isolated medial hoffa fracture: a case series

IAR Journal of Medical Case Reports ISSN Print : 2709-3220 | ISSN Online : 2709-3239 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iarjmcr

Available: https://iarconsortium.org/journal-info/iarjmcr 18

Isolated Medial Hoffa Fracture: A Case Series

Abstract: Introduction: Hoffa in 1904 first described fractures of the femoral condyle in tangential plane and are now known as Hoffa fractures. Approach to isolated medial Hoffa

fracture is, however, confusing. On reviewing literature, majority cases are operated using

parapatellar arthrotomy, some through a medial (subvastus) approach, and few was fixed percutaneously. Materials and Methods: We studied 6 patients of medial Hoffa fracture

presenting in Orthopedics department of Kalpana Chawala Government Medical College,

Karnal. They were evaluated radiologically with X-rays of knee anteroposterior and lateral

view. All patients were approached through subvastus approach, and were treated with

screws and buttress plating. The follow up of patients was done after 2 weeks, 1 month, 3 months and 6 months post operatively. Results: The age of the patients ranged from 27-31

(Mean 29 years). Mean range of motion was 125.83(range 120-130). All our patients had

radiological bony union at 6 months. Functional outcome was calculated by Knee society score which was average 84.16 (range 80-88), which comes under excellent category (80-

100). Conclusion: We concluded that outcome results of operated case of isolated medial

Hoffa’s fracture using medial subvastus approach and fixation of fracture with screws and buttress recon plate are excellent (as per knee society score).

Keywords: Hoffa’s fracture, Subvastus approach.

INTRODUCTION

Hoffa in 1904 first described fractures of the femoral condyle in

tangential plane and are now known as Hoffa fractures(Karim, A., &

Rossiter, N. 2006). They are classified as 33-B3.2 as per AO/OTA

classification(Dhillon, M. S. et al., 2012).

They can be described as intra-articular lateral or medial or bicondylar

fracture that occurs in the coronal plane of the distal femur hence

immediate needing the anatomical reduction with internal fixation as

early as possible(Karim, A., & Rossiter, N. 2006)

Lateral or bicondylar Hoffa fractures and well described in literature

in respect to classification, mechanism of injury, surgical approach,

reduction and fixation methods but Isolated coronal fracture of medial

femoral condyle, with intact lateral femoral condyle, is extremely rare and

barring a few isolated case reports(Ocguder, A. et al., 2008).

This is likely because of the often associated articular comminution,

associated injuries, the relative inaccessibility of the medial femoral

condyle articular surface, the difficulty associated with hardware

placement, and the magnitude of shear forces that must be resisted with

the fixation to avoid loss of fracture reduction(Viskontas, D. G. et al.,

2010).

The mechanism of injury for isolated medial Hoffa fracture is

controversial. Some authors described direct impact with the knee in a flexed position as the mechanism of injury, while

others have attributed the fracture to simultaneous vertical shear and twisting forces(2). Majority of these injuries are a

result of accidents two wheeler riding .The normal riding posture of the motor cyclist involves sitting with the knee

flexed at or beyond 90. In this position with slight abduction, lateral femoral condyle is the leading part of the knee to

receive a direct impact. Medial impact directly to the medial femoral condyle with the knee in greater than 90 of flexion

and an element of adduction and internal rotation can lead to medial Hoffa’s fracture(Lewis, S.L. 1989).

Diagnosis of this fracture is challenging and needs strong suspicion as this type of fracture is rare and misdiagnosis is

common. In cases of isolated fracture without any associated fractures of the knee, diagnosis should be based on physical

examination of skin lesions, oedema, effusion and careful radiological evaluation especially oblique views.

Research Art ic le

Article History

Received: 29.01.2021

Revision: 07.02.2021

Accepted: 15. 02.2021

Published: 28.02.2021

Author Details Dr. Devinder Kumar gupta1, Dr. Ambry garg*2,

Dr.Mohit Jindal3, Dr. Keerty Garg4, Dr. Varsha

Gupta5, Dr. Nikhil Gore6 and Dr. Navjyot Karda1

Authors Affiliations 1Medical Officer (Specialist) PCMS- 1, Civil

Hospital, Mohali, Punjab, India 2Senior resident, department of radiodiagnosis,

Kalpana chawla Government Medical College, Karnal Haryana, India 3Assistant professor, department of orthopedics,

Kalpana chawla Government Medical College, Karnal Haryana, India 4Assistant professor, department of Anaesthesia,

Kalpana chawla Government Medical College, Karnal Haryana, India 5Demonstrator, Department of community medicine, Kalpana Chawla Government medical college,

Karnal, Haryana, India 6Junior Resident, Department of orthopaedics, Kalpana Chawla Government medical college,

Karnal Haryana, India

Corresponding Author* Dr. Ambry garg

How to Cite the Article: Dr. Devinder Kumar gupta, Dr. Ambry garg*,

Dr.Mohit Jindal, Dr. Keerty Garg, Dr. Varsha

Gupta, Dr. Nikhil Gore & Dr. Navjyot Karda

(2021); Isolated Medial Hoffa Fracture: A

Case Series . IAR J Med Cse Rep. 2(1) 18-23.

Copyright @ 2021: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited.

Dr. Devinder Kumar gupta, et al., IAR J Med Cse Rep; Vol-2, Iss- 1 (Jan-Feb, 2021): 18-23

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However, in cases with associated distal femoral

fractures, diagnosis of coronal fractures is quiet difficult

unless a strong index of suspicion is kept for the

same(Marzouki, A. et al., 2013).

The imaging evaluation of distal femoral fractures is

based primarily on radiographs. Supracondylar distal

femoral fractures may be classified as extraarticular,

unicondylar, or bicondylar, and the fractures may have

an intercondylar extension(Skaggs, D.L., & Flynn, J.M.

2014).

Nork et al., strongly recommended preoperative CT

scan in cases of supracondylar-intercondylar fractures

of the distal femur because of misdiagnosis on

conventional radiographs(Fractures, C.P. 2005).

Approach to isolated medial Hoffa fracture is,

however, confusing. On reviewing literature, majority

cases are operated using parapatellar arthrotomy, some

through a medial (subvastus) approach, and few was

fixed percutaneously(Viskontas, D. G. et al., 2010; &

Gao, M. et al., 2015).

MATERIALS AND METHODS

We studied 6 patients of medial Hoffa fracture

presenting in Orthopedics department of Kalpana

chawala government medical college, Karnal, Haryana.

They were evaluated radiologically with X-rays of knee

anteroposterior and lateral view (Figure- 3). Due to

financial constraints of patients CT scan couldn’t be

done. Of 6 patients 5 were male and one was female.

The average age of patients was 29 years (range 27-31

years).

After PAC and obtaining clearance for surgery

patients were taken up for surgery.

The operation was conducted under the guidance of

professional surgeons. The patient was placed supine on

a radiolucent table. Preoperative antibiotics and a

general or spinal anaesthetic were administered. A

tourniquet was placed around the ipsilateral thigh and

inflated at surgeon discretion. The knee was initially

placed in 20° of flexion over a towels and sheets.

All the fractures were treated by open reduction

through the medial subvastus approach is used through

an extensile longitudinal anterior skin incision

approximately 25 cm in length. (Figure-1)

Figure 1 Intra operative picture showing subvastus approach

And after exposure done the vastus medialis muscle,

sartorius muscle and saphenous nerve, which were

retracted forward to the anterior to explore the gracilis,

semimembranosus and semitendinosus muscles. After

that, the semimembranosus and semitendinosus were

retraced to the posterior and we could go through the

interval space between the gracilis muscle and caput

medial of the gastrocnemius to expose the fragment,

and then the origin of the medial collateral ligament

could be clearly exposed and protected. The intact

fragment of Hoffa fracture was reduced and fixed with

one or two cannulated or lag screws and meanwhile a

recon plate was anatomically contoured and used

(Figure - 2) for fixing with angular stability and also


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preventing from the vertical gliding of the fragment (for

buttressing) (Figure 4). Knee immobilizer was given to

the patients post operatively.

The follow up of patients was done after 2 weeks, 1

month, 3 months and 6 months post operatively.

For 12 weeks after surgery, range-of-motion

exercises were unlimited, and weight-bearing was

restricted. All fractures healed, and reductions were

maintained. One patient has superficial wound infection

which was treated with intravenous antibiotics and

antiseptic dressings.

On follow up we measured functional out come by

checking for knee range of motion, knee society score(

Liow, R. Y. et al., 2000) and bony union time.

Observation at 6 months of follow up

Sr. no Range of motion Knee society score Bony union (confirmed

radiologically)

1 0-125 84 Yes

2 0-120 80 Yes

3 0-130 86 Yes

4 0-125 84 Yes

5 0-130 88 Yes

6 0-125 83 Yes

Mean Range of motion of patients was 125.83 (range 120-130). Average knee society score was 84.16 (range 80-88)

which comes under excellent category (80-100). All our patients had bony union at 6 months.

Figure 2 – Intra operative picture showing anatomical reduction of fracture and buttressed with recon plate


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Figure- 3 Antero posterior and lateral radiograph of Left knee showing Isolated medial hoffas fracture

Figure 4- Immediate post operative anteroposterior and lateral radiograph of knee

Figure 5 – Anteroposterior and lateral radiograph of knee at 6 months follow up showing bony union.

DISCUSSION

An isolated coronal plane fracture of the

posteromedial distal femoral condylar was originally

described by Hoffa in 1904(Karim, A., & Rossiter, N.

2006).


22

It is assumed to occur secondary to a high-energy

blunt force trauma that, applied to a flexed knee, causes

shearing of the posterior condyle (1904. HAL).

Associated injuries, which are common, occur in the

ipsilateral knee, lower extremity and more distant

locations (Viskontas, D. G. et al., 2010).

Unicondylar Hoffa fracture has been reported in

several studies (Holmes, S. M. et al., 2004; &

Ostermann, P. A. et al., 1994). However, few reports

about medial Hoffa fracture were shown in the

literature(Bali, K. et al., 2011; Chang, J. J. H. T. et al.,

2010; & Dhillon, M. S. et al., 2012).

Hoffa fractures are usually caused by motor

vehicular accidents. Until now, the injury mechanisms

of this fracture pattern have not been clearly described.

To detect the coronal fractures more accurately, CT

scanning is necessary to these fractures that might be

easily overlooked on plain radiographs. On the other

hand, CT scanning or MRI examination is essential to

find out a potential fracture and other accompanying

structure injuries ( Fractures, C.P. 2005). Ozturk

(Oztürk, A. et al., 2009) recorded a case of neglected

medial Hoffa fracture that was initially missed because

of seemingly normal anteroposterior (AP) radiographs

of the knee.

The medial Hoffa fracture is a kind of intra-articular

fracture, and most of these cases need operation

(Dhillon, M. S. et al., 2012; & Ostermann, P. A. et al.,

1994). Conservative management often leads to non-

union or loss of knee function (Oztürk, A. et al., 2009).

The surgical approaches are usually parapatellar

approaches (anteromedial), or combined with posterior

approaches, depending on the fracture classification and

fixation methods.

Several approaches and fixation methods for distal

femoral coronal fractures have been described, but most

descriptions involve treatment of lateral Hoffa

fragments. Previous descriptions of medial Hoffa

fracture surgical fixation are limited. Attempts at

fixation with a limited medial approach or a medial

parapatellar approach with the knee in extension can be

frustrating. The MCL lies over the typical coronal intra-

articular fracture plane and limits exposure and

reduction. Femoral distraction with the knee in

extension is limited in increasing visualization. In a

case report, Holmes and colleagues (Holmes, S. M. et

al., 2004) described using an anterior midline incision

with a medial parapatellar approach. Although the

parapatellar approach allows access for reduction

anteriorly, visualization of posterior comminution and

ease of reduction may be limited. A medial subvastus

approach allows extensile exposure of the articular

surface and, if needed, access to the posterior femoral

condyle— for placement of fixation in multiple planes.

The subvastus approach has been popularized by

Hofmann and colleagues (Hofmann, A. A. et al., 1991).

As far as we know, there was no clinical comparison

of different fixation methods on Hoffa fracture in the

literatures. Most of Hoffa fractures were treated with

cannulated screws or cancellous screws from anterior to

posterior or the opposite direction, and the clinical

outcomes were different (Holmes, S. M. et al., 2004;

Chang, J. J. H. T. et al., 2010; Oztürk, A. et al., 2009; &

Gavaskar, A. S. et al., 2011). It is generally accepted

that the screw heads are recessed beneath the articular

surface.

A biomechanical study showed that cannulated

screws placed from posterior to anterior provided more

stable fixation of Hoffa fractures in embalmed femurs

than anteroposteriorly placed cannulated screws(Jarit,

G. J. et al., 2006).

CONCLUSION-

We concluded that outcome results of operated case

of isolated medial Hoffa’s fracture using medial

subvastus approach and fixation of fracture with 6.5

cancellous cannulated screws and buttress recon plate

are excellent (as per knee society score). We obtained

very good range of motion (average 125.83) at 6

months follow up. We obtained radiological bony union

in 100% of our cases (fig 5).

Although conclusions about the long-term outcomes

of these injuries cannot be drawn, reduction and

fixation of these high-energy intra-articular injuries

using this surgical approach have been favourable and

may be useful for the medial Hoffa fracture.

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isolated medial hoffa fracture: a case series

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