Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARIA et al

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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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Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARIA et al

  1. 1. Hoffa’s Fracture # Dr Vaibhav BAGARIA MBBS MS FCPS Dip SICOT Consultant Ortho Surg CARE Hospital & ORIGYN health Nagpur, INDIA www.drbagaria.com Ao Trauma 2014
  2. 2. Synopsis Definition Mechanism Radiology Management BAGARIA classification system for Hoffa’s #
  3. 3. Albert Hoffa German Surgeon 1904 Würzburg - koenig Ludwig haus Others: Hoffa’s disease, Physio Personal: Worked at the station
  4. 4. Definition Coronal fracture of the distal femur - intra articular - usually the only attachment is the posterior capsule.
  5. 5. 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
  6. 6. Clinical Exam Effusion ++ Varus/Valgus Instability +- maybe subtle Always check for DNVD
  7. 7. 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.
  8. 8. CT scan
  9. 9. 3 D Recon
  10. 10. 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
  11. 11. Principle of treatment Atraumatic Anatomical Reduction Secure Fixation Early mobilisation & Functional Activity
  12. 12. Planning Approach Reduction Fixation Post op
  13. 13. Approach Lateral Para pateallar Medial Parapatellar Medial Approach TTO Posterior
  14. 14. Medial Para patellar
  15. 15. Lateral Para patellar
  16. 16. Medial approach
  17. 17. TTO
  18. 18. Posterior Approach When the fragment is too small to be fixed from anterior. Prone position
  19. 19. Posterior Approach
  20. 20. 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 #
  21. 21. Reduction Bone Spreader - clear Perisosteal Elevator Reduction clamp Joystick technique
  22. 22. Insert Guide wires
  23. 23. Counter Sink & Screw placement
  24. 24. 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.
  25. 25. Fixation
  26. 26. Post Op X Rays
  27. 27. Complications Loss of Reduction Malunion Neuro vascular damage AVN?
  28. 28. Subsequent Redisplacement
  29. 29. Malunions
  30. 30. Special Conditions Bilateral Unilateral Bicondylar Associated Supracondylar fracture Malunited Arthritic Knees
  31. 31. Bicondylar
  32. 32. Plates as washers
  33. 33. On the Horizon Arthroscopically assisted surgery Rapid Prototyping Bioabsorbable Implants
  34. 34. 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?
  35. 35. 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.
  36. 36. 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
  37. 37. Take Home Message high index suspicion Operative almost always low tech standard technique AO Principle, Articular cartilage, 2 screws
  38. 38. Thank You www.drbagaria.com

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