Diagnosis, Management, and a new classification of Hoffa's Fracture / Bagaria classification.
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
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SYNOPSIS
• Definition
• Mechanism
• Radiology
• Management
• BAGARIA classification system for Hoffa’s Fracture
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ALBERT HOFFA
(31 March 1859 – 31 December 1907)
German Surgeon, Orthopedist and
Physiotherapist
Born in Richmond, Cape of Good Hope
Others: Remembered for introducing an
operation for congenital hip dislocation
(1890)
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Definition
Coronal fracture of the distal femur - intra articular - usually the
only attachment is the posterior capsule.
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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
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X Rays
• On AP Fore shortened Fracture 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.
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Management
• Hoffa Fracture effectively separates Patellofemoral
joint from the Tibiofemoral joint.
• Knee movements particularly weight bearing
result in high Shear forced along the fracture line,
making non operative management unpredictable
and adequate stabilization challenging.
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Principle of treatment
• Atraumatic
• Anatomical Reduction
• Secure Fixation
• Early mobilisation & Functional Activity
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Planning
• Approach
• Reduction Fixation
• Post op
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Approach
• Lateral Para pateallar
• Medial Parapatellar
• Medial Approach
• Posterior
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Steps
• Inspect the Joint
• Visualise the fracture line
• Clean it - use a spreader
• Anatomically reduce and hold
• Initiate drilling at Patellofemoral Joint.
• Perpendicular to Fracture
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Reduction
• Bone Spreader - clear
• Periosteal Elevator
• Reduction clamp
• Joystick technique
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Fixation
• At least two screws - prevent rotation and 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.
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On the Horizon
• Arthroscopically assisted surgery
• Rapid Prototyping
• Bioabsorbable Implants
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What more do we have ?
•
• Developing a new classification system:
“Bagaria Classification” for Hoffa’s Fracture
• Helps to Decide:
1. When to approach anterior and when posterior?
2. When to put screws and when to plate?
•
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Bagaria Classification
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•
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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.
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Management as per Bagaria
Classification of Hoffa Fracture
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Grade 1: Two parallel screw anterior to posterior
(countersunk or headless)
Grade 2: Two parallel screw posterior to anterior
(countersunk or headless)
Grade 3 a & b: Consider buttress plate/ parallel screws.
Grade 4: Anti glide plate
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Take Home Message
• High index suspicion
• Operative almost always
• Low tech standard technique
• AO Principle, Articular cartilage, 2 screws
