Hoffa originally described tangential plane fractures in 1904, which are uncommon. Isolated femoral condyle fractures constitute of only 0.65%. Due to the physiological valgus at the knee, the lateral condyle is at higher risk of injury than the medial. The medial fracture has been documented to be a result of trauma on the medial side while the knee is at 90° of flexion. Being intra-articular and unstable fractures, anatomical reduction and fixation are the mainstays of treatment and if neglected or managed conservatively, it can lead to malunion, nonunion, and avascular necrosis.
A fairly uncommon injury is an isolated fracture to the medial condyle, with only about ten cases documented in the literature. Malunion with lateral femoral condyle intact is extremely rare. A typical technique for extra-articular malunited fracture is osteotomy, however, only a few studies have been published that describe the outcomes of operative management of symptomatic intra-articular malunited medial Hoffa's fracture. Hereby, presenting a report of a 23-year-old male with neglected left medial condyle Hoffa's malunion for whom intra-articular osteotomy was done as a salvage procedure followed by rigid and stable fixation.
A 23-year-old male had a history of a self-fall incident 18 months ago. He was not able to stand or walk immediately after the fall. He took osteopathic treatment for 1 month and started complete weight-bearing mobilization with support 1-month posttrauma. He presented to us with complaints of pain, instability in his left knee, and difficulty in full weight bearing for 5 months which aggravates on walking and was affecting his daily activities of living.
Physical examination revealed antalgic gait and fixed 10° varus deformity. The knee joint had no effusion. Tenderness was present at the medial knee joint line. The range of movements in the left knee was 10°–100° limited by pain, indicating fixed flexion deformity of 10° [Figure 1]. The neurovascular examination was found to be normal.
Radiographs showed a malunited Hoffa's fracture of the medial condyle of the left femur with an intra-articular step of 13 mm. Computed tomography (CT) scan was done and revealed a malunited intra-articular of the femoral condyle with a fracture line extending from the medial cortex of the femur posterosuperiorly to the posterior cortex [Figures 2 and 3].
The surgical concern was that, the fracture line was close to attachments of the Medial collateral ligament (MCL), adductor tubercle, and origin of the gastrocnemius (medial head) [Figure 4]. Exposure was done through the medial subvastus approach with medial parapatellar arthrotomy, with an additional plane between the adductor Magnus and semimembranosus posteriorly to expose the posterior femoral cortex. The malformed fracture site was observable [Figure 5]. There were no injuries to the cruciate ligaments. Osteoclasis was done along the fracture line [Figure 5], keeping the medial soft-tissue sleeve including MCL intact. Malunited portion of the coronal fracture was osteotomized to correct the deformity. Distal radius T antiglide plate was contoured and fixed posterior to the medial condyle. In addition, the fragment was fixed by two 4 mm screws. Stability was assessed and it was found to be satisfactory. Intraoperatively, fluoroscopy showed fracture fragment was reduced, and clinically, terminal extension improved with full flexion preserved [Figure 6]. There was no medial opening on valgus stress.
Postoperatively, quadriceps strengthening, hamstring stretching, and knee range of motion exercises were advised. At 4 weeks of follow-up, there is a 10° extensor lag with pain-free flexion till 110°. After 3 months, he was given the go-ahead for partial weight-bearing, with full weight-bearing from 6 months postoperatively. At 12 months postoperatively, there is no extensor lag with knee flexion till 125° as compared to the right knee [Figure 7]. His Knee Society Score has improved from 54 preoperatively to 75 at 10 months postoperatively. His knee's range of motion was enhanced by osteotomy with stable fixation, maintaining articular congruity, and delaying secondary osteoarthritis.
The Hoffa fracture is a fracture of the posterior aspect of the distal femoral condyle in the coronal plane. It is the lateral condyle in the foremost aspect of the knee that receives oblique or lateral impacts when the knee is flexed more than 90 degrees.
Orthopedic Trauma Association has classified these fractures as Type 33-B3 fractures. According to Letenneur et al., another classification system divides these fractures into three categories based on how far the fracture is from the shaft margin. Type I fracture is the one that runs parallel to the femur's posterior cortex and affects the whole condyle. A fracture of Type II is horizontal to the condyle's base and might vary in size. Oblique femur fractures of Type III had the worst outcome. This classification determined that our patient had a Type III fracture.
These injuries usually occur in young, fit men, and the long-term social consequences of malunion, nonunion, and degenerative changes in a major weight-bearing joint have to be kept in mind. Usually, direct trauma and an element of abduction led to the fracture. The main cause of this fracture is a high-energy injury, i.e., in traffic collisions (80.5% of cases) and falls (9.1% of cases). Although radiographs could be useful, a scan describing fractures in all three planes is typically advised to detect coronal fractures precisely.
The blood supply and the physiological stress during fixation must be kept in mind while approaching these types of fractures. Compared with the lateral condyle, the medial side's intraosseous blood supply has less vascularity. This vascular contribution can be jeopardized by dissection of the posterior condyle, which can lead to medial femoral condyle osteonecrosis. Given the tenuous vascularity of the medial condyle, posterior dissection of the distal femur should be limited. During dissection on the medial side, collateral ligament and oblique posterior ligament femoral attachments should be preserved. When defining the plane of osteotomy, posterior cruciate ligament insertion should be considered.
Nonoperative management usually leads to malunion or nonunion of the fracture, therefore, surgical management is the mainstay treatment of Hoffa's fracture. In our case, the patient was initially managed nonoperatively, i.e., he took osteopathic treatment. The patient presented to us with complaints of pain owing to impingement of malunion against the tibial condyle [Figure 2]. Physical examination showed knee flexion of 10°–100°. This terminal flexion was limited by the posteriorly displaced part of the condyle. Surgical management was advised to prevent secondary osteoarthritis.
There are only a few reports that described corrective osteotomy as a salvage procedure for Hoffa's malunion. In our case, a salvage procedure, i.e., osteotomy was done intra-articularly to correct the deformity. The study has found that the fixation construct undergoes continuous physiological shearing force in the sagittal plane during rehabilitation, as well as stress in the coronal plane, and these biplanar forces might cause the construct to fail. Multiple studies are showing different methods of fixation. Jarit et al. showed increasing stability by putting the screws in from the front to the back. However, clinically, it is difficult to put screws in that configuration. Headless compression screws were used in Hoffa's fracture, as shown by Borse et al. A study conducted by Tetsunaga et al. applied a technique of placing a buttress plate with a lateral compression plate to enhance the stable fixation of the Hoffa fracture.
In our case of neglected malunion, Hoffa fracture we used an antiglide T plate posteriorly in adjunct with cannulated screws to neutralize shearing stress as lag screws alone can offer only interfragmentary compression. Bony union at the osteotomized site was visible on radiographs, and joint flexion and knee discomfort were also improved to 125° as compared to the right knee.
Intra-articular osteotomy should be taken into consideration when treating a neglected malunited Hoffa's fracture. In addition to cannulated screws, fixation with an antiglide plate provides more rigid, stable fixation, overcomes shear stress and it shows favorable outcomes.
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