hoffa's fracture: diagnosis, management & new classification system by bagaria et al
DESCRIPTION
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.TRANSCRIPT
Hoffa’s Fracture #
Dr Vaibhav BAGARIAMBBS MS FCPS Dip SICOTConsultant Ortho Surg
CARE Hospital & ORIGYN healthNagpur, INDIA
www.drbagaria.com
Ao Trauma 2014
Synopsis
Definition
Mechanism
Radiology
Management
BAGARIA classification system for Hoffa’s #
Albert Hoffa
German Surgeon
1904
Würzburg - koenig Ludwig haus
Others: Hoffa’s disease, Physio
Personal: Worked at the station
Definition
Coronal fracture of the distal femur - intra articular - usually the only attachment is the posterior capsule.
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
Clinical Exam
Effusion ++
Varus/Valgus Instability +- maybe subtle
Always check for DNVD
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.
CT scan
3 D Recon
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
Principle of treatment
Atraumatic
Anatomical Reduction
Secure Fixation
Early mobilisation & Functional Activity
Planning
Approach
Reduction
Fixation
Post op
Approach
Lateral Para pateallar
Medial Parapatellar
Medial Approach
TTO
Posterior
Medial Para patellar
Lateral Para patellar
Medial approach
TTO
Posterior Approach
When the fragment is too small to be fixed from anterior.
Prone position
Posterior Approach
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 #
Reduction
Bone Spreader - clear
Perisosteal Elevator
Reduction clamp
Joystick technique
Insert Guide wires
Counter Sink & Screw placement
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.
Fixation
Post Op X Rays
Complications
Loss of Reduction
Malunion
Neuro vascular damage
AVN?
Subsequent Redisplacement
Malunions
Special Conditions
Bilateral
Unilateral Bicondylar
Associated Supracondylar fracture
Malunited
Arthritic Knees
Bicondylar
Plates as washers
On the Horizon
Arthroscopically assisted surgery
Rapid Prototyping
Bioabsorbable Implants
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?
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.
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
Take Home Message
high index suspicion
Operative almost always
low tech standard technique
AO Principle, Articular cartilage, 2 screws
Thank You
www.drbagaria.com