First described by Hoffa in 1904, the Hoffa fracture is a unicondylar, intra-articular femur fracture in the coronal plane.1 The Hoffa fracture is a rare injury pattern, and multiple surgical techniques have been described in treatment of the Hoffa fracture, including anteroposterior and posteroanterior screw placement and contoured locking plates with cannulated or lag screws.2–5 Because of the low incidence rate of Hoffa fractures, there is limited data available as to the most effective fixation construct. The purpose of this Supplemental Digital Content 1 (see video, https://links.lww.com/JOT/A24) is to demonstrate the technique of Hoffa fracture fixation using posteroanterior headless screw compression.
The patient is a 25-year-old man who sustained a left knee injury while playing sports. Radiographs of the knee demonstrate a comminuted and displaced posterolateral condyle fracture of the distal femur, also known as a Hoffa fracture. He is indicated for open reduction and internal fixation, as operative fixation of this fracture pattern provides good long-term outcomes.4,6,7
The patient is placed in the right lateral decubitus position with the left knee elevated. A longitudinal incision is made midway between the posterior border of the fibula and extended proximally. The peroneal nerve is identified proximally and traced to be protected throughout the procedure with a vessel loop. The iliotibial band is elevated off of the posterolateral aspect of the femur, exposing the fracture site. Several small osteochondral fragments that are not reconstructable are removed to afford reduction. A tear is in the posterolateral horn of the lateral meniscus is identified intraoperatively and is repaired before fracture fixation. Although lateral meniscus tears are common after tibial plateau fractures, there is no published literature on the incidence of the lateral meniscal tear in concert with a Hoffa fracture. Two suture anchors are drilled and placed into the posterolateral tibia. After implant of suture anchors, the meniscus is directly repaired to the menisco–synovial junction. A second suture anchor is drilled and placed. Next, the Hoffa fracture is reduced and reduction is confirmed in 2 planes. Kirschner wires are then placed from posterior to anterior across the fracture and are left short of the anterior cortical surface. Intraoperative fluoroscopy confirms their placement. Next, the wires are measured and overdrilled. Partially threaded compression screws are placed over the wire to compress the fracture fragment. This screw system provides for a headless screw and independent compression after screw placement. After screw placement, the guide wires are removed. The nerve is found to be free and clear. Final radiographs confirm implant placement.
Postoperatively, the patient is kept non–weight-bearing for 10 weeks and early range of knee motion in a hinged brace. By 9 months postoperatively, his fracture is fully healed and he has returned to full activities. The benefit of this approach to fracture fixation includes the ability to gain compression of the displaced fracture fragment to the intact segment. Headless crews allow for lack of prominent hardware in the articular surface.2 Two prospective studies have reported good-to-excellent results after early screw fixation for a Hoffa fracture, yet these studies used anterior-to-posterior fixation as opposed to the posterior-to-anterior fixation demonstrated in this case.4,7 However, despite the limited information in the literature concerning Hoffa fractures, multiple studies have confirmed that early surgical treatment will provide for fracture stabilization and early range of motion that will ultimately improve patient outcomes.2,4–9
REFERENCES
1. Hoffa A. Lehrbuch Der Frakturen Und Luxationen. Stuttgart, Germany: Verlag von Ferdinand Enke; 1904.
2. Borse V, Hahnel J, Cohen A. Hoffa fracture: fixation using headless compression screws. Eur J Trauma Emerg Surg. 2010;36:477–479.
3. Shi J, Tao J, Zhou Z, et al. Surgical treatment of lateral Hoffa fracture with a locking plate through the lateral approach. Eur J Orthop Surg Traumatol. 2014;24:587–592.
4. Gavaskar AS, Tummala NC, Krishnamurthy M. Operative management of Hoffa fractures—a prospective review of 18 patients. Injury. 2011;42:1495–1498.
5. Holmes SM, Bomback D, Baumgaertner MR. Coronal fractures of the femoral condyle: a brief report of five cases. J Orthop Trauma. 2014;18:316–319.
6. Ostermann PA, Neumann K, Ekkernkamp A, et al. Long term results of unicondylar fractures of the femur. J Orthop Trauma. 1994;8:142–146.
7. Sahu RL, Gupta P. Operative management of Hoffa fracture of the femoral condyle. Acta Med Iran. 2014;52:443–447.
8. Dhillon MS, Mootha AK, Bali K, et al. Coronal fractures of the medial femoral condyle: a series of 6 cases and review of literature. Musculoskelet Surg. 2012;96:49–54.
9. Moussa ME, Boykin RE, Earp BE. Missed locked posterior shoulder dislocation with a reverse Hill-Sachs lesion and subscapularis rupture. Am J Orthop (Belle Mead NJ). 2013;42:E121–E124.
