Hoffa’s Fracture #

Dr Vaibhav BAGARIAMBBS MS FCPS Dip SICOTConsultant Ortho Surg

CARE Hospital & ORIGYN healthNagpur, INDIA

www.drbagaria.com

Ao Trauma 2014

Synopsis

Definition

Mechanism

Radiology

Management

BAGARIA classification system for Hoffa’s #

Albert Hoffa

German Surgeon

1904

Würzburg - koenig Ludwig haus

Others: Hoffa’s disease, Physio

Personal: Worked at the station

Definition

Coronal fracture of the distal femur - intra articular - usually the only attachment is the posterior capsule.

Mechanism of Injury

Shearing force on the posterior condyle

Axial Load with knee flexed >= 90 -> tangential force pattern

Typically a motor bike accident in young patient

Subject to shear force in both sagittal and coronal plane -> Intrinsically unstable

Clinical Exam

Effusion ++

Varus/Valgus Instability +- maybe subtle

Always check for DNVD

X Rays

On AP Fore shortened # condyle may lead to appearance of varus or valgus mal-alignment.

On true lat the femoral condyles are not superimposed.

Be wary to misinterpret those as poor X ray

Oblique view may be useful but when in doubt CT is preferred.

CT scan

3 D Recon

Management

Hoffa Fracture effectively separates Patellofemoral joint from the Tibiofemoral joint.

Knee movements particularly WB result in high Shear forced along the fracture line, making non operative management unpredictable and adequate stabilisation challenging

Principle of treatment

Atraumatic

Anatomical Reduction

Secure Fixation

Early mobilisation & Functional Activity

Planning

Approach

Reduction

Fixation

Post op

Approach

Lateral Para pateallar

Medial Parapatellar

Medial Approach

TTO

Posterior

Medial Para patellar

Lateral Para patellar

Medial approach

TTO

Posterior Approach

When the fragment is too small to be fixed from anterior.

Prone position

Posterior Approach

Steps

Inspect the Joint

Visualise the fracture line

Clean it - use a spreader

Anatomically reduce and hold

Initiate drilling at Pat Fem Jn.

Perpendicular to #

Reduction

Bone Spreader - clear

Perisosteal Elevator

Reduction clamp

Joystick technique

Insert Guide wires

Counter Sink & Screw placement

Fixation

At least two screws - prevent rotation & achieve compression

Implants not to violate the articular surface

Choice of implant: 3.5/4.5 cortical compression vs CC Vs Headless

BeckerPL,StafordPR,GouletR,etal. Comparative analysis for the fixation of coronal distal intraarticular femur fractures. Presented at the 67th annual meeting of the American Academy of Orthopaedic Surgeons, March 15–19, 2000.

Fixation

Post Op X Rays

Complications

Loss of Reduction

Malunion

Neuro vascular damage

AVN?

Subsequent Redisplacement

Malunions

Special Conditions

Bilateral

Unilateral Bicondylar

Associated Supracondylar fracture

Malunited

Arthritic Knees

Bicondylar

Plates as washers

On the Horizon

Arthroscopically assisted surgery

Rapid Prototyping

Bioabsorbable Implants

Whats in store?

• Developing a new classification system: “Bagaria Classification” for Hoffa’s #

Helps Decide:

• When to approach anterior and when posterior?

• When to put screws and when to plate?

Bagaria Classification

• Grade 1: Fragment > 2.5 cm on CT axial section at the level of medial epicondyle

• Grade 2: Fragment < 2.5 cm on CT axial section at the level of medial epicondyle

• Grade 3: Communition present at the fracture site a) > 2.5 b) < 2.5

• Grade 4: Presence of a sagittal fracture line in addition to coronal fracture.

Mgmt as per Bagaria

Classification of Hoffa #• Grade 1: Two parallel screw anterior

to posterior ( countersunk or headless)

• Grade 2: Two parallel screw posterior to anterior ( countersunk or headless)

• Grade 3a & b: Consider buttress plate/ parallel screws.

• Grade 4: Anti glide plate

Take Home Message

high index suspicion

Operative almost always

low tech standard technique

AO Principle, Articular cartilage, 2 screws

Thank You

www.drbagaria.com