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Peez C, Deichsel A, Briese T, Gueorguiev B, Richards RG, Zderic I, Glasbrenner J, Kittl C, Raschke MJ, Herbst E. Exposure of Hoffa Fractures Is Improved by Posterolateral and Posteromedial Extensile Approaches: A Qualitative and Quantitative Anatomical Study. J Bone Joint Surg Am 2024; 106:809-816. [PMID: 38377221 DOI: 10.2106/jbjs.23.01151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND The current literature lacks recommendations regarding surgical approaches to best visualize and reduce Hoffa fractures. The aims of this study were to (1) define surgical corridors to the posterior portions of the lateral and medial femoral condyles and (2) compare the articular surface areas visible with different approaches. METHODS Eight fresh-frozen human cadaveric knees (6 male and 2 female donors; mean age, 68.2 ± 10.2 years) underwent dissection simulating 6 surgical approaches to the distal femur. The visible articular surface areas for each approach were marked using an electrocautery device and subsequently analyzed using image-processing software. The labeled areas of each femoral condyle were statistically compared. RESULTS At 30° of flexion, visualization of the posterior portions of the lateral and medial femoral condyles was not possible by lateral and medial parapatellar approaches, as only the anterior 29.4% ± 2.1% of the lateral femoral condyle and 25.6% ± 2.8% of the medial condyle were exposed. Visualization of the lateral femoral condyle was limited by the posterolateral ligamentous structures, hence a posterolateral approach only exposed its central (13.1% ± 1.3%) and posterior (12.4% ± 1.1%) portions. Posterolateral extension by an osteotomy of the lateral femoral epicondyle significantly improved the exposure to 53.4% ± 2.7% and, when combined with a Gerdy's tubercle osteotomy, to 70.9% ± 4.1% (p < 0.001). For the posteromedial approach, an arthrotomy between the anteromedial retinaculum and the superficial medial collateral ligament, and one between the posterior oblique ligament and the medial gastrocnemius tendon, allowed visualization of the central (13.5% ± 2.2%) and the posterior (14.6% ± 2.3%) portions of the medial femoral condyle, while a medial femoral epicondyle osteotomy significantly improved visualization to 66.1% ± 5.5% (p < 0.001). CONCLUSIONS Visualization of the posterior portions of the femoral condyles is limited by the specific anatomy of each surgical corridor. Extension by osteotomy of the femoral epicondyles and Gerdy's tubercle significantly improved articular surface exposure of the femoral condyles. CLINICAL RELEVANCE Knowledge of the surgical approach-specific visualization of the articular surface of the femoral condyles might be helpful to properly reduce small Hoffa fragments.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | | | | | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Mushtaq M, Dhar SA, Bhat TA, Dar TA. A case report of the Hoffa fracture and a review of literature. Chin J Traumatol 2022; 25:293-301. [PMID: 35370061 PMCID: PMC9458991 DOI: 10.1016/j.cjtee.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/28/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023] Open
Abstract
The Hoffa fracture is an uncommon fracture. There is a lot of confusion about its diagnosis and management with several conflicting reports in literature. We reported a 25-year-old patient with non-union of Hoffa fracture, and meanwhile tried to develop an algorithm-based treatment for Hoffa fractures. A systematic review of the available literature was performed. Medline, Embase, the Cochrane Library and PubMed were searched for relevant articles. Fifty-five articles were reviewed, and the clinical knowledge base was summarized. The understanding of the mechanism of trauma has become more nuanced. The literature has also evolved to classify the fracture with the purpose of surgical management in mind. This can be used to plan approach and fixation with preservation of blood supply. Classification can also prognosticate the outcomes in Hoffa fracture.
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Jiang ZX, Wang P, Ye SX, Xie XP, Wang CX, Wang Y. Hoffa’s fracture in an adolescent treated with an innovative surgical procedure: A case report. World J Clin Cases 2022; 10:1410-1416. [PMID: 35211577 PMCID: PMC8855179 DOI: 10.12998/wjcc.v10.i4.1410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/10/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hoffa fracture is rare, especially in adolescents, and has a high rate of complications such as avascular necrosis and osteoarthritis; moreover, there are no definitive guidelines for its treatment. This report could provide a new potential treatment for Hoffa fracture.
CASE SUMMARY A 16-year-old girl presented to the orthopedic emergency department of No. 2 People’s Hospital of Yibin City with persistent pain following a right knee injury sustained during a sprint race. Her knee was swollen and tender, and the range of motion was restricted by the pain. X-ray and computed tomography revealed a Hoffa fracture in the right knee. After consultation, surgical treatment was performed, and the fracture was fixed with three 3.5-mm cannulated cancellous screws; osteochondral plugs that were harvested from the screw insertion site were re-implanted to cover the screw head. The patient’s fracture and osteochondral plug healed 6 mo postoperatively, and she presented a knee range of motion of 0–135 without pain, and was walking without support with a normal gait.
CONCLUSION Here, we describe an innovative surgical procedure for Hoffa fracture that could provide a new possibility for the treatment of similar fractures, and further improve their management.
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Affiliation(s)
- Zu-Xin Jiang
- Department of Orthopaedics, No. 2 People’s Hospital of Yibin City, Yibin 644000, Sichuan Province, China
| | - Pan Wang
- Department of Orthopaedics, No. 2 People’s Hospital of Yibin City, Yibin 644000, Sichuan Province, China
| | - Shun-Xin Ye
- Department of Orthopaedics, No. 2 People’s Hospital of Yibin City, Yibin 644000, Sichuan Province, China
| | - Xiao-Ping Xie
- Department of Orthopaedics, No. 2 People’s Hospital of Yibin City, Yibin 644000, Sichuan Province, China
| | - Chun-Xiu Wang
- Department of Oncology, No. 2 People’s Hospital of Yibin City, Yibin 644000, Sichuan Province, China
| | - Yue Wang
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu 640000, Sichuan Province, China
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Mierzwa AT, Toy KA, Tranovich MM, Ebraheim NA. Surgical Approaches, Postoperative Care, and Outcomes Associated with Intra-Articular Hoffa Fractures: A Comprehensive Review. JBJS Rev 2019; 7:e8. [PMID: 31460990 DOI: 10.2106/jbjs.rvw.18.00143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Adam T Mierzwa
- University of Toledo Medical Center, University of Toledo College of Medicine, Toledo, Ohio
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Zhou Y, Pan Y, Wang Q, Hou Z, Chen W. Hoffa fracture of the femoral condyle: Injury mechanism, classification, diagnosis, and treatment. Medicine (Baltimore) 2019; 98:e14633. [PMID: 30813201 PMCID: PMC6408088 DOI: 10.1097/md.0000000000014633] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hoffa fractures are coronal-plane fractures of the femoral condyle, which are rarer than sagittal-plane condylar fractures. This study aimed to systematically review the clinical knowledge base of Hoffa fractures to facilitate the diagnosis and management of such injuries. METHODS We searched Medline, Embase, Cochrane Library, Google Scholar, China National Knowledge Infrastructure, and China Biology Medicine disc, using the terms "Hoffa fracture" and "coronal fracture of femoral condyle." RESULTS One hundred five articles on Hoffa fractures were reviewed, and the clinical knowledge base was summarized. High-energy trauma is a common cause of a Hoffa fracture, although low-energy trauma and iatrogenic injury can also lead to these fractures. Commonly used classifications include the Letenneur classification, a computed tomography (CT) classification, the AO classification, and modified AO classification. Radiography can reveal fracture lines. If radiographic findings are negative in questionable cases, CT and magnetic resonance imaging (MRI) should be performed. Nondisplaced fractures can be managed conservatively; however, they involve a high risk of redisplacement. Open reduction and internal fixation are preferred. For young patients with good compliance, simple medial or lateral condylar fractures can be treated via a medial or lateral parapatellar approach. After fracture exposure, headless compression screws can be inserted perpendicularly to the fracture line from posterior to anterior. For bicondylar fractures, a median parapatellar incision can be used. For complex fractures in patients with osteoporosis or a high body mass index, cannulated screws with antigliding plate fixation should be used. CONCLUSION Here, we summarized the injury mechanism, diagnosis, classification, and treatment options of Hoffa fractures.
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Affiliation(s)
- Yabin Zhou
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Orthopedic Research Institution of Hebei Province, Key Laboratory of Biomechanics of Hebei Province
- Department of Orthopedic Surgery, Shijiazhuang The Third Hospital
| | - Ying Pan
- Department of Pharmacy, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qingxian Wang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Orthopedic Research Institution of Hebei Province, Key Laboratory of Biomechanics of Hebei Province
| | - Zhiyong Hou
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Orthopedic Research Institution of Hebei Province, Key Laboratory of Biomechanics of Hebei Province
| | - Wei Chen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Orthopedic Research Institution of Hebei Province, Key Laboratory of Biomechanics of Hebei Province
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Relationships between Hoffa fragment size and surgical approach selection: a cadaveric study. Arch Orthop Trauma Surg 2018; 138:1679-1689. [PMID: 30099576 DOI: 10.1007/s00402-018-3022-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Fixation of a small Hoffa fragment requires a selection of the proper surgical approach for reduction and posterior to anterior screws fixation. However, currently there are no guidelines regarding how to select the best approach for small posterior Hoffa fractures. OBJECTIVES To compare the size of Hoffa fractures that are appropriate for reduction and fixation with the medial parapatellar approach (MPPA) and those which require the direct medial approach (DMA), and to make a similar comparison between the lateral parapatellar approach (LPPA) and the posterolateral approach (PLA). MATERIALS AND METHODS Twenty extremities of fresh cadavers were included. After completion of each approach, the articular surface boundaries were marked and soft tissue was removed. On the medial condyle, an imaginary line was drawn from the most anterior (A) to the most posterior (B) point, representing the AP diameter (d3). The most posterior boundary of MPPA (C) and the most anterior boundary of DMA (D) were similarly marked. Distances between B and C (d1) and between B and D (d2) were measured as well as the anterior-posterior diameter of the condyle (d3). The same measurements were made for the lateral condyle. RESULTS On the medial condyle, the average values of d1, d2, and d3 were 10.8 mm ± 3.8, 17.3 mm ± 3.3, and 60.1 mm ± 3.2, while percentages of d1/d3 and d2/d3 were 18.3% ± 6.4 and 28.7% ± 4.7. In lateral condyle, the averages for d1, d2, d3 were 6.1 mm ± 1.4, 12.1 mm ± 2.8 and 60.9 mm ± 3.3 mm and the percentages of d1/d3 and d2/d3 were 10.1% ± 2.3 and 19.9% ± 4.9. CONCLUSIONS When the Hoffa fragment is less than 18.3% of the AP diameter of medial condyle or 10.1% of lateral condyle, the fracture is invisible with the PPA. When the Hoffa fragment is more than 28.7% of the medial condyle or 19.9% of the lateral condyle, the PPA should be selected. If the Hoffa fragment is less than 28.7% of the medial condyle or 19.9% of the lateral condyle, the DMA or PLA with posterior-to-anterior screws is recommended. Combined approaches should be considered in some complex cases with articular comminution.
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Orapiriyakul W, Apivatthakakul T, Buranaphatthana T. How to determine the surgical approach in Hoffa fractures? Injury 2018; 49:2302-2311. [PMID: 30526925 DOI: 10.1016/j.injury.2018.11.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical approach selection and fixation of Hoffa fractures is difficult and remains controversial. Evolving trends emphasize the importance of fracture morphology, fracture location, and comminution, all of which guide decisions regarding surgical approach and implant selection. This focused review highlights factors affecting Hoffa fracture available surgical approaches, treatment outcomes, and recommendations for selecting an optimal approach.
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Affiliation(s)
- Wich Orapiriyakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Theerachai Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Thailand.
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Kapoor C, Merh A, Shah M, Golwala P. A Case of Distal Femur Medial Condyle Hoffa Type II(C) Fracture Treated with Headless Screws. Cureus 2016; 8:e802. [PMID: 27790391 PMCID: PMC5081261 DOI: 10.7759/cureus.802] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Coronal plane fractures of the distal femur are less frequent compared to sagittal plane fractures. They were described by Hoffa in 1904 and are known as Hoffa fractures (AO type B3). They are isolated fractures of the femoral condyle and rare in occurrence. The objective in the treatment of these fractures is to achieve anatomical reduction of the articular surface and a stable fixation to prevent joint damage in future and prevent post-traumatic arthritis of the joint. We report the case of a young male patient who had a rare type of medial Hoffa fracture which was treated by open reduction and internal fixation using headless Herbert screws using a posterior approach. The fracture was united in eight weeks, and the patient had a full range of knee movement. We advocate this approach and modality of treatment for Hoffa type II(C) fractures.
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Affiliation(s)
- Chirag Kapoor
- Orthopaedics, Sumandeep Vidyapeeth, Vadodara, Gujarat
| | - Aditya Merh
- Orthopaedics, Sumandeep Vidyapeeth, Vadodara, Gujarat
| | - Malkesh Shah
- Orthopaedics, Sumandeep Vidyapeeth, Vadodara, Gujarat
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Xu Y, Li H, Yang HH, Pan ZJ. A comparison of the clinical effect of two fixation methods on Hoffa fractures. SPRINGERPLUS 2016; 5:1164. [PMID: 27512623 PMCID: PMC4960084 DOI: 10.1186/s40064-016-2861-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/18/2016] [Indexed: 12/29/2022]
Abstract
Introduction Hoffa fractures are rare and difficult to treat for orthopaedic surgeons. The mechanism of injury of Hoffa fracture is still unknown and the operation approch and fixation method are still controversial. The aim of this study is to compare the clinical effect between two fixation methods on Hoffa fractures. Case description From April 2004 to July 2013, we treated eleven patients (new method group) with Hoffa fracture using the new fixation method (fixed with intercondylar screw and crossed screws) and sixteen patients (traditional method group) using the traditional fixation method (fixed with anteroposteriorly placed screws). All documents from their admission until the last followup in December 2015 were reviewed, data regarding complications collected and results were evaluated using the Knee Society Score. Discussion and Evaluation After an average follow-up period of 27.1 months (range 24–32 months), all fractures had healed. The average healing time of the new method group was 11.36 weeks (range 9–14 weeks) and the average healing time of the traditional method group was 11.88 weeks (range 9–14 weeks). According to the Knee Society Score, the average score of the new method group was 176.36 points (range 125–199 points), and the average score of the traditional method group was 171.19 points (range 148–197 points). Statistical analysis (t test, t = 0.76, P > 0.05) showed that the difference of both the healing time (t test, t = 0.94, P > 0.05) and the score between these two groups was not significant. Conclusions These results indicate that the new fixation method for Hoffa fracture is as effective as the traditional method and may provide a new way to treat Hoffa fractures.
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Affiliation(s)
- Yi Xu
- Department of Orthopaedics, The First People's Hospital of Huzhou (The First Affiliated Hospital of Huzhou Teachers College), Zhejiang University, Huzhou, 313000 Zhejiang China
| | - Heng Li
- Department of Orthopaedics, The First People's Hospital of Huzhou (The First Affiliated Hospital of Huzhou Teachers College), Zhejiang University, Huzhou, 313000 Zhejiang China
| | - Hong-Hang Yang
- Department of Orthopaedics, The First People's Hospital of Huzhou (The First Affiliated Hospital of Huzhou Teachers College), Zhejiang University, Huzhou, 313000 Zhejiang China
| | - Zhi-Jun Pan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 Zhejiang China
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