The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 10

Scientific Articles | October 01, 2007

Morphology of the Femoral Intercondylar Notch

Lutul D. Farrow, MD¹; Michael R. Chen, MD¹; Daniel R. Cooperman, MD¹; Brian N. Victoroff, MD¹; Donald B. Goodfellow, MD¹

¹ Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail address for L.D. Farrow: lutulfarrowmd@yahoo.com

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Oct 01;89(10):2150-2155. doi: 10.2106/JBJS.F.01191

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Abstract

Background: During anterior cruciate ligament reconstruction, proper femoral tunnel placement is important. The purpose of the present study was to characterize the osseous anatomy of the femoral intercondylar notch.

Methods: We studied the morphology of the femoral intercondylar notch in 200 human femora from skeletally mature donors, with specific attention being paid to the morphology of the ridge on the lateral wall of the intercondylar notch and the posterolateral rim of the intercondylar notch. The distances from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge and from the posterolateral rim of the intercondylar notch to the inlet of the intercondylar notch (notch depth) were measured at the nine, ten, and eleven o'clock positions for right knees and at the one, two and three o'clock positions for left knees.

Results: The lateral intercondylar ridge was present in 194 femora and absent in six. The mean distance from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge was 9.0, 11.0, and 12.7 mm at the nine, ten, and eleven o'clock positions in right knees and the one, two, and three o'clock positions in left knees, respectively. We observed three different types of morphology of the posterolateral rim of the intercondylar notch. The morphology of the posterolateral rim of the intercondylar notch was distinct in 183 of 200 specimens. A distinct, straight border (type 1) was seen in 175 femora (87.5%); a distinct, V-shaped border (type 2) was seen in eight (4%); and an indistinct border (type 3) was seen in seventeen (8.5%).

Conclusions: The morphology of the femoral intercondylar notch varies little. Occasionally, the posterolateral rim of the intercondylar notch is not well-defined. In these knees, accurate placement of commercial femoral tunnel aiming guides may be difficult.

Clinical Relevance: This improved knowledge of the morphology of the intercondylar notch may assist the surgeon in placing the femoral tunnel in the proper location when performing anterior cruciate ligament reconstruction.

Figures in this Article

The most common technical error that occurs during anterior cruciate ligament reconstruction is incorrect placement of the femoral tunnel^1,2. This error is the most common cause of graft failure^3-5. The normal femoral attachment of the anterior cruciate ligament has a precise location, and small deviations in tunnel placement can result in large alterations of knee biomechanics and graft tension^6-11. The purpose of the present study was to characterize the morphology of the femoral intercondylar notch. We hope that this information will assist the surgeon in placing the femoral tunnel properly during anterior cruciate ligament reconstruction.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Two hundred human femora (100 from male donors and 100 from female donors) were selected from the Hamann-Todd Osteological Collection at The Cleveland Museum of Natural History. With >3100 skeletons, the Hamann-Todd Collection is one of the world's largest human skeletal collections containing demographic data for its specimens. The height and weight of each specimen at the time of autopsy are also recorded. We selected paired femora from skeletally mature individuals who had been thirty years of age or younger at the time of death. Each specimen's race was listed as either black or white. Specimens from skeletally immature specimens, those from specimens without paired femora, and those that showed any signs of degenerative arthrosis (such as marginal osteophytes) were excluded from the study.

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Fig. 1-A: Axial view of the lateral wall of the intercondylar notch of the left femur. The lateral intercondylar ridge (white arrowhead) and the posterolateral rim (black arrowhead) are shown.

We made observations of the osseous anatomy of the intercondylar notch. There is a crest at the junction of the popliteal surface of the distal part of the femur with the posterior outlet of the intercondylar notch. This crest is the medial border of the "over-the-top position" of the lateral femoral condyle¹². We termed this crest the posterolateral rim of the intercondylar notch. An osseous ridge on the lateral wall of the intercondylar notch slightly anterior to the posterior outlet can be mistaken for the true posterolateral rim of the intercondylar notch (Fig. 1-A). This prominence was termed the "resident's ridge" by William G. Clancy, Jr.¹³. We called this rim the lateral intercondylar ridge. When the femoral tunnel is placed anterior to this ridge, the reconstructed graft is too far anterior and will be prone to failure^6-11. There is a ridge of bone along the medial wall of the intercondylar notch that is analogous to the lateral intercondylar ridge. This ridge lies posterior to the femoral attachment of the posterior cruciate ligament. We have named this the medial intercondylar ridge.

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Fig. 1-B: Measurements from the posterolateral rim to the lateral intercondylar ridge (short arrow) and from the posterolateral rim to the articular cartilage junction (notch depth; long arrow) were made at one, two, and three o'clock positions in the left femur.

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Fig. 2: The ridge angle was measured with respect to an imaginary line that was parallel to the plane of the posterior outlet of the notch. This image shows a left femur.

We inspected each femur for the presence or absence of the lateral intercondylar ridge and the medial intercondylar ridge. The morphology of the lateral intercondylar ridge and the posterolateral rim of the intercondylar notch was recorded. Measurements were made at the nine, ten, and eleven o'clock positions in right knees and the one, two, and three o'clock positions in left knees (Fig. 1-B). We utilized a method similar to that described by Mejia et al. to determine the clock positions in each femur¹⁴. All measurements were made with use of a digital caliper (Absolute Digimatic Caliper Series 500; Mitutoyo, Tokyo, Japan). The instrumental error was ±0.02 mm. The angle of the lateral intercondylar ridge with respect to the posterior outlet of the notch (the ridge angle) was measured with a goniometer (Fig. 2). Repeat measurements were made in twenty femora for the ridge angle, the distance from the posterolateral rim to the inlet of the intercondylar notch (notch depth), and the distance from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge at the eleven o'clock position.

Statistical Analysis

We utilized chi-square analysis to evaluate the differences between our nonparametric values. We used a non-paired student t test to evaluate the differences between femora from male and female specimens. The repeatability of measurements was assessed with use of a Wilcoxon signed-rank test. The level of significance was set at p < 0.05. All statistical analysis was performed with use of Minitab statistical software (Minitab 14; Minitab, State College, Pennsylvania).

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

The average age and height for our sample population were 24.6 years and 168.3 cm, respectively (Table I). The average heights of male and female specimens were 173.4 and 163.7 cm, respectively. The average ages of the male and female donors at the time of death had been 24.2 and 24.9 years, respectively. There was a significantly higher ratio of black to white specimens in the female group as compared with the male group.

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TABLE I Demographic Data

	Total (N = 100)	Male (N = 50)	Female (N = 50)	P Value
Average height^*(cm)	168.3 ± 8.9	173.4 ± 7.9	163.7 ± 7.2	<0.0001
Average age^*(yr)	24.6 ± 2.7	24.2 ± 3	24.9 ± 2.5	0.203
Race
Black	71	30	41	0.025
White	29	20	9

The data are given as the mean and the standard deviation.

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TABLE I Demographic Data

	Total (N = 100)	Male (N = 50)	Female (N = 50)	P Value
Average height^*(cm)	168.3 ± 8.9	173.4 ± 7.9	163.7 ± 7.2	<0.0001
Average age^*(yr)	24.6 ± 2.7	24.2 ± 3	24.9 ± 2.5	0.203
Race
Black	71	30	41	0.025
White	29	20	9

The data are given as the mean and the standard deviation.

The lateral intercondylar ridge was present in 194 femora and absent in six. The ridge was present in all of the specimens from male donors and in ninety-four of 100 specimens from female donors. In ninety-five of the 194 femora in which it was present, the ridge was well-defined. Fifty-five of 100 specimens from male donors had a well-defined lateral intercondylar ridge. Forty of ninety-four specimens from female donors had a well-defined ridge. The remainder of the specimens did not have a visibly raised ridge (Table II). The medial intercondylar ridge was present in 187 specimens, and it was absent in thirteen (including three male and ten female specimens). In the majority of specimens, the medial intercondylar ridge was more vertically oriented in the notch than the lateral intercondylar ridge was (Fig. 3).

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TABLE II Osseous Morphology

	Total (N = 200)	Male (N = 100)	Female (N = 100)	P Value
Lateral intercondylar ridge				0.025
Present	194	100	94
Absent	6	0	6
Lateral intercondylar ridge morphology				0.1
Defined	95	55	40
Smooth	99	45	54
Posterolateral rim morphology				0.01
Distinct	183	97	86
Indistinct	17	3	14
Medial intercondylar ridge				0.05
Present	187	97	90
Absent	13	3	10

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TABLE II Osseous Morphology

	Total (N = 200)	Male (N = 100)	Female (N = 100)	P Value
Lateral intercondylar ridge				0.025
Present	194	100	94
Absent	6	0	6
Lateral intercondylar ridge morphology				0.1
Defined	95	55	40
Smooth	99	45	54
Posterolateral rim morphology				0.01
Distinct	183	97	86
Indistinct	17	3	14
Medial intercondylar ridge				0.05
Present	187	97	90
Absent	13	3	10

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Fig. 3: The medial intercondylar ridge in the left femur (arrowheads).

We observed three different types of morphology of the posterolateral rim of the intercondylar notch. The posterolateral rim was distinct in 183 of the 200 specimens. This distinct morphology was seen in ninety-seven of the specimens from male donors and eighty-six of the specimens from female donors (Table II). This gender difference was significant (p = 0.01). This distinct border had two different orientations. In 175 (87.5%) of the 200 femora, it had a straight border (type 1). The rim was directed horizontally in a mediolateral direction along a line almost tangential to the posterior aspect of the femoral condyles. In eight (4%) of 200 femora, it had a V-shaped border (type 2). In these specimens, the rim came to an apex, which was oriented toward the shaft of the femur. The remaining seventeen specimens (8.5%) had an indistinct posterolateral rim of the intercondylar notch (type 3). In type-3 specimens, the cortex of the intercondylar notch blended smoothly with that of the femoral metaphysis without a sharp step-off as seen in the other specimens.

The average distance from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge was 9.0, 11.0, and 12.7 mm at the one, two and three o'clock positions for left knees and at the eleven, ten, and nine o'clock positions for right knees (Table III). At the one o'clock position for left knees and the eleven o'clock position for right knees, the distance was 9.6 and 8.4 mm for specimens from male and female donors, respectively. At the two o'clock position for left knees and at the ten o'clock position for right knees, the distance was 11.8 and 10.3 mm for specimens from male and female donors, respectively. At the three o'clock position for left knees and the nine o'clock position for right knees, the distance was 13.4 and 11.9 mm for specimens from male and female donors, respectively. All differences between specimens from male and female donors were significant (p < 0.0001) (Table III). The average distance from the posterolateral rim of the intercondylar notch to the front of the intercondylar notch (notch depth) in left knees averaged 23.3, 21.3, and 20.3 mm at the one, two, and three o'clock positions for left knees and the eleven, ten, and nine o'clock positions for right knees. The notch depth was also compared between specimens from male and female donors. At the one or eleven o'clock position, the notch depth was 24.8 and 21.8 mm in specimens from male and female donors, respectively. At the two or ten o'clock position, it was 22.6 and 20.1 mm in specimens from male and female donors, respectively. At the three or nine o'clock position, it was 21.2 and 19.4 mm in specimens from male and female donors, respectively. All differences between specimens from male and female donors were significant (p < 0.0001) (Table III). The average ridge angle was 29.2° (30.4° in specimens from male donors and 27.9° in specimens from female donors) (Table III). This difference was significant (p < 0.0001).

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TABLE III Measurement Data

Posterolateral Rim to Lateral Intercondylar Ridge Distance^*(mm)

Notch Depth^*(mm)

Ridge Angle^*(deg)

Position (Left, Right)

Total (N = 194)

Male (N = 100)

Female (N = 94)

P Value

Total (N = 200)

Male (N = 100)

Female (N = 100)

P Value

Total (N = 194)

Male (N = 100)

Female (N = 94)

P Value

1 o'clock, 11 o'clock

9.0 ± 1.6

9.6 ± 1.6

8.4 ± 1.4

<0.0001

23.3 ± 2.5

24.8 ± 2.1

21.8 ± 1.8

<0.0001

—

2 o'clock, 10 o'clock

11.0 ± 1.7

11.8 ± 1.6

10.3 ± 1.4

<0.0001

21.3 ± 2.3

22.6 ± 2.0

20.1 ± 1.8

<0.0001

—

3 o'clock, 9 o'clock

12.7 ± 1.8

13.4 ± 1.7

11.9 ± 1.6

<0.0001

20.3 ± 2.0

21.2 ± 1.9

19.4 ± 1.8

<0.0001

—

29.2 ± 4.4

30.4 ± 4.8

27.9 ± 3.6

<0.0001

The data are given as the mean and the standard deviation.

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TABLE III Measurement Data

Posterolateral Rim to Lateral Intercondylar Ridge Distance^*(mm)

Notch Depth^*(mm)

Ridge Angle^*(deg)

Position (Left, Right)

Total (N = 194)

Male (N = 100)

Female (N = 94)

P Value

Total (N = 200)

Male (N = 100)

Female (N = 100)

P Value

Total (N = 194)

Male (N = 100)

Female (N = 94)

P Value

1 o'clock, 11 o'clock

9.0 ± 1.6

9.6 ± 1.6

8.4 ± 1.4

<0.0001

23.3 ± 2.5

24.8 ± 2.1

21.8 ± 1.8

<0.0001

—

2 o'clock, 10 o'clock

11.0 ± 1.7

11.8 ± 1.6

10.3 ± 1.4

<0.0001

21.3 ± 2.3

22.6 ± 2.0

20.1 ± 1.8

<0.0001

—

3 o'clock, 9 o'clock

12.7 ± 1.8

13.4 ± 1.7

11.9 ± 1.6

<0.0001

20.3 ± 2.0

21.2 ± 1.9

19.4 ± 1.8

<0.0001

—

29.2 ± 4.4

30.4 ± 4.8

27.9 ± 3.6

<0.0001

The data are given as the mean and the standard deviation.

The twenty repeat measurements of ridge angle, notch depth, and distance from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge were not significantly different (p = 0.510, 0.374, and 0.741, respectively).

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Various intraoperative and radiographic landmarks have been described for femoral tunnel placement during anterior cruciate ligament reconstruction, including the posterolateral rim of the intercondylar notch and the lateral intercondylar ridge. Endoscopic and two-incision aiming devices are available^12,15,16. Hutchinson and Ash showed that the anterior cruciate ligament femoral attachment lies just posterior to the lateral intercondylar ridge and that this ridge represents a change in the slope of the intercondylar wall¹³. It is likely that the lateral intercondylar ridge represents the anterior border of the femoral attachment of the anterior cruciate ligament. At the eleven o'clock position in the right knee and the one o'clock position in the left knee, the femoral attachment of the anterior cruciate ligament is located along the posterior two-fifths of the lateral wall of the intercondylar notch. At the ten o'clock position (in the right knee), this location is halfway back along the lateral wall of the intercondylar notch. The ridge was absent in only 3% of the specimens in our study. We are not sure of the importance of an absent ridge.

We have demonstrated the variable anatomy of the posterolateral rim of the intercondylar notch. In the presence of a type-3 posterolateral rim of the intercondylar notch (seen in 8.5% of the knees in the present study), endoscopic femoral tunnel aiming guides that reference from the posterolateral rim of the intercondylar notch may be difficult to place accurately¹². Unfortunately, the morphology of the posterolateral rim of the intercondylar notch cannot be classified preoperatively.

The medial intercondylar ridge was present in 93.5% of our specimens. We are uncertain of the clinical importance of this ridge as the posterior cruciate ligament insertion is easily visualized during routine arthroscopy.

We believe that the posterolateral rim of the intercondylar notch and the lateral intercondylar ridge may serve as checkpoints to confirm correct femoral tunnel placement during anterior cruciate ligament reconstruction. During anterior cruciate ligament reconstruction, the lateral intercondylar ridge is commonly removed as it may obscure visualization of the posterolateral rim of the intercondylar notch. Nevertheless, we believe that the location of the lateral intercondylar ridge should be noted prior to its removal because a properly placed femoral tunnel should be slightly posterior to it. A lateral intercondylar ridge is present in the majority of femora, so if the ridge is not visualized during surgery, the surgeon should suspect that what may appear to be the back of the intercondylar notch is actually the lateral intercondylar ridge. Accurate identification of these osseous landmarks should help the surgeon to place the tunnel in a correct location. However, the surgeon should keep in mind that anatomic variations of both the lateral intercondylar ridge and the posterolateral rim of the intercondylar notch are not uncommon. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank The Cleveland Museum of Natural History Hamann-Todd Osteological Collection for the skeletal specimens used in our study.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Kaplan MJ, Howe JG, Fleming B, Johnson RJ, Jarvinen M. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II. A specific sport review. Am J Sports Med. 1991;19: 458-62.19458 1991 [CrossRef]

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Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o'clock and 10 o'clock femoral tunnel placement. Arthroscopy. 2003;19: 297-304.19297 2003 [PubMed][CrossRef]

Howell SM, Taylor MA. Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J Bone Joint Surg Am. 1993;75: 1044-55.751044 1993 [PubMed]

Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GA. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20: 1016-24.201016 2002 [CrossRef]

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Hutchinson MR, Ash SA. Resident's ridge: assessing the cortical thickness of the lateral wall and roof of the intercondylar notch. Arthroscopy. 2003;19: 931-5.19931 2003 [PubMed][CrossRef]

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Lutul D. Farrow, Michael R. Chen, Daniel R. Cooperman, Brian N. Victoroff, Donald B. Goodfellow; Morphology of the Femoral Intercondylar Notch. The Journal of Bone & Joint Surgery. 2007 Oct;89(10):2150-2155.

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