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Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARIA et al
- 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
- 3. Albert Hoffa German Surgeon 1904 Würzburg - koenig Ludwig haus Others: Hoffa’s disease, Physio Personal: Worked at the station
- 4. Definition Coronal fracture of the distal femur - intra articular - usually the only attachment is the posterior capsule.
- 6. 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
- 7. Clinical Exam Effusion ++ Varus/Valgus Instability +- maybe subtle Always check for DNVD
- 8. 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.
- 12. CT scan
- 13. 3 D Recon
- 14. 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
- 15. Principle of treatment Atraumatic Anatomical Reduction Secure Fixation Early mobilisation & Functional Activity
- 17. Approach Lateral Para pateallar Medial Parapatellar Medial Approach TTO Posterior
- 20. Medial approach
- 21. TTO
- 22. Posterior Approach When the fragment is too small to be fixed from anterior. Prone position
- 24. 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 #
- 25. Reduction Bone Spreader - clear Perisosteal Elevator Reduction clamp Joystick technique
- 27. Counter Sink & Screw placement
- 28. 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.
- 29. Fixation
- 30. Post Op X Rays
- 31. Complications Loss of Reduction Malunion Neuro vascular damage AVN?
- 33. Malunions
- 34. Special Conditions Bilateral Unilateral Bicondylar Associated Supracondylar fracture Malunited Arthritic Knees
- 35. Bicondylar
- 37. On the Horizon Arthroscopically assisted surgery Rapid Prototyping Bioabsorbable Implants
- 39. 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?
- 40. 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.
- 41. 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
- 42. Take Home Message high index suspicion Operative almost always low tech standard technique AO Principle, Articular cartilage, 2 screws