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Hoffa Fractures

Partial articular, coronal plane fractures of the posterior part of femoral


condyles are called Hoffa fractures. It was first described by Albert Hoffa;
a German surgeon in 1904.
They are rare and account for less than 1% of distal femoral fractures. In
one study on supracondylar intercondylar fractures of distal femur, 38%
had a coronal fracture. Of these 76% were unicondylar and rest were
bicondylar. 85% of unicondylar fractures involved the lateral condyle.
They are three times more common in the lateral femoral condyle
probably because of following reasons;
1) Physiologic genu valgum which puts greater compressive stresses
on the lateral side
2) Frontal impact on a flexed knee is more likely to involve the outer
aspect resulting in shearing force on the posterior part of lateral
femoral condyle.
Mechanism of injury
High velocity injuries such as road traffic accidents are the most common
mechanism of injury. Usually the patient reports a history suggestive of
direct hit over the front of the knee which was flexed varying degrees,
resulting in a vertical shearing force on the posterior femoral condyles.
Clinical features
Clinically patients present with inability to weight bear and haemarthrosis
of knee. Usually there is no deformity. The knee is usually stable in
extension, but varus-valgus instability may be present in a partially flexed
position when examined under anaesthesia.
Imaging
About 1/3 of these injuries are missed on the x-rays especially if
undisplaced as the anterior part of the condyle is intact. In the AP view
irregularity or step in the subchondral line of involved condyle may be
seen. Lateral view may show loss of normal overlap of condyles or break
in the subchondral line. If fracture is displaced, step or discontinuity may
be seen on careful examination. Oblique view may be necessary to show
the fracture line clearly. CT scan is a must to clearly delineate the fracture
line, detect comminution and to identify the associated injuries.
Classification

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As per AO classification, it is classified as type 33B3 fracture. Letenneur in


1978, classified these fracture into 3 types depending on the distance of
the fracture line from the posterior femoral cortex and it's direction, but
subsequent studies failed to validate the classification.
Type I- Fracture line parallel to the posterior femoral cortex involving the
entire posterior condyle.
Type II- Fracture occurs in the area behind the line parallel to the posterior
femoral cortex. The posterior condyle is divided into one thirds and
depending on the relationship of fracture line to the thirds the type II is
subclassified into A,B and C.
Type III- Oblique fracture of posterior femoral condyle.
A cadaveric study found that type I and III fractures have preservation of
soft tissue attachments and the type II fragments lack soft tissue
attachments and are prone for osteonecrosis and nonunion.
Management
As they are intra-articular fractures, they should be treated by anatomical
reduction, rigid internal fixation and early mobilisation to restore function.
Nonoperative treatment results in poor outcomes as there is high chance
of displacement. In addition, being an intra-articular fracture prolonged
immobilisation will result in joint stiffness.
The surgical approach will depend on the condyle involved, location and
orientation of fracture line and the presence of comminution. Standard
medial or lateral parapatellar approach is sufficient if there is no posterior
comminution. Once the arthrotomy is done, the patella is dislocated if
necessary and the knee is deeply flexed exposing the posterior condyle.
Swashbuckler approach, a variation of lateral parapatellar approach that
spares the quadriceps muscle belly may be used in Hoffa fractures of
lateral femoral condyle. In lateral Hoffa fractures with posterior
comminution, Gerdy's tubercle osteotomy and proximal retraction of
iliotibial band may be necessary.
In medial Hoffa fractures with posterior comminution, subvastus approach
with arthrotomy of knee anterior and posterior to the medial collateral
ligament may be necessary.

Supine position on a radiolucent table.


Tourniquet optional.
Knee flexed to 300 degrees with a cushion or rolled towels behind the
knee.
Anterior midline incision.
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Develop medial skin flap protecting the infrapatellar branch of


saphenous nerve
Elevate the vastus medialis from the intermuscular septum.
Anterior capsulotomy done at the anterior margin of medial collateral
ligament to expose the medial condyle.
Retract the patella laterally.
Flex the knee maximally to expose the posterior condyle.
If needed another capsulotomy may be done posterior to the medial
collateral ligament to expose the posterior condyle better.

In patients with Hoffa fractures of both condyles combined lateral


parapatellar and medial subvastus approach may be used. Minimally
invasive approaches with arthroscopic assistance have been described
but their role is not yet established.
Reduction may be difficult especially if there is delay in treatment. The
attachment of cruciate ligament on the inner aspect may make
manipulation of fragment difficult especially if the fragment has only part
of the cruciate insertion and the ligament is torn longitudinally into two
bundles. Use of Schanz screw on the outer surface as a joystick for
manipulation and use of pelvic reduction forceps for compression may be
necessary.
Fixation can be done with 3.5 mm or 4.5mm screws. At least 2 parallel
screws must be used to prevent rotation of fragment. Screws are usually
inserted from anterior to posterior. Ideally the screws should be
perpendicular to the fracture line. If there is comminution avoid excessive
compression. Articular surface should be avoided if possible; otherwise
use the smallest diameter screws and countersunk the screw heads.
Headless screw may as well be used for fixation but their role is not yet
established. In presence of comminution, small plates may be used as a
buttress for fixation.
If fragment is small, a posterior approach and posterior to anterior screws
may be necessary. Postoperatively early mobilisation is advised if fixation
is stable but weight bearing is delayed till the fracture is consolidated.
Further Reading
1. Hoffa A. Lehrbuch der Frakturen und Luxationen. 4th ed.Stuttgart:
Ferdinand Enke-Verlag, 1904, 453.
2. Letenneur J, Labour PE, Rogez JM, et al. Fractures de Hoffa : a propos
de 20 observations. Ann Chir 1978;32:213-219.
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3. Sean E York, Daniel N Segina, Kamran Aflatoon, David P Barei,


Bradford Henley, Sarah Holt, Stephen K Benirschke. The Association
between Supracondylar-Intercondylar Distal Femoral Fractures and
Coronal Plane Fractures. JBJS Vol 87-A Number 3. 2005; 564- 569.
4. Starr AJ, Jones AL, Reinert CM. The swashbuckler: a modified
anterior approach for fractures of the distal femur. J Orthop Trauma
1999;13:138140.
5. Liebergall M, Wilber JH, Mosheiff R, Segal D. Gerdys tubercle
osteotomy for the treatment of coronal fractures of the lateral
femoral condyle. J Orthop Trauma 2000;14:214215.
6. Hofmann AA, Plaster RL, Murdock LE. Subvastus (southern)
approach for primary total knee arthroplasty. Clin Orthop Relat Res
1991;269:7077.
7. Viskontas DG, Nork SE, Barei DP, Dunbar R. Technique of reduction
and fixation of unicondylar medial Hoffa fracture. Am J Orthop (Belle
Mead NJ) 2010;39:424428.
8. https://www2.aofoundation.org/wps/portal/surgery?
bone=Femur&segment=Distal&classification=33B3.2/3&showPage=indication
9. http://en.wikipedia.org/wiki/Albert_Hoffa

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