ORIGINAL ARTICLE

A new fixation method for Hoffa fracture

Y. Xu • H. Li • H.-H. Yang

Received: 31 October 2011 / Accepted: 27 October 2012 / Published online: 12 November 2012

� Springer-Verlag Berlin Heidelberg 2012

Abstract

Purpose To investigate the clinical effect of a new fixa-

tion method for Hoffa fractures.

Methods We treated eleven patients with Hoffa fracture

using the new fixation method (fixation with one screw

inserted from the femoral intercondylar notch and two

screws inserted from the nonarticular lateral (or medial)

surface of the fractured condylar fragment; the two sets of

screws were crossed).

Results After an average follow-up period of 24 months

(range 5–28 months), all fractures had healed. The average

healing time was 11.6 weeks (range 9–14 weeks). On the

version of the Knee Society Score modified by Dr. John

Insall in 1993, the average score was 174.6 points (range

125–199 points).

Conclusions The new fixation method for Hoffa fracture

is effective, and may provide a new way to treat Hoffa

fractures.

Keywords Hoffa fracture � Femoral intercondylar notch �Internal fixation � Open reduction

Introduction

Hoffa fractures are intraarticular fractures that are classi-

fied as type 33-B3 fractures by the Orthopaedic Trauma

Association. Most of them need surgical treatment to

achieve a good outcome. Traditional methods of fixation for

Hoffa fractures have resulted in either complex constructs, in

order to achieve stability, or in large articular surface defects

that are created while countersinking lag screws. Both have

negative implications for the patient [1]. We have treated

eleven patients with Hoffa fracture using a new fixation

method. In this novel technique, the fracture is fixed with

three screws: one screw is inserted from the femoral interc-

ondylar notch, and the other two screws are inserted from the

nonarticular lateral (or medial) surface of the fractured

condylar fragment. The two sets of screws are crossed so that

both sides of the fracture lines are completely compressed,

meaning that the fixation is more stable. This method only

damages the articular cartilage in non-weight-bearing

regions, thus decreasing the risk of osteoarthritis.

Patients and methods

From April 2004 to July 2009, we treated eleven fractures in

eleven patients using the new fixation method. There were

nine males and two females aged from 23 to 48 years

(average 37.3 years). Seven fractures were lateral and four

were medial. In all patients, the mechanism of injury was a

motor vehicle accident. According to the Letenneur clas-

sification [2], seven fractures were type I, one was type II,

and three were type III. Preoperative X-rays and MR images

of one of the eleven cases are shown in Figs. 1 and 2.

Surgical technique for the new method

Under general anesthesia with full muscle relaxation, the

patient lies supine with the affected limb exsanguinated

Y. Xu � H. Li � H.-H. Yang (&)

Department of Orthopaedics, The First Affiliated

Hospital of Huzhou Teachers College,

Huzhou 313000, Zhejiang, China

e-mail: 13857290270@163.com

Y. Xu

e-mail: xuyi0806@163.com

123

Eur J Trauma Emerg Surg (2013) 39:87–91

DOI 10.1007/s00068-012-0238-2

and supported on a thigh bolster. A standard anterolateral

(or anteromedial) incision with lateral (or medial) parapa-

tellar release and medial (or lateral) dislocation of the

patella allows direct access to the articular aspect of the

fracture. With full flexion of the knee, the fragment is

reduced and fixed preliminarily with two Kirschner wires.

The fracture is fixed with three cancellous screws. One

screw (3.5 mm or 4.5 mm) is inserted from the femoral

intercondylar notch (Figs. 3, 4) and threads through the

fractured condylar fragment. The tip of the screw points

anterolaterally (or anteromedially). The positioning of the

screws for each fracture type is shown in Fig. 5. To

facilitate screw removal when the fracture is healed, the

screw head is not countersunk. The other two screws

(6.5 mm) are inserted from the nonarticular lateral (or

medial) surface of the fractured condylar fragment (Fig. 3),

and are directed medially (or laterally) to thread through

the fracture lines. The tips of the screws reach the opposite

femoral condyle. The two sets of screws are crossed. In

order to obtain sufficient stability, the intercondylar screw

thread must extend beyond the fracture lines by more than

1 cm but must not penetrate the opposite articular cartilage

Fig. 1 Anteroposterior and

lateral radiographs show a

Hoffa fracture of the lateral

femoral condyle

Fig. 2 Coronal and sagittal

plane MRI of the knee clearly

shows a coronal fracture of the

lateral femoral condyle

88 Y. Xu et al.

123

or cortex. The soft tissue elements attached to the fractured

condylar fragment are not stripped off to avoid damaging

the blood supply to the fragment.

Postoperatively, all patients immediately begin to

exercise with no restriction on the range of motion.

Although the initial weight-bearing status is limited, all

patients are allowed full weight-bearing within

three months.

Results

After an average follow-up period of 24 months (range

15–28 months), all of the fractures healed both clinically

and radiologically, without deep infection, delayed union,

nonunion, malunion, osteonecrosis, or hardware removal.

The fracture healing time was 9–14 weeks (average:

11.6 weeks). Based on the version of the Knee Society

Score modified by Dr. John Insall in 1993, the average

score was 174.6 points (Table 1).

Discussion

Coronal fractures of the femoral condyle are rare and were

first described by Hoffa in 1904. A Hoffa fracture is an

unstable intraarticular fracture, so accurate anatomic

reduction and stable fixation are extremely important to

allow early postoperative knee motion and reduce potential

complications. In traditional methods of fracture fixation,

the fracture is fixed with multiple screws using complex

constructs in an attempt to achieve stability, but this is

difficult to achieve. In order to expose and fix the fracture

fragment, the soft tissue elements attached to the fractured

condylar fragment are stripped off such that the blood

supply to the fragment [3] is damaged, which may result in

nonunion or osteonecrosis. The new fixation method

described in the present work uses only three screws. The

soft tissue elements are not stripped, thus maintaining the

blood supply to the fragment, which is helpful for fracture

healing. Countersunk head lag screws create large articular

surface defects and increase the risk of osteoarthritis. The

new fixation method produces only small articular surface

defects on the femoral intercondylar notch, and does not

damage the functional articular surface (such as the

Fig. 3 Anteroposterior and

lateral radiographs show a

fracture that has been fixed with

three screws; one screw was

inserted from the femoral

intercondylar notch

Fig. 4 The screw (arrow) is inserted from the femoral intercondylar

notch

A new fixation method for Hoffa fracture 89

123

articular surface of the patellofemoral joint and the tibio-

femoral joint), so it rarely affects knee function and

decreases the risk of osteoarthritis.

In our opinion, the positioning of the screws depends on

the fracture type and the fracture lines. In Letenneur type I

Hoffa fractures, the entry site for the intercondylar screw is

very close to the site of ACL (anterior cruciate ligament)

insertion, so cruciate functioning could be affected.

Therefore, we believe that it is important to remove the

screws when the fracture is healed. In Letenneur type II

Hoffa fractures, the area of the fracture fragment in the

intercondylar notch must be large enough to allow screw

insertion; otherwise, the screw head may be too near the

weight-bearing area of the articular cartilage and affect

knee function. If necessary, the screw head should be

countersunk. The other two screws are near the posterior of

the femoral condyle and may injure the collateral ligament.

More soft tissue elements are stripped off, such that the

blood supply to the fragment may be damaged, which may

be a disadvantage for fracture healing. We therefor believe

that a posterior approach and countersunk head lag screws

may be a better choice. In Letenneur type III Hoffa frac-

tures, the condylar fragment is big enough to insert an

intercondylar screw. The entry site for the screw is neither

close to the ACL insertion site nor near an area of weight-

bearing articular cartilage. We therefore believe that this

new method is more suited to Letenneur type III Hoffa

fractures.

A biomechanical study designed by Friedman et al. [4]

showed that the crossed screw technique is more rigid than

the parallel screw technique, especially in relation to

resisting torsional stresses. In our new fixation method, the

screws are crossed, which enhances stabilization.

Becker et al. [5] performed a cadaveric study in which

the stiffnesses and loads to failure were compared among

3.5 mm cortical lag screws, 4.5 mm cortical lag screws,

and 6.5 mm cancellous screws that were used to fix

experimentally created Hoffa fractures. There was no dif-

ference in stiffness between any of the groups, but the load

to failure was significantly higher for 6.5 mm screws than

Fig. 5 The positioning of the

screws in each Letenneur

fracture type

Table 1 Information and results for eleven patients

Case Sex Age

(years)

Lateral or

medial

Type Results

Fracture healing time

(weeks)

Objective score

(points)

Functional score

(points)

Total score

(points)

1 F 36 Lateral I 9 76 80 156

2 M 48 Medial I 11 88 100 188

3 M 27 Lateral I 11 99 100 199

4 M 42 Lateral I 14 95 90 185

5 M 32 Medial III 10 88 90 178

6 M 46 Lateral III 12 65 60 125

7 M 23 Lateral I 12 94 100 194

8 M 40 Lateral III 11 90 90 180

9 F 42 Medial II 14 86 80 166

10 M 29 Medial I 13 90 90 180

11 M 45 Lateral I 11 89 80 169

90 Y. Xu et al.

123

for 3.5 mm screws. In our study, the screw inserted from

the femoral intercondylar notch was a 3.5 mm or 4.5 mm

screw, in order to decrease articular cartilage defects.

However, the other two screws were 6.5 mm screws that

can bear more of the load.

Jarit et al. [6] reported that lag screws placed posterior to

anterior provided more stable fixation of Hoffa fractures in

embalmed femurs than anteroposteriorly placed lag screws.

However, this technique requires that the screw heads are

recessed beneath the articular surface, and produces a large

articular surface defect. In our new method, the screw

inserted from the femoral intercondylar notch is placed

posterior to anterior, but the other two screws are placed in

a lateral to medial direction, which is not perfect. However,

our new method does not damage the articular surface, so

we recommend it.

Borse et al. [1] reported that they treated a case of Hoffa

fracture by open reduction and internal fixation with

headless compression screws. This method placed two

screws in a posterior to anterior direction. This provides

more stable fixation, allows for a minimally invasive

approach, and reduces the chance of damage to the artic-

ular surface. However, this method has not been described

anywhere else in the literature. Because of this, the feasi-

bility of this method must be studied further clinically. Our

new method does not damage the functional articular

surface, and the fixation is stable, so we believe that our

new method is effective.

McCarthy and Parker [7] presented a case report

describing an alternative treatment method: arthroscopic

reduction and internal fixation of a displaced, malrotated

intraarticular lateral femoral condyle fracture of the knee.

The potential benefits included decreased blood loss,

shortened operative time, excellent intraarticular visuali-

zation, decreased soft tissue dissection, and shortened

postoperative recovery. However, the arthroscopic reduc-

tion associated with this method requires a highly skilled

surgeon, and so has only seldomly been reported. On the

other hand, our new fixation method is easy to learn and

requires less equipment, so we expect this novel technique

to be a more popular option.

Michael et al. [8] reported that they treated Hoffa frac-

tures using a posterior approach. Because of the complex

popliteal anatomy involved, this approach was not com-

monly used. In our study, open reduction for Letenneur

type II Hoffa fractures was difficult. We therefore believe

that the posterior approach may be more well suited to

Letenneur type II Hoffa fractures.

However, the results of our study do not allow us to

draw any solid conclusion about the stability of the new

method in comparison to the traditional methods, so further

mechanical and clinical studies are needed. Also, long-term

follow-up is needed to compare the risk of osteoarthritis

among these methods.

In conclusion, we believe that our new fixation method

for Hoffa fracture is effective and may provide a new way

to treat Hoffa fractures.

Conflict of interest None.

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