterolateral arthrotomy, subchondral cortical window, bone tamp to manually restore LFC shape, and with subchondral autologous cancellous bone grafting to scaffold the reduction. This allowed for excellent restoration of the LFC native contour and lateral knee biomechanics.
Contraindications
This technique is contraindicated in patients with advanced cartilage degeneration defined as International Cartilage Repair Society grade greater than 2, displaced articular surface fractures, or spontaneous osteonecrosis of the knee.
Surgical Technique
Patient Positioning
The patient is placed in the supine position. A nonsterile thigh tourniquet is used to control intraoperative bleeding. The affected limb is positioned in a leg holder, prepped, and draped in accordance with standard sterile protocol.
Diagnostic Arthroscopy
The procedure begins with an arthroscopic evaluation of the subchondral impaction fracture of the LFC. Visualization is achieved through the anterolateral portal, with the lesion clearly identified near full knee extension (Fig 2, Video 1). ACLR with BTB autograft is completed after diagnostic arthroscopy per standard protocol.
Fig 2.
Arthroscopic view from the anterolateral portal of the impaction fracture of the lateral femoral condyle (LFC) in the foreground with the medial femoral condyle (MFC) and intercondylar eminence of the tibia in the background. The damaged lateral meniscus is also visible in the lower half of the image. Notably, the articular cartilage overlying the area of the impaction fracture is intact and demonstrates a concave appearance that is pathognomonic for LFC impaction fractures. Also, the anterior cruciate ligament (ACL) (not visualized in this figure) was completely ruptured. These diagnostic arthroscopy findings confirmed our preoperative suspicions of a LFC impaction fracture in the setting of an ACL tear from the patient’s MRI findings; this met all the indication criteria and none of the contraindication criteria for open reduction of the LFC impaction fracture with use of autologous cancellous bone obtained from the ACL reconstruction bone−patellar tendon−bone autograft tibial harvest site and tibial tunnel.
Open Reduction of LFC Subchondral Compression Fracture
With the knee flexed to 90° and secured in a leg holder, access is gained through the previously established approach for the BTB harvest. A small lateral parapatellar arthrotomy is performed, providing direct visualization of the LFC lesion (Fig 3, Video 1).
Fig 3.
View of the anterior left knee after anterior cruciate ligament reconstruction with bone−patellar tendon−bone (BTB) autograft depicting the anterolateral arthrotomy used to obtain access to the lateral femoral condyle (LFC). This view exposes the LFC through the previously created BTB incision and a parapatellar arthrotomy. Also, of note in this view are the tibial-sided BTB harvest site and reamed tibial tunnel, which will both be used for autologous bone grafting of the LFC. The patella marks the proximal portion of the knee. This exposure is essential for proper access to the superolateral edge of the articular surface where a subchondral cortical window will be created to allow a bone tamp and autologous bone graft to enter the LFC and reduce the impaction fracture.
A vertical incision is made through the periosteum at the superolateral edge of the articular surface. An osteotome is then used to create a cortical window through which the subchondral bone of the lateral femoral condyle can be accessed in a retroarticular (subchondral) fashion (Fig 4, Video 1). Through this cortical window, a small bone tamp is used to reduce the depressed portion of the LFC reduced under direct visualization in order to re-establish the native contour of the LFC (Fig 5, Video 1). The resulting void is then backfilled with autologous cancellous bone, which is harvested from both the tibial bone plug donor site as well as the tibial tunnel (Fig 6, Video 1).
Fig 4.
View of the anterior left knee after anterior cruciate ligament reconstruction (ACLR) with bone−patellar tendon−bone (BTB) autograft demonstrating an exposure of the lateral femoral condyle (LFC) impaction fracture achieved through the BTB harvest incision and an anterolateral parapatellar arthrotomy. The patellar tendon is retracted horizontally to provide exposure of the lateral femoral condyle (LFC). The infrapatellar fat pad is clearly seen inferior to the arthrotomy. A 13-mm curved osteotome is used to create a 20-mm osteotomy at the proximal superolateral articular cartilage border that parallels the impaction fracture defect. It is essential to be cautious during the creation of the subchondral cortical window with the osteotome to avoid iatrogenic injury to the surrounding articular cartilage. This window will allow for the small bone tamp to enter the LFC and reduce the impaction fracture. Afterwards, autologous cancellous bone will be taken from the tibial BTB autograft harvest site and tibial tunnel used during ACLR. It will be placed through this same cortical window in the LFC to provide subchondral support and biologically augmented healing of the reduced impaction fracture.
Fig 5.
View of the anterior left knee after anterior cruciate ligament reconstruction (ACLR) with bone−patellar tendon−bone (BTB) autograft and an anterolateral arthrotomy to expose the lateral femoral condyle (LFC). A bone tamp is introduced into the LFC through a previously established subchondral cortical window created via osteotomy. The LFC impaction fracture is visible as a depression at the central aspect of the LFC in this view. The bone tamp is tapped with a mallet to gently reexpand the subchondral bone of the LFC in the impaction zone under direct visualization. Care should be taken during this portion of the operation to not cause an overt fracture of the articular portion of the LFC or cause chondral damage. The area expanded by the bone tamp will be filled with autologous cancellous bone from the BTB autograft tibial harvest site and the ACLR tibial tunnel. This will restore the native LFC contour and mitigate posttraumatic complications by supporting the healing of the impaction fracture.
Fig 6.
View of the left anterior knee demonstrating the lateral femoral condyle (LFC) impaction fracture after anterior cruciate ligament reconstruction (ACLR) with bone−patellar tendon−bone (BTB) autograft and creation of an anterolateral arthrotomy. The LFC impaction fracture was reduced by a bone tamp and is located at the center of the LFC in this view. Autologous cancellous bone from the tibial BTB harvest site and tibial tunnel is placed into the previously created subchondral cortical window at the superolateral edge of the articular cartilage. A 6-mm curved osteotome is used to support the bone graft as it is guided through the cortex of the LFC and into the subcortical cancellous bone to restore volume to the LFC, improve healing, mitigate long-term sequelae, and restabilize the knee.
Rehabilitation
After a LFC impaction fracture open reduction with ACLR using BTB autograft, patients should be placed in a hinged knee brace locked in extension until good quadriceps muscle control returns. Patients should be restricted to partial-weight-bearing for 6 weeks but allowed to range the knee fully. Postoperative radiographs should be obtained to verify reduction of the impaction fracture (Fig 7, Video 1). Subsequent rehabilitation decisions should be guided by the ACLR and any additional concomitant procedures performed such as a lateral meniscus root repair.
Fig 7.
Preoperative (A) lateral radiograph of the left knee demonstrating the lateral femoral condyle (LFC) impaction fracture (white arrow) near the terminal sulcus and one day postoperative (B) lateral radiograph of the patient’s left knee demonstrating reduction of the LFC impaction fracture (yellow arrow) with anterior cruciate ligament reconstruction interference screws in place. This comparison depicts the restored contour of the LFC after use of this technique during a concomitant anterior cruciate ligament reconstruction (ACLR) with bone−patellar tendon−bone (BTB) autograft. It is important to note that visual reduction was achieved intraoperatively with a bone tamp that was employed through a subchondral cortical window placed just superolateral to the LFC articular cartilage and subchondral support from tibial BTB harvest site and tibial tunnel cancellous bone autograft. This radiographic depiction confirms adequate reduction and success of the technique.
Discussion
The presented technique describes a step-by-step reduction of a LFC impaction fracture and stabilization with autologous bone graft in the setting of ACLR with BTB autograft. We believe that large and deep impaction lesions need to be addressed.7 If left untreated, they can lead to residual rotational instability and potentially a greater risk of reinjury to the ACL graft and/or lateral meniscus.7,11
A lesion deeper than 1.5 to 2 mm has been associated with increased graft failure rates, lower postoperative patient-reported outcome scores, and persistent pivot shift on examination.7 Dimitriou et al.5 found that patients with notch depths greater than 1.8 mm had a 4-fold increased risk of a residual pivot shift and ACL graft failure compared with those with shallower lesions. Similarly, Lucidi et al.12 reported that lesions deeper than 2 mm were correlated with increased rotational laxity during navigated pivot-shift assessments.
In addition to instability, LFC impaction fractures frequently are associated with chondral damage and meniscal injury. Importantly, Bernholt et al.10 reported that LFC impaction fractures are associated with a significantly higher incidence of lateral meniscus injury, particularly involving the posterior root that is a key stabilizer of the lateral compartment.
Few studies have described treatment strategies. Malinowski et al.9 reported an arthroscopic-assisted technique involving elevation of the depression and placement of bone allograft through a cortical flap to restore the femoral condyle’s contour. Tollefson et al.11 expanded upon this approach by using a lateral arthrotomy to perform fracture reduction in conjunction with a multiligament reconstruction and meniscal repair in complex cases.
The technique presented here offers a simple and reproducible open method for addressing LFC impaction fractures encountered during ACLR. By using autologous bone graft harvested from the existing BTB harvest sites and tibial tunnel bone chips, this approach eliminates the need for a separate bone graft donor site while providing immediate subchondral support to the LFC. The use of autograft offers biological advantages that promote bone healing and integration.13,14 In addition, this cost-effective strategy may help reduce the risk of ACL graft failure by restoring the convex contour of the lateral femoral condyle, which plays a key role in maintaining rotational stability. Anatomical realignment of the subchondral surface may also mitigate the progression of posttraumatic osteoarthritis, particularly in cases associated with lateral meniscal injury and lateral compartment overload.7 Overall, this technique offers a biologically favorable, efficient, and accessible option for managing an underrecognized yet clinically impactful injury. The pearls and pitfalls of the procedure are summarized in Table 1, and advantages and disadvantages are discussed in Table 2.
Table 1.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| Uses autologous bone harvested intraoperatively (BTB plug and tibial tunnel), enhancing graft incorporation and avoiding the need for allograft or synthetic materials. | Without BTB autograft harvest and fixation, there are no tibial plug harvest site and tibial tunnel bone chips. |
| Eliminates the need for additional implants or graft sources, reducing overall surgical costs. | Increased risk of postoperative pain and bleeding with long anteromedial incision. |
| Restoration of LFC contour improves joint congruity and may decrease graft overload and failure rates. | Additional procedure to perform after ACLR with need for controlled surgical re-expansion of the LFC. |
| By restoring subchondral support and joint biomechanics, this technique may help prevent degenerative changes, particularly in the lateral meniscus and compartment. | Exposure of the articular cartilage during arthrotomy, use of an osteotome near the border of the articular cartilage, and the use of a bone tamp on the subchondral surface pose a risk of iatrogenic cartilage damage. |
| It can be performed using standard instruments and surgical exposure; suitable for incorporation into routine ACLR workflows. | Depending on size of the impaction fracture, the surgeon may exhaust their supply of tibial tunnel bone chips; there may not be remaining bone chips to plug the patellar and tibial BTB graft harvest sites. |
Shown are pearls and pitfalls of the open reduction technique for LFC impaction fractures in the setting of ACLR with BTB autograft.
ACLR, anterior cruciate ligament reconstruction; BTB, bone−patellar tendon−bone; LFC, lateral femoral condyle.
Table 2.
Advantages and Disadvantages
| Advantages | Disadvantages |
|---|---|
| Directly and immediately restores the altered lateral compartment’s bony biomechanics in a biologically sound method via autologous cancellous bone grafting and targeted subchondral support of the impaction fracture. | Joint restoration is dependent on the use of an adequate volume of cancellous bone, so large impaction fractures may not be fully reduced intraoperatively with too small a volume of bone graft. It is important to check final reduction both visually and radiographically. |
| After ACLR, refractory pivot shift and rotational instability may be reduced by addressing LFC impaction fractures, leading to lower ACLR complication rates and improved patient outcomes and ability to return to sports and work. | There are very limited outcomes data on LFC impaction fracture treatment, so although addressing the biomechanics of the lateral tibiofemoral compartment is important, its effect size on ACLR complication rates and patient-reported outcomes is unknown. |
| By using autologous cancellous bone from the tibial BTB harvest site and the ACLR’s tibial tunnel, there is no need for a separate, isolated bone autograft harvest site. | Tibial cancellous bone that may have been suitable for plugging the patellar and tibial BTB harvest sites is repurposed. This may inadvertently prolong BTB harvest site healing and increase postoperative anterior knee pain. |
Shown is a summary of the advantages and disadvantages of using this technique for LFC impaction fracture reduction in the setting of ACLR with BPTB autograft.
ACLR, anterior cruciate ligament reconstruction; BTB, bone−patellar tendon−bone; LFC, lateral femoral condyle.
In conclusion, this technique offers a safe and effective method to treat patients with LFC impaction fractures encountered during ACLR. It is a simple, reproducible approach that uses autologous bone graft to restore subchondral support and articular congruity, with potential benefits in reducing ACL graft failure, preserving meniscal integrity, and mitigating long-term joint degeneration.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.C. reports board membership with the American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine; consulting or advisory with Arthrex, CONMED Linvatec, Ossur, and RTI Surgical; travel reimbursement from Breg, DePuy Synthes Sales, Joint Restoration Foundation, Medical Device Business Services, Pacira Pharmaceuticals, and SI-BONE; speaking and lecture fees from Medwest Associates; consulting or advisory and speaking and lecture fees from Smith & Nephew; and consulting or advisory and travel reimbursement from Vericel Corporation. R.F.L. reports consulting or advisory with Smith & Nephew; board membership with International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, American Journal of Sports Medicine, Knee Surgery, Sports Traumatology, Arthroscopy, Journal of Experimental Orthopaedics, Operative Techniques in Sports Medicine, and the Journal of Knee Surgery. R.F.L. reports board membership with International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine. All other authors (J.T.M., N.T., J.F.V., G.O.P.L., F.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Shown is the first author’s technique to treat large and deep lateral femoral condyle (LFC) impaction fractures. This technique is indicated for posttraumatic osteochondral impaction fractures of the LFC that are greater than 2 mm in depth with intact overlying articular cartilage and without displacement, advanced cartilage degeneration, or spontaneous osteonecrosis of the knee. It is performed in the setting of a concomitant anterior cruciate ligament reconstruction (ACLR) with a bone−patellar tendon−bone (BTB) autograft, and it makes use of autologous cancellous bone graft from the tibial BTB harvest site and from the bone chips resulting from reaming the tibial tunnel during ACLR. This video provides a step-by-step guide to performing the technique and highlights the potential implications of use. The procedure begins with a diagnostic arthroscopy through the anterolateral portal that identifies the impaction fracture. The ACLR with BTB autograft is completed in standard fashion, then attention is turned to the LFC impaction fracture. The knee is flexed to 90° in a leg holder. The previously established BTB harvest incision is used for access to the lateral knee. A parapatellar arthrotomy is performed, creating an opening through which the LFC impaction fracture can be seen. An incision is made through the periosteum at the superolateral edge of the LFC’s articular surface, then an osteotome is used to make a subchondral cortical window. A small bone tamp is placed through this window and gentle pressure is applied to visually restore the native contour of the LFC. Afterwards, autologous cancellous bone from the tibial BTB harvest site and the ACLR tibial tunnel is used to fill the resulting defect. This restores normal knee biomechanics, provides subchondral support, improves the biological healing of the fracture, and mitigates posttraumatic complications.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Shown is the first author’s technique to treat large and deep lateral femoral condyle (LFC) impaction fractures. This technique is indicated for posttraumatic osteochondral impaction fractures of the LFC that are greater than 2 mm in depth with intact overlying articular cartilage and without displacement, advanced cartilage degeneration, or spontaneous osteonecrosis of the knee. It is performed in the setting of a concomitant anterior cruciate ligament reconstruction (ACLR) with a bone−patellar tendon−bone (BTB) autograft, and it makes use of autologous cancellous bone graft from the tibial BTB harvest site and from the bone chips resulting from reaming the tibial tunnel during ACLR. This video provides a step-by-step guide to performing the technique and highlights the potential implications of use. The procedure begins with a diagnostic arthroscopy through the anterolateral portal that identifies the impaction fracture. The ACLR with BTB autograft is completed in standard fashion, then attention is turned to the LFC impaction fracture. The knee is flexed to 90° in a leg holder. The previously established BTB harvest incision is used for access to the lateral knee. A parapatellar arthrotomy is performed, creating an opening through which the LFC impaction fracture can be seen. An incision is made through the periosteum at the superolateral edge of the LFC’s articular surface, then an osteotome is used to make a subchondral cortical window. A small bone tamp is placed through this window and gentle pressure is applied to visually restore the native contour of the LFC. Afterwards, autologous cancellous bone from the tibial BTB harvest site and the ACLR tibial tunnel is used to fill the resulting defect. This restores normal knee biomechanics, provides subchondral support, improves the biological healing of the fracture, and mitigates posttraumatic complications.