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| CASE REPORTS |
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| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 81-85 |
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Bicondylar hoffa fracture: A rare variant of intra-articular fracture
Shailendra Singh1, Prakhar Mishra2, Ravindra Mohan1, Deepak Kumar1, Arpit Singh1
1 Department of Orthopedics, KGMU, Lucknow, Uttar Pradesh, India
2 Department of Orthopedics, RMLIMS, Lucknow, Uttar Pradesh, India
| Date of Submission | 17-Nov-2022 |
| Date of Acceptance | 24-Nov-2022 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Ravindra Mohan
Department of Orthopedics, 4th Floor, RALC Building, KGMU, Lucknow, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbjd.jbjd_38_22
A Shear fracture of posterior aspect of femoral condyles in coronal plane is known as Hoffa fracture. This fracture pattern, originally described by Hoffa, is an intra-articular fracture and radiologically and clinically silent most of the times and thus commonly missed. The bicondylar variant of this fracture is a rare injury. We report a case of 38-year old male patient presenting with one day old bicondylar Hoffa fracture managed with headless compression screw and cannulated cancellous screws. Keywords: Bicondylar Hoffa fracture, Intra-articular knee fractures, lateral para-patellar approach
How to cite this article:
Singh S, Mishra P, Mohan R, Kumar D, Singh A. Bicondylar hoffa fracture: A rare variant of intra-articular fracture. J Bone Joint Dis 2023;38:81-5 |
How to cite this URL:
Singh S, Mishra P, Mohan R, Kumar D, Singh A. Bicondylar hoffa fracture: A rare variant of intra-articular fracture. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:81-5. Available from: http://www.jbjd.in/text.asp?2023/38/1/81/374426 |
| Introduction | |  |
Albert Hoffa[1] in 1904 described intra-articular fracture of femoral condyles in coronal plane. Hoffa fracture is a rare fracture pattern and comprises of about 8.7% to 13% of fractures of distal end of femur.[2] Hoffa fracture is generally used for involvement of single condyle of femur. Due to physiological Genu valgum of knee joint, the lateral femoral condyle is commonly involved.[3] Hoffa fracture is mainly caused by high energy collisions like road traffic accidents, however, low energy impacts in osteoporotic bones[4] and iatrogenic[5] causes are also mentioned in the literature. The bicondylar variant of this fracture is associated with a posterior and upward directed force to the knee joint.[6] Due to its close proximity, Hoffa fracture is also associated with cruciate ligament injury. In this case report we present a bicondylar Hoffa fracture with complete anterior cruciate ligament tear.
| Case History | | |
A 38-year-old male on bicycle after being hit by a speeding motor-cycle was referred to the emergency department 24 hours after the injury. Complete ATLS protocol was followed and primary survey of the patient was within normal limits.
On examination, (L) knee of the patient showed swelling and tenderness. Movements of the (L) lower limb were grossly restricted. Patient’s vitals were stable with no injury in other limb or system.
Fluid resuscitation and parentral analgesia was administered and left lower limb was splinted over Bohler-Braun cradle with ankle traction application and plain radiographs of (L) knee with thigh and leg antero-posterior and lateral view were ordered.
Radiographs revealed displaced Letennneur III type[7] coronal plane fracture of both condyles of (L) femur, [Figure 1] following which CT scan of (L) knee, [Figure 2] was advised with 3-D reconstruction, [Figure 3]. CT scan revealed a bicondylar Hoffa fracture. Urgent routine blood investigations were sent and patient was taken under spinal anaesthesia after pre-op preparations. Lateral Para-patellar approach to distal femur was used to expose the distal femur. A rolled towel was kept under the knee to produce 20° to 30°of knee flexion. A midline incision was given extending just above tibial tuberosity to 5 cm proximal to centre of patella. Deep dissection showed preserved extensor retinaculum. A vertical incision of 8–10 centimetres was given through the lateral para-patellar retinaculum and patella was everted medially to expose the joint and fracture configuration was observed, [Figure 4]. On exploration anterior cruciate ligament was found to be torn.
Fracture was reduced and provisionally reduction maintained using k-wires. Reduction was confirmed under bi-planar fluoroscopy and final fixation of medial condyle femur was done using 6 mm partially threaded cannulated screws from anterior to posterior direction under C-arm visualisation and heads were countersunk. Similarly lateral condyle was fixed using headless screws. An additional 6 mm cannulated screw was used to fix lateral condyle of femur, [Figure 5]. Intra-operative range of motion was found to be 0–100°.Thorough wash was given and layer-wise closure was done.
Post operatively leg was immobilised in a range of motion knee brace. Range of motion exercises from 0–30° were initiated from third post op day onwards on the hinged knee brace. Patient was kept non weight bearing for 6 weeks following with partial weight bearing for next 6weeks. At 3-month follow–up, radiographs showed satisfactory union, [Figure 6] patient was pain free, the wound healed uneventfully and patient had a knee range of motion of 0–60 °, [Figure 7]. CPM exercises were started and gradually patient achieved 0–100° painless range of motion on 6-month follow up [Figure 8].
| Discussion | | |
Coronal plane fracture of femoral condyles was first described by Albert Hoffa in 1904. Fracture presents in various morphologies like unicondlar, bicondylar or conjoint bicondylar variants.
High speed injuries like road traffic accidents fall from height account for most of the cases of Hoffa fracture. However low-energy impacts may also cause similar fracture pattern in children and osteoporotic bones. Iatrogenic injuries in femoral tunnel formation during arthroscopic anterior cruciate ligament reconstruction have also been reported in literature.[5]
Several mechanisms of injury have been described earlier. Shearing forces on femoral condyle causing both vertical and twisting impact are commonly associated with Hoffa fracture. These forces commonly disrupt the extensor mechanism as well as the cruciate ligaments of the knee. Lateral condyle is commonly involved due to physiological genu-valgum of knee.
Fracture is classified on the basis of classification given by Letenneur et al[7] as type I (Fracture line is vertical and parallel to the posterior cortex of femur and involves the entire condyle), Type II (fracture line located at attachment of anterior cruciate ligament and lateral collateral ligament) and Type III (Oblique fracture with fracture line located anterior to the joint capsule, anterior cruciate ligament, lateral collateral ligament, popliteal tendon and lateral head of gastrocnemius muscle). In AO classification, fracture is classified as Type B3.2 (Hoffa fracture) and B3.3 (Bicondylar Hoffa).
Hoffa fracture is an intra-articular fracture and surgical stabilization is required to achieve required stable anatomic configuration and function of knee joint. Closed reductions with casting and arthroscopic techniques have also been employed to achieve the same results. Several surgical approaches have been advocated for adequate exposure of both condyles. We used lateral para-patellar approach for this case. Using a single approach prevents breach of extensor mechanism, lesser fibrosis and early range of motion. Arthroscopic assisted fixation of Hoffa fracture are also mentioned in literature,[8] which may be useful in minimally comminuted fractures with large fragments. Arthroscopic assisted fixation provides additional advantage of minimal soft-tissue dissection, early mobilisation and less blood loss.
List of Abbreviations
Nil.
Acknowledgements
Nil.
Contribution Details
Ravindra Mohan: Conceptualisation, methodology, Shailendra Singh: Planning, Follow up, Deepak Kumar: Visalisation, Writing- reviewing, Arpit Singh: Software, Validation, Prakhar Mishra: writing- original draft, data curation.
Patient declaration of consent statement: The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
Nil.
| References | | |
| 1. | Hoffa A Text-book of Fractures and Dislocations for Physicians and Students. F. Enke; 1904. 614 p.  |
| 2. | Gavaskar AS, Tummala NC, Krishnamurthy M Operative management of hoffa fractures–a prospective review of 18 patients. Injury 2011;42:1495-8. |
| 3. | Jain A, Aggarwal P, Pankaj A Concomitant ipsilateral proximal tibia and femoral hoffa fractures. Acta Orthop Traumatol Turc 2014;48:383-7. |
| 4. | Mootha AK, Majety P, Kumar V Undiagnosed hoffa fracture of medial femoral condyle presenting as chronic pain in a post-polio limb. Chin J Traumatol 2014;17:180-2. |
| 5. | Werner BC, Miller MD Intraoperative hoffa fracture during primary ACL reconstruction: Can hamstring graft and tunnel diameter be too large? Arthroscopy 2014;30:645-50. |
| 6. | Ul Haq R, Modi P, Dhammi I, Jain AK, Mishra P Conjoint bicondylar hoffa fracture in an adult. Indian J Orthop 2013;47: 302-6. |
| 7. | Letenneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV [Hoffa’s fractures. Report of 20 cases (author’s transl)]. Ann Chir 1978;32:213-9. |
| 8. | Wallenböck F, Ledinski C [Indications and limits of arthroscopic management of intra-articular fractures of the knee joint]. Aktuelle Traumatol 1993;23:97-101. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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