|Ahead of print publication
Buttress plate-assisted fixation for lateral hoffa fractures: A case report and review of literature
Graded Specialist, Department of Orthopaedics, Military Hospital Kirkee, Pune, Maharashtra, India
|Date of Submission||28-May-2020|
|Date of Decision||22-Jun-2020|
|Date of Acceptance||25-Jun-2020|
|Date of Web Publication||02-Sep-2020|
Military Hospital Kirkee, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
The purpose of this article is to provide a review of coronal fractures of the femoral condyles, known as Hoffa fractures, and to describe a unique fixation modality entailing the use of lag screws in combination with a posterior buttress plate. This case report of a lateral Hoffa fracture focuses on the evaluation, general approach, and surgical management of this subset of distal femoral fractures using this novel technique.
Keywords: Buttress plate, early mobilization, femur, Hoffa fracture, modified swashbuckler, open reduction
| Introduction|| |
“Hoffa” fractures are those that involve the femoral condyles in the coronal plane and represent a small proportion (0.65%) of all femoral fractures., Though originally reported by Freidrich Busch in 1869, they were named after Albert Hoffa, who described them in 1904. The reported incidence of Hoffa fractures among all femoral fractures in adults is 6%–8%. These may occur as isolated injuries or in combination with intra or supracondylar fractures. The essence of the fracture lies in its sagittal plane location, making isolated uni-condylar fractures a rare occurrence. Lateral Hoffa fractures are more common as compared to medial.,, Apart from these, two distinct clinical entities, namely unilateral bicondylar Hoffa and open Hoffa fractures, have also been reported.,, Isolated medial condylar fractures are relatively rare with a few reported cases in literature. The most common modes of injury are motor vehicle accidents, falls from a height, and other high-velocity injuries. The mechanism of injury is believed to be a shearing or tangential force applied to the femoral condyles with the knee in 90° or more of flexion. It is imperative to rule out concomitant injuries of the pelvis, hips, femur, tibia, patella and the extensor mechanism at the initial presentation. A swollen and tender knee may preclude a detailed clinical examination in the acute setting, however, ligamentous injuries of the knee need to be ruled out once the hematoma resolves. Several techniques of internal fixation have been described entailing the use of cancellous or headless screws, plates, and a combination of the two, with a variable functional outcome. [13,14] Till date, no sole “gold standard” technique has been adopted for the fixation of these unstable fractures.
| Case Report|| |
A 40-year-old male sustained a fall from a two wheeler and presented with a painful swelling of the right knee with inability to bear weight on the affected limb. On evaluation, there was a tense hemarthrosis with bruising over the posterolateral aspect of the knee. Standard anteroposterior (AP) and lateral radiographs were taken, which showed an isolated lateral condylar fracture [Figure 1]. Once the pain and swelling subsided, further imaging (computed tomography [CT] scanning) was done which revealed a comminuted, displaced lateral condylar fracture in the coronal plane, with a subtle articular depression of the lateral tibial plateau [Figure 2]. The fracture was classified as Type 1 of the Letenneur classification and Type 3 (comminuted) as per the Bagaria classification. On examination, under regional anesthesia, marked valgus instability was present in 30° of knee flexion but not in extension. The patient was positioned supine with the knee flexed in order to counter the deforming force of the gastrocnemius. An open reduction was performed using a modified Swashbuckler approach, which is essentially a lateral approach extended distally between lateral patellar retinaculum and the vastus lateralis, which culminates into a lateral parapatellar arthotomy. The quadriceps muscle and patella were reflected medially to obtain better visualization of the lateral femoral condyle. The articular surface was inspected carefully for all fracture lines, and the fracture classification was confirmed. The osteochondral fragments were identified and preserved for later re-attachment. The articular block was provisionally reduced to the meta-diaphysis using pointed clamps and K-wires, followed by insertion of 6.5 mm partially threaded cancellous lag screws. A 3.5 mm locking compression plate (LCP), which was precontoured to match the curvature of the posterior condylar surface [Figure 3], was applied in a buttress mode to prevent the proximal migration/displacement of the lateral condyle. Finally, after confirming the reduction on fluoroscopy, the osteochondral fragments were fixed using headless screws [Figure 4]. Wound closure was done in a routine manner over a drain.
|Figure 2: Preoperative three-dimensional reconstructed noncontrast computed tomography of the knee showing the fracture plane|
Click here to view
|Figure 3: 3.5-mm titanium locking compression plate precontoured using a femur saw bone model|
Click here to view
|Figure 4: Intra-operative images of fracture reduction and fixation of articular surface|
Click here to view
Postoperatively, gradual controlled passive motion was initiated from the 3rd postoperative day followed by active, assisted range of motion (ROM) exercises for the knee. The patient was kept nonweight bearing on the operated limb for a total duration of 6 weeks, followed by partial, walker-assisted ambulation. Full weight bearing was resumed at 12 weeks. Clinico-radiological follow-up was carried out at periodic intervals up to 12 months postoperatively [Figure 5] and [Figure 6]. At each visit, the functional outcome of the surgery was assessed using the knee society score (including the knee and functional subsets), the ROM and the visual analog scale (VAS) score. A knee society score between 80 and 100 was graded as excellent, between 70 and 79 was good, between 60 and 69 was fair, and <60 was graded as poor.
|Figure 6: Twelve months postoperative X-ray anteroposterior and lateral views|
Click here to view
| Results|| |
At final follow-up, the individual had a painless, functional ROM of 0°–130° of flexion. He was able to perform all activities involving deep flexion of the knee including squatting and sitting cross legged [Figure 7]. The knee society score was 85, implying an excellent functional outcome. The VAS score was 0. No complications such as wound necrosis, delayed union, non-union, infections or nerve palsies were encountered.
| Discussion|| |
Hoffa fractures, which are essentially distal femur fractures in a tangential coronal plane, are a result of high-energy trauma and pose a daunting challenge to trauma surgeons. These require an extensive surgical approach to visualize and reduce the articular fragments, particularly in complex fractures. The insult to the periarticular soft tissues caused both by the initial trauma and subsequent surgical approach, leads to problems with early postoperative rehabilitation predisposing to knee stiffness. Conservative treatment including skeletal traction, even for undisplaced fractures is not recommended, since it is riffed with complications such as malunion, nonunion, stiffness, and secondary osteoarthritis. Surgical management in the form of open reduction and internal fixation is the gold standard of treatment. CT scanning with three-dimensional reconstruction, as a part of the preoperative workup, is essential to identify the complex geometry of the fracture fragments and to avoid erroneous interpretation of plain radiographs. The goal of treatment is to achieve anatomical reduction of the joint with stable internal fixation in order to resume early mobilization of the knee.
Being an unstable fracture involving a weight bearing joint, it is mandatory to obtain an accurate reduction which can only be achieved with a good exposure. Multiple surgical approaches have been described previously to obtain a good exposure of distal femoral articular surface, including the medial parapatellar approach, lateral parapatellar (anterolateral) approach Gerdy's tubercle osteotomy or a combination of these.,, It is desirable to choose an approach that is less extensive and has fewer complications such as delayed wound healing and flap necrosis. The parapatellar approaches provide a sufficient articular exposure but involve splitting of the quadriceps mechanism, which may lead to scarring or adhesions. Furthermore, the ease of extension of the surgical incisions is limited. Starr et al. described a modified Swashbuckler approach to the distal femur, which facilitated complete exposure of distal femoral articular surface and quicker postoperative rehabilitation. This anterolateral skin incision has now been adopted universally due to its versatility and excellent visualization of both articular and extra-articular parts of the distal femur. In addition, it spares the quadriceps muscle belly thereby facilitating faster return of quadriceps strength and function.
Historically, Hoffa fractures have been fixed using headless compressions screws or lag screw technique using either cortical or cancellous screws. A cadaveric study involving a comparison of the strength of fixation using 3.5-mm and 4.5-mm cortical lag screws and 6.5-mm cancellous screws did not show any significant difference in terms of stiffness of construct or pull-out strength between the cortical and cancellous groups. However, the 6.5-mm cancellous screws showed a higher load failure as compared to the other groups. Other studies have also reported good success rates with the use of 6.5- and 7-mm cancellous screws., The chief drawback of headless screws is their small size and length. In the present case, two 6.5 mm partially threaded cannulated cancellous screws were used to achieve the lag effect. Regarding the direction of screw placement, both anterior-to-posterior as well as posterior-to-anterior directions have been described, ensuring that the screws remain as perpendicular to the fracture line as possible for optimum interfragmentary compression. Screws that are inserted through the articular cartilage should have their heads countersunk beneath the surface. In a study by Jarit et al., it was postulated that lag screws directed from posterior-to-anterior have a higher mechanical advantage as compared to anterior-to-posterior screws. On the contrary, I prefer to insert screws in the anterior-to-posterior direction for the ease of insertion. Moreover, the risk of iatrogenic shattering of the condylar fragments during drilling or tightening of the screws is considerably decreased. There is one reported case of a lateral Hoffa fracture fixed arthroscopically with two 6.5-mm cannulated screws and washers.
Many authors have reported the use of a buttress plate for additional stability, which may be positioned either postero-laterally or posteriorly., A buttress plate is paramount to counteracting the pull of the powerful gastrocnemius. Tetsunaga et al., in their series of five cases, used a 1/3rd tubular plate as a buttress plate in addition to an LCP distal femur plate as a neutralizing plate and concluded that a posterior buttress plate was beneficial in increasing stability and provided good short-term results. However, they highlighted that a 1/3rd tubular plate, by itself, is not sufficiently stable and needs to enhanced with a lateral LCP for optimum stability. Min et al. reported the use of a precontoured reconstruction plate as back buttress plate, which was placed either postero-medially or postero-laterally. Their outcome was reported as excellent in six patients and good in two, according to the Hospital for Special Surgery scoring system. For this case, a 3.5-mm precontoured titanium LCP was placed along the extra-articular surface of the lateral condyle in addition to the cancellous lag screws for extra stability. This minimized the chances of fracture displacement on resumption of weight bearing, thereby promoting early rehabilitation and restoration of function. Precontouring was done using a saw bone model to exactly match the distal femoral curvature and to shorten intra-operative time. This construct was found to be adequately stable biomechanically, on performing intraoperative ROM and stress testing.
| Conclusion|| |
Buttress plate-assisted fixation is a useful enhancement of the conventional technique of lag screw fixation of lateral Hoffa fractures. I reckon that this simple procedure results in lesser chances of fracture re-displacement leading to an earlier recovery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hoffa A. Lehrbuch der Frakturen und Luxationen. 4th
ed. Stuttgart: Ferdinand Enke-Verlag, 1904, 453.
Manfredini M, Gildone A, Ferrante R, Bernasconi S, Massari L. Unicondylar femoral fractures: Therapeutic strategy and long-term results. A review of 23 patients. Acta Orthop Belg 2001;67:132-8.
Doshi HK, Wenxian P, Burgula MV, Murphy DP. Clinical outcomes of distal femoral fractures in the geriatric population using locking plates with a minimally invasive approach. Geriatr Orthop Surg Rehabil 2013;4:16-20.
Nork SE, Segina DN, Aflatoon K, Barei DP, Henley MB, Holt S, et al
. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am 2005;87:564-9.
Allmann KH, Altehoefer C, Wildanger G, Gufler H, Uhl M, Seif el Nasr M, et al
. Hoffa fracture – A radiologic diagnostic approach. J Belge Radiol 1996;79:201-2.
Letenneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV. Hoffa's fractures. Report of 20 cases (author's transl). Ann Chir 1978;32:213-9.
Kumar R, Malhotra R. The Hoffa fracture: Three case reports. J Orthop Surg (Hong Kong) 2001;9:47-51.
Calmet J, Mellado JM, García Forcada IL, Giné J. Open bicondylar Hoffa fracture associated with extensor mechanism injury. J Orthop Trauma 2004;18:323-5.
Papadopoulos AX, Panagopoulos A, Karageorgos A, Tyllianakis M. Operative treatment of unilateral bicondylar Hoffa fractures. J Orthop Trauma 2004;18:119-22.
Neogi DS, Singh S, Yadav CS, Khan SA. Bicondylar Hoffa fracture? A rarely occurring, commonly missed injury. Injury Extra 2008;39:296-8.
Federlin M, Krifka S, Herpich M, Hiller KA, Schmalz G. Partial ceramic crowns: Influence of ceramic thickness, preparation design and luting material on fracture resistance and marginal integrity in vitro
. Oper Dent 2007;32:251-60.
White EA, Matcuk GR, Schein A, Skalski M, Marecek GS, Forrester DM, et al
. Coronal plane fracture of the femoral condyles: Anatomy, injury patterns, and approach to management of the Hoffa fragment. Skeletal Radiol 2015;44:37-43.
Arastu MH, Kokke MC, Duffy PJ, Korley RE, Buckley RE. Coronal plane partial articular fractures of the distal femoral condyle: Current concepts in management. Bone Joint J 2013;95-B: 1165-71.
Min L, Tu CQ, Wang GL, Fang Y, Duan H, Liu L, et al
. Internal fixation with headless compression screws and back buttress plate for treatment of old Hoffa fracture. Chin J Traumatol 2014;17:79-83.
Bagaria V, Sharma G, Waghchoure C, Chandak RM, Nemade A, Tadepelli K, et al
. A proposed radiological classification system of Hoffa's fracture based on fracture configuration and consequent optimal treatment strategy along with the review of literature. SICOT J 2019;5:18.
Schatzker J. Fractures of the distal femur revisited. Clinical Orthopaedics and Related Research®. 1998 Feb 1;347:43-56
Krettek C, Schandelmaier P, Miclau T, Bertram R, Holmes W, Tscherne H. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28 Suppl 1:A31-41.
Olerud S. Operative treatment of supracondylar--condylar fractures of the femur. Technique and results in fifteen cases. J Bone Joint Surg Am 1972;54:1015-32.
Khalil Ael-S, Ayoub MA. Highly unstable complex C3-type distal femur fracture: Can double plating via a modified Olerud extensile approach be a standby solution? J Orthop Traumatol 2012;13:179-88.
Garofalo R, Wettstein M, Fanelli G, Mouhsine E. Gerdy tubercle osteotomy in surgical approach of posterolateral corner of the knee. Knee Surg Sports Traumatol Arthrosc 2007;15:31-5.
Starr AJ, Jones AL, Reinert CM. The “swashbuckler”: A modified anterior approach for fractures of the distal femur. J Orthop Trauma 1999;13:138-40.
Borse V, Hahnel J, Cohen A. Hoffa fracture: Fixation using headless compression screws. Eur J Trauma Emerg Surg 2010;36:477-9.
Becker P, editor. Comparative analysis for the fixation of coronal distal intraarticular femur fractures. The 67th
Annual Meeting of the American Academy of Orthopaedic Surgeons; March 15-19, 2000.
Lewis SL, Pozo JL, Muirhead-Allwood WF. Coronal fractures of the lateral femoral condyle. J Bone Joint Surg Br 1989;71:118-20.
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;39:424-8.
Jarit GJ, Kummer FJ, Gibber MJ, Egol KA. A mechanical evaluation of two fixation methods using cancellous screws for coronal fractures of the lateral condyle of the distal femur (OTA type 33B). J Orthop Trauma 2006;20:273-6.
McCarthy JJ, Parker RD. Arthroscopic reduction and internal fixation of a displaced intraarticular lateral femoral condyle fracture of the knee. Arthroscopy 1996;12:224-7.
Tetsunaga T, Sato T, Shiota N, Yoshida M, Mochizuki Y, Tetsunaga T, et al
. Posterior buttress plate with locking compression plate for Hoffa fracture. J Orthop Sci 2013;18:798-802.
Bel JC, Court C, Cogan A, Chantelot C, Piétu G, Vandenbussche E, et al
. Unicondylar fractures of the distal femur. Orthop Traumatol Surg Res 2014;100:873-7.
Chang JJ, Fan JC, Lam HY, Cheung KY, Chu VW, Fung KY. Treatment of an osteoporotic Hoffa fracture. Knee Surg Sports Traumatol Arthrosc 2010;18:784-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]