Conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture: A rare case

Adnan Anwer; Yasir Salam Siddiqui; Mazhar Abbas; Madhav Chowdhry

doi:10.4103/jbjd.jbjd_10_23

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CASE REPORTS

Year : 2023 | Volume : 38 | Issue : 1 | Page : 115-119

Conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture: A rare case

Adnan Anwer, Yasir Salam Siddiqui, Mazhar Abbas, Madhav Chowdhry
Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission	20-Feb-2023
Date of Acceptance	15-Mar-2023
Date of Web Publication	20-Apr-2023

Correspondence Address:
Madhav Chowdhry
Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_10_23

Abstract

Conjoint bicondylar Hoffa’s fracture is a rare fracture pattern with a coronal split of posterior femoral condyles with an interconnecting bridge of bone. This fracture pattern generally occurs in high-velocity road traffic accidents and is associated with injuries around distal femur, proximal tibia, patella, or extensor mechanism at the knee joint. Due to extensive associated injury patterns, definitive surgical management often varies. This is a case of conjoint bicondylar Hoffa’s fracture with associated comminuted supracondylar fracture of femur. A 40-year-old male presented to the emergency room after sustaining injury to his right knee, previously ambulating on a malunited tibia. Radiographic examination demonstrated conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture right distal femur. Open reduction and internal fixation was done using two T-plates fixed with screws. Due to malunited tibial and fibular fracture with intra-articular extension of the implant, the patient had a decreased range of motion (ROM) up to 120° preoperatively. Early physiotherapy was emphasized, and postoperatively similar ROM was achieved. Conjoint bicondylar Hoffa’s fracture is a rare fracture pattern, which can be associated with a supracondylar fracture of the femur. For this combined fracture fixation, open reduction internal fixation with two T-plates and screws offers a viable treatment option. The patient achieved complete preoperative ROM.

Keywords: Bicondylar, conjoint, coronal split, distal femur, fracture, Hoffa’s fracture, supracondylar, trauma

How to cite this article:
Anwer A, Siddiqui YS, Abbas M, Chowdhry M. Conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture: A rare case. J Bone Joint Dis 2023;38:115-9

How to cite this URL:
Anwer A, Siddiqui YS, Abbas M, Chowdhry M. Conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture: A rare case. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:115-9. Available from: http://www.jbjd.in/text.asp?2023/38/1/115/374420

Introduction

Hoffa’s fracture is a fracture of distal femur with a coronally oriented fracture line leading to a posterior split of the medial, lateral, or both condyles. Due to the natural valgus of the knee joint and direct transmission of forces, Hoffa’s fracture of the lateral condyle is more common.^[1] A conjoint bicondylar Hoffa’s fracture is a rare fracture pattern with a fracture line involving both the condyles of femur posteriorly and an interconnecting bridge of bone.^[2] Although Hoffa’s fracture commonly presents as an isolated fracture, in rare instances, it is associated with injuries around the knee joint. These include fractures involving distal femur, proximal tibia, patella, extensor mechanism rupture, patellar dislocation, and patellar tendon incarceration.^{[1],[2],[3],[4]} These injury patterns occur in high-velocity road traffic accidents, generally affecting younger population. Open reduction and internal fixation using plates and screws, along with arthroscopic-assisted reduction and fixation of this fracture pattern, can be done, depending on the presence of concomitant osseous injuries. We report a rare case of a 40-year-old male with conjoint bicondylar Hoffa’s fracture with comminuted supracondylar fracture of right femur, ambulating upon malunited fracture of both bones in right leg.

Case History

A 40-year-old male presented to the emergency department after sustaining an injury to his right knee, when the motorcycle he was riding collided with another motorcycle at high speed. He had a direct impact of his semiflexed knee with the ground. On presentation, the patient was conscious, oriented, and vitally stable. There was no history of head injury, loss of consciousness, vomiting, Ear-Nose-Throat bleed, and blunt trauma to chest or abdomen. The patient had a significant history of another road traffic accident with injury to ipsilateral leg, 2 years back. He sustained segmental fracture shaft right tibia along with fracture shaft right fibula, for which he was operated outside where three Titanium Elastic Nailing System (TENS) nails were inserted, along with encerclage wire. Due to the intra-articular extent of one of the nail, patients’ range of motion (ROM) at knee joint, before injury, was up to 120°, as alleged by the patient.

On local examination, there was diffuse swelling present over his right knee. Overlying skin on the right knee was intact. Movements of the right knee were painfully restricted. Abnormal bony mobility and tenderness were not elicited due to pain. Distal neurovascular status was intact on the right side, and the compartment was soft.

Plain radiograph of the right knee, antero–posterior and lateral view [Figure 1] revealed fracture distal end right femur with malunion fracture shaft right tibia with implant in situ (three TENS nails and one encerclage wire) with malunited fracture shaft right fibula. However, plain radiographs were insufficient to delineate the fracture pattern in its entirety. Noncontrast, computed tomography with three-dimensional reconstruction was performed, which established the diagnosis of conjoint bicondylar Hoffa’s fracture [Figure 2] and [Figure 3].

Figure 1: Plain radiolograph of right knee (antero–posterior and lateral views) showing fracture distal end right femur with malunion fracture shaft right tibia with implant in situ (three TENS nails and one encerclage wire) with malunited fracture shaft right fibula

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Figure 2: Three-dimensional reconstruction, computed tomographic scan of right knee joint showing comminuted supracondylar fracture right femur with conjoint bicondylar Hoffa’s fracture right distal femur

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Figure 3: Noncontrast computed tomographic scan of right knee joint showing conjoint fragment of bicondylar Hoffa’s fracture (coronal and axial sections)

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The patient was operated 7 days later once the swelling subsided. Operation was performed in supine position under tourniquet and spinal anesthesia. Knee joint was exposed using modified anterior approach (Swashbuckler Approach), and lateral parapatellar arthrotomy was done. Vastus lateralis was retracted laterally, and patella, along with the rest of the extensor mechanism, was retracted medially to expose both the femoral condyles adequately. On exposure, a coronal split fracture involving both posterior femoral condyles, joined together by a thin bridge of intact bone, was noted. Both the cruciate ligaments and menisci were intact. The fracture was reduced by traction, counter traction, and flexion. Medial fragment was held in a reduction position with the help of K-wire and fixed using 45-mm cannulated cancellous screws (CCS). The lateral fragment was also held in reduction using K-wires and fixed using a Herbert screw (34 mm) and CCS (50 mm). Two T-plates were applied, one medial (five hole) and another lateral (six hole), and fixed to the bone with screws [Figure 4]. Final reduction was checked under fluoroscopy. The wound was closed in layers.

Figure 4: Immediate postoperative and postoperative 8 weeks, plain radiograph of right knee (antero–posterior and lateral views) showing fixation of fracture using two T-plates, one medial (five hole) and another lateral (six hole). Three months postoperative radiograph showing hypertrophic callus formation at the fracture site. (a) Immediate postoperative. (b) At 3 months postoperatively

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ROM knee brace was applied with 30° knee flexion, and static quadricep drill was advised for 1 week. It was increased to maximum possible knee ROM subsequently along with isometric strengthening exercises. Partial weight-bearing with the help of axillary crutches was started at 2 weeks, with subsequent weight-bearing as tolerated at 3 months postoperatively after fracture union. At 3 months postoperatively, the radiograph of knee joint [Figure 4] revealed hypertrophic callus formation with knee ROM from 0° to 120° [Figure 5]. Patient was able to sit in squatting position and do all of his daily activities comfortably. Radiograph at 3 month postoperatively showed no signs of avascular necrosis, osteoarthritis, or implant failure. Consent was taken from the patient for using his data for research and publication purposes.

Figure 5: Patient capabilities at 3 months follow-up: shows full extension of the knees with patient squatting. Knee range of motion appears from 0° to 120°

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Conclusion

Hoffa’s fracture is a rare type of intra-articular fracture of distal femur, which occurs due to violent trauma. Isolated Hoffa’s fracture constitutes around 0.65% of all femoral fractures.^[5] Depending on the number of condyles involved, Hoffa’s fractures could be unicondylar (lateral or medial) or bicondylar (conjoint or nonconjoint). Due to the physiologic genu valgum of the knee joint, lateral condyle is more vulnerable to injury, and hence, lateral unicondylar Hoffa’s fractures are much more common, constituting approximately 75%–85% of all Hoffa’s fractures, followed by bicondylar (nonconjoint) and medial unicondylar.^[1],[5] A bicondylar conjoint Hoffa’s fracture is an exceedingly rare injury, with little understanding of the mechanism of injury, types of associated injuries, optimal surgical management, and prognosis of the patient.

The most common mode of injury causing Hoffa’s fracture is high-energy trauma, either road traffic accidents or a fall from height. The exact mechanism of injury causing a Hoffa’s fracture is not completely understood. When sudden breaking occurs in a hyperflexed knee (> 90° flexion), axial forces traveling downward along the femur and upward along tibia toward tibial plateau converge over posterior femoral condyles, resulting in fracture and gross displacement of the condyle(s). These forces can cause concomitant extensor mechanism injury, ligamentous injury of the knee, as well as perforation of the overlying skin, leading to an open injury. The inclination angle of the fracture line depends on the degree of knee flexion at the time of trauma. As the angle of knee flexion increases, the fracture line occurs farther from the posterior cortex of the femoral condyle. Although low-energy trauma (in skeletally immature, poliomyelitis, and osteoporotic patients)^[6] and iatrogenic injury (during anterior cruciate ligament reconstruction)^[7] have also been described in the literature as other modes of injury, their incidence is exceedingly rare. In our case, the patient had a direct impact of his semiflexed knee with the ground, when the motorcycle he was driving collided with an oncoming motorcycle from the front.

Nonoperative treatment using plaster casts can lead to nonunion, instability, joint contracture, and deformity.^[8] Open reduction and internal fixation is the treatment of choice. Due to a variety of concomitant osseous injuries associated with such fracture pattern, fixation methods are widely reported in the literature.^{[1],[2],[3],[4]} In this case, open reduction and anatomical internal fixation using two T-plates along with screws were done. In literature, arthroscopy-assisted reduction and fixation of Hoffa’s fracture have also been reported, using a minimally invasive approach.^[8],[9]

In conclusion, this case report describes a rare type of conjoint bicondylar Hoffa’s fracture with a supracondylar fracture of the femur, managed successfully via open reduction and internal fixation with two T-plates. The patient was able to achieve the preinjury status of the knee and was able to perform most of his activities of daily living. Hence, the final surgical treatment in the rare presentation of Hoffa’s fracture is dependent on concomitant osseous injury and warrants early fixation along with early mobilization of the knee joint to achieve excellent long-term outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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