Hoffa is a difficult fracture. It requires skill in approach, choice of implant, and reduction process.

1. Hoffa fracture
DR.HTEIN LIN AUNG

2. History of Hoffa- Coronal fracture

3. Problems in Hoffa
 Uncommon
 Difficult to detect
 Problems in reduction
 Lack of acquaintance with posterior cortex comminution
 Failure to completely remove articular fragments
 Failure to maintain them in good alignment
 Fixation problems
 Implants
 Screws
 Plate placements
 Spare articular surface

4. Case summary
 25 yr, male
 MOI -RTA
 Associated injury(-)
 Medical problem (-)
 Post injury 12th day.

5. Imaging
 X-rays
 AP and lateral
 Oblique and stress view
 CT gold standard

6. X rays

7. CT

8. Classifications
 Letennur – most popular
 base on fracture line and ligament position
 Cannot guide management
 Govascar and Lewis
 Base on articular comminution and blood supply
 Bagaric
 CT based focus on fragment size
 Difficult to apply and failed to recognize posterior cortex comminution
 Chadrabose
 More focus on all aspect of fracture morphology and implant choice

9. Letennur

10. Chadrabose

11. Chadrabose recommend
 A
 PA (4-6.5) lag screw
 If poster fragment is too small
 Lower risk of displacement
 B
 Anatomical reduction and disimpaction
 C
 Main coronal ---- lag screw
 Posterolateral ---- antiglide plate.
 Lateral antiglide is superior to posterior (soft tissue stripping and vascular)

12. Approach (screw trajectory and
reduction)

13. Pires et.al , 2018 (proposed algorithm)

14. Pre-op preparation
 Position- supine
 Pre-op antibiotic
 Spinal
 C-arm
 Tourniquet
 Lateral approach in knee flexion bolster
 Small fragments (locking) set
 Large fragment (locking )set
 Cannulated screws and K- wires

15. Lateral approach and access fracture

16. Cartilage impaction in fracture line

17. Lateral Antiglide plate

18. Post-op X-ray

19. Discussion on implants
 Plate placement
 Posterior
 Lateral antiglide
 Screws
 Parallel 2 screws
 Reasonable biomedical stability
 Cross screw method
 3.5 femoral intercondylar notch
 2nd and 3rd through non articular area

20. After care
 Functional
 CPM , Quadriceps strengthening and straight leg raises
 Weight bear
 Touch down 10-15 kg with crutch or walker for 10 weeks
 Full wight bear – 12 weeks

21. Thank you
For your attention and comments.

22. Posteromedial Herderson

23. Post- op review
 OT time – one hour
 No need to transfuse
 Reduction – satisfactory
 Implants – cannulated screw 6.5 desire length shortage
 Tourniquet – not in proper function

24. Swashbuckler

25. 1. Fracture line parallel to posterior femoral cortex
2. Parallel to base of condyle / posterior to attachment of LCL (high risk for
nonunion)
3. Anterior to joint capsule, ACL, LCL

26. Approach discussion
 Think
 Fracture size
 Parapatella
 Medial fragment > 28 % of AP diameter
 Lateral > 19 %
 Determine reduction
 Fixation
 Combination approach