Case report
Medial femoral condyle fracture during an Oxford
1
Ortopedia y Traumatologia,
Clinica Alemana de Santiago
SA, Vitacura, Chile
2
Clínica Alemana de Santiago
SA, Vitacura, Santiago, RM,
Chile
3
Clinica Alemana de Santiago
SA, Vitacura, Metropolitan
Region, Chile
4
Knee Fellow, Clinica Alemana
de Santiago SA, Vitacura,
Metropolitan Region, Chile
Correspondence to
Dr Rafael Calvo, Ortopedia y
Traumatologia, Clinica Alemana
de Santiago SA, Vitacura 5951,
Chile; ​rcalvo61@​gmail.​com
Received 18 March 2020
Revised 21 October 2020
Accepted 1 November 2020
Published Online First
15 December 2020
© International Society of
Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine
2021. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Calvo R, Figueroa D,
Anastasiadis Z, et al. J
ISAKOS 2021;6:182–184.
182
unicompartmental knee replacement surgery:
case report
Rafael Calvo,1 David Figueroa,1 Zoy Anastasiadis  ‍ ‍,2 Gonzalo Espinoza,3
Daniel Sarango4
ABSTRACT
Oxford unicompartmental knee arthroplasty
has been used as a good alternative for medial
unicompartmental osteoarthritis due to its association
with early rehabilitation and a low rate of intraoperative
complications. This case describes a rare complication
during the procedure of an intraoperative fracture of the
medial condyle that was treated with osteosynthesis with
6.5 mm cannulated screws and a compression technique.
The patient followed a non-­weight-­bearing protocol for
6 weeks and reached full range of motion at 3 months.
Complete radiological fusion and good functional
outcome were observed. Intraoperative fractures can
benefit from stable osteosynthesis that allows free range
of motion and does not jeopardise the final surgical
result.
INTRODUCTION
Knee osteoarthritis (OA) can become a very inval-
idating pathology because of severe pain and func-
tional impairment. Unicompartmental knee OA
incidence is estimated between 20% to 50%, being
more frequent on the medial side.1–3 Different
surgical options from high tibial osteotomy to
total knee arthroplasty are valid in medial OA
treatment; however, the best decision will depend
on the patient’s status and OA stage. Unicompart-
mental knee arthroplasty (UKA) has been used as an
alternative to total replacement and it is preferred
by some surgeons for the benefits of minimal
blood loss, less postoperative pain, better range
of motion and associated early rehabilitation.4–6
UKA is indicated in patients with degenerative or
post-­traumatic OA, and osteonecrosis that affects
a single knee compartment; functionally they
should have anterior cruciate and medial collateral
ligament indemnity and correctible deformity. In
the last two decades, Oxford UKA has become an
accepted procedure for medial OA with good long-­
term results with experienced hands.7–9 In addition,
it has proven to be a safe procedure and is asso-
ciated with low perioperative complication rate.10
A search through the PubMed database was done
using the following keywords: unicompartmental
knee replacement, UKA, periprosthetic fracture and
unicompartmental knee arthroplasty complication.
The most important complications reported were:
aseptic loosening (0.25%–1.4%), dislocation of
polyethylene (0.4%–3%), unexplained pain (0.5%–
1.6%), infection (0.25%–3%) and periprosthetic
fractures (0.1%).5 6 11 Periprosthetic fractures are an
Calvo R, et al. J ISAKOS 2021;6:182–184. doi:10.1136/jisakos-2019-000311. Copyright © 2021 ISAKOS
uncommon complication and have been described
mostly in the tibial plateau. Pandit et al12 reported
a fracture incidence of less than 1% in 1000 arthro-
plasty cases.
THE CASE
A female patient in her 70s with a 10-­year history
of well-­tolerated medial UKA on the left side and a
3-­year-­old avascular necrosis on the right side that
caused medial knee OA, that did not respond to
conservative treatment (figure 1).
An Oxford UKA was performed by an experi-
enced orthopaedic surgeon following the manu-
facturer’s guidelines. During the surgery and at
the moment the cemented femoral component was
impacted, a medial femoral condyle fracture took
place in the coronal plane with minimal displace-
ment (Hoffa fracture). Internal reduction and stable
fixation were carried out with two compressive
screws in the same procedure. Afterwards, the
radiographs showed an anatomical reduction and
correct stabilisation (figure 2).
The patient completed 6 weeks with two crutches
and without weight-­ bearing, and free range of
motion was allowed during the immediate post-
operative period. Twelve weeks after the surgery
the patient could walk correctly without crutches
and her knee’s range of motion was 125°of flexion
and no extension deficit. The result at the 4-­year
follow-­up was satisfactory with a Knee injury and
Osteoarthritis Outcome Score (KOOS) of 92.7.
DISCUSSION
Unicompartmental arthroplasty is a minimally inva-
sive procedure that allows rapid recovery, preserves
bone stock and reproduces more normal knee kine-
matics; it is associated with lower morbidity and
excellent results in the medium term and the long
term.2–8 Some studies have even reported better
functional results than with total knee prosthesis,
but it is associated with a higher revision rate.13
The case study describes the findings of a medial
femoral condyle periprosthetic fracture with an
intraoperative complication during UKA. Only one
case of a medial femoral condyle intraoperative peri-
prosthetic fracture has been previously reported.14
Two other femoral condyle fractures15 16 have also
been reported, occurring respectively 1 year and 3
years after index arthroplasty. As other authors have
described, we believe that mechanical resistance of
the femur and the impact technique could have
been possible fracture causes.14 Factors that could

Figure 1  Preoperative orthostatic X-­ray shows medial unicompartmental
osteoarthritis.
contribute to decreased mechanical resistance are osteoporosis
and insufficient bone support; our case study presented a patient
with medial OA due to osteonecrosis that could have decreased
bone support, but unfortunately, a dual-­energy x-­ray absorp-
tiometry scan was not done to prove the role of osteoporotic
bone as a risk factor. Excessive femoral bone resection during
the preparation could be another risk factor to be considered. As
reported by Brinke et al14 in his article, we also believe that the
impaction technique could have played a role in producing the
Hoffa fracture in our patient. The femoral component impaction
should be in line with the femoral condyle, but tilting slightly
dorsally could increase the shear force in the medial condyle
and result in a fracture. Besides, the force of the impact must be
considered according to the hammer size used. Another hypoth-
esis15 considers the use of the femur intramedullary alignment
guide as an increase in the femoral tension.
Brinke et al14 described a non-­displaced intraoperative medial
femoral condyle fracture in the coronal plane, noted at the
immediate postoperative radiography, that was treated with a
Figure 2  Postoperative anteroposterior and lateral X- ray shows
anatomical reduction and correct position of the unicompartmental
components.
Calvo R, et al. J ISAKOS 2021;6:182–184. doi:10.1136/jisakos-2019-000311
Case report
10° knee flexion immobiliser without varus-­valgus stress and a
non-­weight-­bearing protocol for 6 weeks, achieving satisfactory
results after 12 weeks. However, in our case, we recognised the
fracture during the surgery, and carried out anatomical reduction
and stable fixation during the same procedure. We considered
that a stable osteosynthesis would allow early mobilisation to
avoid complications such as stiffness. Condyle femoral fractures
with minimal displacement and good bone quality can be treated
with 6.5 mm cannulated screws. A review by Arastu et al17 reaf-
firms that osteosynthesis is the best treatment option for femoral
condyle fractures in the coronal plane since conservative treat-
ment has been associated with poor results. Akan et al15 reported
a medial femoral condyle fracture case with minimal displace-
ment at 1 year postoperation. Additionally, closed reduction and
percutaneous fixation were performed with 6.5 mm cannulated
screws after checking that the tibial and femoral components
were stable. Kim et al16 reported another case with minimal
displacement 3 years after surgery, that also had closed reduc-
tion and percutaneous fixation with 6.5 mm cannulated screws,
had a non-­weight-­bearing protocol for 6 weeks, and at 12 weeks
they observed complete bone healing and full functional ranges.
Periprosthetic fractures associated with UKA are infrequent
and are mostly observed at the tibial plateau level.18 This is
unlike total arthroplasty periprosthetic fractures in which they
are most frequently related to the femur.9 19–21 Both fractures can
be managed with reduction and osteosynthesis in the absence of
component loosening. Kim et al21 described a series of 1576 uni
arthroplasties with six cases of periprosthetic fractures in which
only one corresponded to the femoral location. The remaining
five corresponded to tibial plateau fractures (one intraoperative),
of which two were converted to total knee replacement. There
are no reported cases of unicompartmental arthroplasty revi-
sions secondary to a prosthetic femoral fracture.
In the case described, a Hoffa fracture was produced as an
intraoperative complication with minimal displacement, and a
stable intraoperative fixation was used to allow free range of
motion in the immediate postoperative period and thus avoid the
risk of stiffness and/or arthrofibrosis. The patient was in a non-­
weight-­bearing rehabilitation protocol for 6 weeks and achieved
complete bone fusion and excellent functional outcome at 12
weeks postoperatively. The final range of motion was slightly
lower than that reported by other authors, like Pandit,12 who
published a mean knee joint flexion of 133°. Nevertheless, the
KOOS of 92.7 at the 4-­year follow-­up was satisfactory, an excel-
lent result compared with the average KOOS of 84.3, which has
been reported for medial UKA in the midterm outcomes.22
CONCLUSION
A medial femoral condyle fracture is a rare UKA complication,
and according to this report, only two intraoperative cases have
been reported in the literature. The resolution of this type of
fracture depends on fracture displacement, bone quality and the
implant condition. Fractures with minimal displacement without
component loosening and good bone quality can be treated
with anatomical reduction and stable fixation with cannulated
screws. Immediate osteosynthesis is a suitable option when a
fracture is observed during the surgical procedure. In our expe-
rience, adequate stability, early motion and excellent functional
outcome were achieved.
Contributors  ZA and DS wrote the manuscript with support from RC, DF and GE.
All authors discussed the case and contributed to the final manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
183
 Case report
Competing interests  None declared.
Patient consent for publication  Obtained.
10 Morris MJ, Molli RG, Berend KR, et al. Mortality and perioperative complications after
Ethics approval  As a case report, it did not need the institutional review board
approval.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iD
Zoy Anastasiadis http://​orcid.​org/​0000-​0003-​3564-​7624
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Calvo R, et al. J ISAKOS 2021;6:182–184. doi:10.1136/jisakos-2019-000311