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
Received September 27, 2013; revised October 20, 2013; accepted October 27, 2013
Copyright © 2013 Massimiliano Salvi et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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
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  and one
isolated ; two reported cases of abnormal tibial at-
tachment of the ACL  and one reported case of OCD
of the medial femoral condyle associated with ACL and
lateral meniscus hypoplasia .
We report a case of abnormal femoral origin of the
ACL associated with OCD of the medial femoral
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
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
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
opyright © 2013 SciRes. SS
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.
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
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
 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  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 .
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-
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-
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 .
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.
 F. F. Hoffmann, “Abnormal Femoral Origin of the Ante-
rior Cruciate Ligament Combined with a Discoid Lateral
Meniscus,” Arthroscopy, Vol. 13, No. 2, 1997, pp. 254-
 A. Sarsilmaz and F. Gelal, “A New Variation: An Ante-
rior Cruciate Ligament Attached to the Accessory Ossi-
cle,” Clinical Anatomy, Vol. 24, No. 8, 2011, pp. 991-993.
 O. U. Calpur, M. Ozcan and H. Gurbuz, “Deltoid (Trian-
gular)-Shaped Anterior Cruciate Ligament that Caused
Notch Impingement: A Report of Two Cases,” Arthro-
scopy, Vol. 20, No. 6, 2004, pp. 637-640.
Copyright © 2013 SciRes. SS
M. SALVI ET AL.
Copyright © 2013 SciRes. SS
 T. Mitsuoka, S. Horibe and M. Hamada, “Osteochondritis
Dissecans of the Medial Femoral Condyle Associated
with Congenital Hypoplasia of the Lateral Meniscus and
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 P. M. Aichroth, D. V. Patel and C. L. Marx, “Congenital
Discoid Lateral Meniscus in Children. A Follow-Up
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and Joint Surgery (British Volume), Vol. 73, No. 6, 1991,
 T. Beyzadeoglu, A. Gokce and H. Bekler, “Osteochondri-
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