Injury, Int. J.

Care Injured 49 (2018) 2302–2311

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

How to determine the surgical approach in Hoffa fractures?

Wich Orapiriyakula,b , Theerachai Apivatthakakula,c,* , Thanawat Buranaphatthanaa
a
Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
b
Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
c
Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Thailand

A R T I C L E I N F O A B S T R A C T

Surgical approach selection and fixation of Hoffa fractures is difficult and remains controversial. Evolving
trends emphasize the importance of fracture morphology, fracture location, and comminution, all of
which guide decisions regarding surgical approach and implant selection. This focused review highlights
factors affecting Hoffa fracture available surgical approaches, treatment outcomes, and recommenda-
tions for selecting an optimal approach.
© 2018 Elsevier Ltd. All rights reserved.

Introduction
The Hoffa fracture was first described by Albert Hoffa in 1904 who
defined it as a unicondylar intra-articular fracture in the coronal plane
[1]. This type of fracture is both rare and often overlooked in
conventional radiographs. Hoffa fractures occur more frequently in the
lateral than the medial condyle in a ratio of approximately 2:1 [2].
Previous reports have shown that non-operative treatment can result
further displacement, malunion, and a higher incidence of poor clinical
outcomes [3,4]. For that reason, surgical fixation is the gold standard
treatment. Recently, Xie et al. proposed a system of three-dimensional
Hoffa fracture mapping which illustrates fracture characteristics and
the comminution zone of the femoral condyle. This system of fracture
mapping of Hoffa fracture morphology guides surgeons toward the
most appropriate surgical approach and achieving stable internal
fixation [2]. The four goals of Hoffa fracture treatment consist of
anatomical reduction of the articular surface, preservation of the blood
supply through the use of minimally invasive approaches, stable
internal fixation, and early knee mobilization. In the case of large Hoffa
fragments, surgical treatment is done using the parapatellar approach
(PPA); however, in cases with small fragments that approach becomes
more complex, especially when complicated bycomminution. In cases
with a large Hoffa fragment, fracture reduction and fixation with
anterior to posterior screws through PPA is the most popular technique
[5,6], but some small Hoffa fragments (Letenneur type II) cannot be
visualized using this approach [7]. Thus, proper surgical approach is
* Corresponding author at: Department of Orthopaedics, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand.
E-mail addresses: wich.orapir@gmail.com (W. Orapiriyakul),
tapivath@gmail.com (T. Apivatthakakul), oak.thanawat@gmail.com
(T. Buranaphatthana).
important for achieving the best screw trajectory. Poor surgical
reduction and fixation can lead to unsatisfactory outcomes such as
malreduction which can cause early osteoarthritis and knee stiffness
[8]. Various fixation techniques such as screws (either anterior to
posterior (A–P) or posterior to anterior (P-A) and plating are
commonly used while the specific indications remain unclear.
Additionally, screw length and trajectory can affect fixation stability.
All of these factors have to be comprehensively considered when
dealing with this type of fracture.
Presently, the minimally invasive surgical approach with
combined incisions for articular fracture treatment, e.g., tibial
plateau and pilon fracture, is gaining popularity. This emerging
trend is also applicable to Hoffa fractures. In some difficult cases, a
Hoffa fracture could be reduced using one approach, but would
require a different approach for fixation due to the limited surgical
approach area. More complete understanding of available surgical
approaches in the armamentarium related to the distal femur
would assist surgeons in determining the proper surgical
treatment of this difficult fracture.
Letenneur classification
To understand the configuration, size, and location of the fracture,
in 1978 Letenneur proposed a classification system for Hoffa
fractures which defined different types of coronal fractures of the
femoral condyle and introduced the concept of avascular necrosis
prediction [3,4]. A type I fracture line is parallel to the posterior
femoral cortex and involves the entire posterior condyle. A type II
fracture occurs in the area behind and parallel to the posterior
femoral cortex line. Type II fractures are subdivided into A, B and C by
fragment size as a percentage of condyle diameter (A = 75%, B = 50%
and C = 25%). A type III oblique fracture of the posterior femoral
condyle is shown in Fig. 1. The Letenneur classification is not

https://doi.org/10.1016/j.injury.2018.11.034
0020-1383/© 2018 Elsevier Ltd. All rights reserved.
 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311
Fig. 1. Letenneur classifications. Type I: Fracture line parallel to the posterior femoral cortex involving the entire posterior condyle. Type II: Fracture in the area behind a line
parallel to the posterior femoral cortex. Subclassified into A–C by fragment size (A = 75%, B = 50% and C = 25%). Type III: Oblique fracture of the posterior femoral condyle.
designed to determine the surgical approach and fixation treatment,
but rather provides an advantage by describing the anatomical
relationship between the fragment and the surrounding structures.
From a surgical perspective, type I and III fractures can be treated via
PPA. However, small fragments in some type II fractures cannot be
visualized and thus cannot be fixed through PPA. A further
subclassification of fragment size in Letenneur type II fractures
could potentially aid in surgical approach selection.
Factors related to Hoffa fracture treatment outcomes
Blood supply
Letenneur et al. and Bel et al. reported an incidence of avascular
necrosis in small Hoffa fractures of approximately 2% which was
significantly associated with the posterior approach [4,9]. Better
understanding of the vascular anatomy surrounding the distal
femoral condyle could potentially minimize further vascular
disruption of the fragment and thus improve treatment strategy
selection. The main extraosseous blood vessels are comprised of the
superior medial genicular artery (SMGA) and the descending
genicular artery (DGA) of the medial condyle as well as the superior
lateral genicular artery (SLGA) and the inferior lateral genicular
artery (ILGA) of the lateral condyle. These vessels provide nutrients
and osteoarticular perforating branches to the condylar aspect and
intraosseously arcade within the bone (Fig. 2A, C). Lewis et al.
showed that the soft tissue surrounding large Hoffa fragments
(Letenneur types I and III) remains intact, while the small Hoffa
fragments (type II) represent a complete intraarticular fracture
without surrounding soft tissue. The fracture plane of a small
fragment possibly disrupts the intraosseous blood supply located
posteriorly to the nutrient arteries [3] (Fig. 2B, D). Onay et al.
reported that results of treatment of lateral Hoffa fractures are
better than those of medial Hoffa fractures [8]. This might be
because the blood supply of the lateral condyle is better than that of
the medial condyle as reported in previous studies. The intraosseous
blood supply in the lateral condyle contributes multiple branches to
the subchondral bone, while the medial condyle is supplied mainly
by a single vessel at the middle third area of the condyle [10].
Recently, buttressing plate fixation has been used as an option for
Hoffa fragment fixation and has resulted in successful treatment
outcomes, especially in fractures with a metaphyseal extension [11–
13]. Technically, that process involves placing the plate posteriorly,
posteromedially (medial Hoffa fractures), or posterolaterally
(lateral Hoffa fractures), a procedure which involves risk of injury
to the extraosseous blood supply. It thus requires meticulous
surgical dissection to protect these vessels [10,14–16].
Fracture characteristics
It is usually difficult to determine the actual fracture
configuration from plain radiographs in AP and lateral view. At
present, CT scans with 2D and 3D reconstruction are the gold
standard for investigation of Hoffa fractures. Scans can be used to
2303
identify the size of the fracture, the fracture plane, and
comminution, three characteristics which are crucial for surgical
treatment planning.
Fracture size
Fracture size is a keystone of surgical treatment strategy. Large
Hoffa fractures (Letenneur I and III) can be fixed by various patterns
of A–P screws [5,17], P-A screws [18,19], or cross screws through
PPA [20]. The A–P screw trajectory avoids cartilaginous damage on
the weight-bearing surface area of the posterior condyle from the
screw head countersinks. In a large fragment, the screw achieves
purchase in cancellous bone over a long distance, producing high
pullout force and high interfragmentary compression. Fixation of
small Hoffa fragments with A–P screws engaging a thin
subchondral Hoffa fragment involves risks of excessive screw
length resulting in less stability and articular penetration. In small
Hoffa fragments (<28% of the AP diameter of the medial condylar
width and <20% of the of the lateral condyle), fracture visibility can
be limited with PPA, resulting subsequently in poor fracture
reduction and fixation due to obstruction by surrounding
structures. It is recommended that P-A screws be used with
posterior approaches e.g., the direct medial approach (DMA), the
direct lateral approach (DLA), and the posterolateral approach
(PLA) [7].
Fracture plane
A screw trajectory which is perpendicular to fracture plane
provides the best mechanical advantage [21]. However, the
Letenneur classification defines fractures based on a single
dimension in the lateral view. The result can be that some
dimensions of the fracture plane, especially in axial view, are
overlooked. Considering the lateral view together with the axial
view, using 3D-CT reconstruction images can help surgeons choose
the proper surgical approach and determine the best screw
trajectory. Xie et al. described the Hoffa fracture plane in two
dimensions. In the lateral condyle, the sagittal fracture line runs in
an anteroinferior to posterosuperior direction and exits at the
posterior aspect of the distal metaphysis. The axial fracture line
commonly extends from anterolateral to posteromedial. In the
medial condyle, sagittal fracture lines run from anteroinferior to
posterosuperior while axial fracture lines go from anteromedial to
posterolateral [2]. In a large Hoffa fragment, these oblique fracture
lines allow A–P screw fixation perpendicular to the fracture plane
via PPA. A–P screw fixation of large fragments can help avoid
cartilage damage on weight-bearing articular surfaces, but some
damage is unavoidable in small Hoffa fragments requiring P-A
screws through DMA, DLA or PLA.
Fracture comminution
Hoffa fractures with comminution are more common in the
lateral condyle. Dealing with this type of complex fracture requires
greater awareness of surgical approach limitations to help prevent
poor treatment outcomes such as malunion and knee stiffness
[2,22,23]. Anatomical reduction of this type of fracture may require
2304 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311

Fig. 2. Extra/intraosseous blood supplies. a, c Extraosseous blood supply showing DGA, SMGA, and SLGA branches from the popliteal artery supplying the medial and lateral
condyle. Aggressive soft tissue dissection at posterior or posteromedial/lateral area (yellow rectangle) for buttress plate can potentially disturb the blood supply. b, d
Intraosseous blood supply. Small Hoffa fragment (yellow highlight) is vulnerable to avascular necrosis. DGA - descending genicular artery; DGAP - descending genicular artery
perforator; SMGA - superior medial genicular artery; SLGA - Superior lateral genicular artery; DAB - deep articular branch; SPB - superficial patellar branch; NA - Nutrient
artery; OA - osteoarticular.

combined approaches to access the bone approximation in
different views as well as to achieve the proper screw trajectory
to secure the fragment.
Surgeons
The optimal surgical approach and proper implant selection is
determined and can be controlled by the surgeons.
Surgical approach
Surgical approaches for Hoffa fracture treatment include those
for anterior groups, e.g., PPA, medial subvastus approach, and those
for posterior groups, e.g., DMA, DLA and PLA. PPA, previously
named the anteromedial or anterolateral approach, is the most
commonly used approach, while the medial subvastus approach
(MSVA) is used in isolated medial condyle fractures. As noted
above, some small Hoffa fragments cannot be visualized by PPA or
MSVA. In those cases, the posterior approach plays an important
role in fracture reduction and fixation. Details of surgical
approaches for Hoffa fracture treatment are described in the
following section.
Types of fixation
Screw fixation. Screw diameter and the number of screws used for
fixation is directly related to fixation stability. Hak et al.
demonstrated that fixation with two screws is better than with
one screw. Fixation with two 6.5 mm partially threaded cancellous
screws provides better mechanical advantage than two 3.5 mm
fully threaded cortical screws [24]. Additionally, the screw
trajectory and the threaded length that gains purchase in
cancellous bone are also important factors in determining
fixation stability [25,26]. The concept of Hoffa fracture
treatment, especially small Hoffa fragments, is comparable to
that of a scaphoid fracture. Both Hoffa and scaphoid fragments are
covered by a cartilaginous surface and both require an intraosseous
blood supply to promote fracture healing. Fixation with fewer but
effectively placed screws can help preserve the articular surface
while at the same time gaining the best possible mechanical
advantage. An excess number of fixation screws decreases the area
for bone to bone healing and also has a deleterious effect on the
articular surface. The ideal screw fixation strategy is to use two to
three long screws which gain purchase in the Hoffa fragment and
which are perpendicular to the fracture plane [21] with screw
heads countersunk under the cartilage.
Plate fixation. Plate fixation intended to produce a buttress or anti
gliding function (posterior placement) or to neutralize a deforming
force (medial or lateral placement) are not commonly used with
Hoffa fractures. That type of plate fixation is indicated in fractures
where there is proximal extension of the metaphysis. Sun et al.
recently demonstrated that the combination of plate fixation and
screws in Letenneur type I fractures provides greater mechanical
stability than the screw fixation system alone and that P-A screw
fixation is more stable than A–P screw fixation [27]. Trikha et al.
proposed a plate-screw application that can be used to improve
fixation stability in some specific cases such as comminuted Hoffa
fractures and osteoporosis [22]. Disadvantages of plating include
 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311
the difficulty of plate contouring, the requirement for extensive
dissection, and the increased risk of blood supply disturbance.
Thus, fracture characteristics can guide selection of surgical
approach and fixation technique. Surgical procedures must be
performed gently to reduce the risk of disruption of the blood
supply to the Hoffa fragment. The relationship of three major
factors is illustrated in Fig. 3.
Surgical approaches for Hoffa fractures
Parapatellar approach (PPA). PPA is a useful approach for the
treatment of intraarticular distal femoral fractures that most
surgeons are familiar with. PPA can be done on the lateral or medial
side of the patella and is indicated for large Hoffa fragments
(Letenneur type I and III). The approach is done in the supine
position with slight knee flexion using a bolster. An incision is
started from the tibial tubercle, curved medially or laterally, and
extended proximally to 2.5 cm above the superior pole of the
patella. A medial or lateral arthrotomy is made from the proximal
part through the vastus muscle, extended distally to the
retinaculum, ending at the tibial tubercle. The patella is pushed
either laterally or medially and 120 degrees of knee flexion is used
to expose the femoral condyle (Fig. 4A). PPA allows articular
visualization and A–P screw fixation when the Hoffa fragment size
is more than 28.7% of the AP diameter of the medial condyle or
19.9% of the lateral condyle [7]. In Hoffa fractures with a concurrent
distal femoral fracture, a single incision through the lateral PPA can
be used to fix both the Hoffa fragment and the distal femur.
Medial subvastus approach (MSVA). MSVA is indicated in medial
Hoffa fractures with metaphyseal extension requiring a buttress
plate at the apex of the posteromedial spike. A skin incision is
started at the adductor tubercle and extended proximally just
posterior to the vastus medialis. The interval between the vastus
medialis and the sartorius is identified and an anterior elevation of
the vastus medialis is then performed to expose the medial femoral
condyle. A medial arthrotomy is used to directly visualize the
articular surface. To expose the posteromedial spike, the adductor
magnus intermuscular septum has to be detached from the bone.
Dissection must be performed with meticulous care to avoid
iatrogenic injury of the popliteal vessels which lie behind this
Fig. 3. Factors related to successful Hoffa fracture treatment. Fracture characteristics, especially fracture size, determine surgical approach and fixation technique. The proper
surgical approach provides satisfactory outcomes. Surgical treatment should be performed with minimal extra- and intraosseous blood vessel disturbance.
2305
septum (Fig. 4B and VDO 1). Viskontas et al. proposed an extensile
medial approach plus strategic knee positioning which allows
access to both the anterior and posterior aspects of the medial
condyle through anterior and posterior arthrotomy. With that
approach, two surgical windows are opened anterior and posterior
to the superficial medial collateral ligament [28]. This approach is a
combination of MSVA and DMA which provides greater
visualization and can be used with a comminuted fracture. It
does, however, require a larger skin incision with extensive
surgical dissection.
Direct medial approach (DMA). DMA is suitable for addressing the
posterior and partially posteromedial aspect of the medial condyle.
There are a few variations of using the intermuscular plane to
access the medial condyle. Gao et al. accessed the medial condyle
through the intermuscular plane between the gracilis and
semimembranosus [29]. Orapiriyakul et al. proposed a medial
approach using a simple technique to expose the posteromedial
aspect of the medial condyle with minimal dissection. That
technique is performed in the supine position with slight knee
flexion and external rotation of the hip. A 10 cm incision is started
at the adductor tubercle (8 cm proximal to the joint level), and
extended distally along the proximal tibia (2 cm distal to the joint
level). The medial collateral ligament is identified and protected. A
longitudinal capsulotomy is then performed along the posterior
border of the medial collateral ligament to expose the posterior
part of the medial femoral condyle. Knee manipulation in flexion
and extension can enhance surgical visibility of the posterior part
of the medial condyle for direct P-A screw fixation perpendicular
to the fracture plane [7] (Fig. 4C and VDO 2).
Direct lateral approach (DLA). DLA is indicated in lateral Hoffa
fractures with comminution in the middle part or in the
metaphyseal extension. It can be used for reduction and fixation
with A–P screws or a buttress plate [22]. Lewis et al. and Shi et al.
reported the use of DLA with small Hoffa fragments of the lateral
condyle through the intermuscular plane between the iliotibial
band and the bicep femoris with deep dissection through the plane
between the lateral head of the gastrocnemius and the lateral
collateral ligament (LCL) [3,11]. The articular surface is approached
2306 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311

Fig. 4. Visible area related to surgical approach. A - Lateral parapatellar approach; B - Medial subvastus approach; C - Direct medial approach; D - Direct lateral approach;
E - Posterolateral approach. (M = medial, L = lateral, P = posterior, D = distal, MCL = medial collateral ligament, LCL = lateral collateral ligament).

through windows which are anterior and posterior to LCL.
Anatomically, this approach needs an elevation or a partial
incision of the iliotibial band which can increase the risk of
extraosseous blood vessel injury, in particular the SLGA. Therefore,
surgical dissection must be performed with caution (Fig. 4D).
Posterolateral approach (PLA). PLA is indicated for small lateral
Hoffa fractures which are less than 19.9% of the AP diameter of the
lateral condyle [7]. Simple and direct accesses to the posterior
aspect of the lateral condyle is gained through a single posterior
skin incision. Previously, Tan et al. proposed a technique to access
small Hoffa fragments located at the posterolateral aspect of the
lateral condyle via a modified posterolateral approach between the
biceps and the common peroneal nerve (CPN), but they did not
indicate the precise intermuscular plane [30]. Pires et al. described
a posterolateral approach between the CPN and the lateral head of
the gastrocnemius to fix Letenneur type II fragments [31].
Orapiriyakul et al. proposed a surgical plane to directly access
the posterior aspect of the lateral condyle. This approach is
performed in the prone position. A 10 cm incision is started 6 cm
above the popliteal crease and extended to 4 cm below the crease,
slightly medial to the fibula head. The common peroneal nerve
(CPN), which lies posterior to the biceps femoris, is identified and
retracted together laterally. The lateral head of the gastrocnemius
muscle is retracted laterally to expose the posterior capsule. The
popliteal vessels are protected on the medial side. A vertical
capsulotomy is performed to access the posterior femoral condyle
as well as to allow direct reduction and P-A screw fixation
perpendicular to the fracture plane [7] (Fig. 4E and VDO 3).
Arthroscopic fixation
Arthroscopy is a minimally invasive procedure for fixation of
Hoffa fractures. It is indicated in Letenneur type I or III fractures
with minimal displacement and no comminution [32]. Ercin et al.
reported excellent outcomes in a series of 3 lateral and 5 medial
Hoffa fractures treated with arthroscopically assisted fixation [33].
Arthroscopy provides some significant advantages such as minimal
soft tissue dissection, better visualization, and reduction of the
articular fractures, as well as identification of injuries that would
otherwise be missed because they cannot be visualized with open
surgical techniques. In technical terms, the fragment has to be
 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311
fixed from the anterior portal using A–P cannulated screws. In
some cases, there is failure to achieve a screw trajectory
perpendicular to the fracture plane. That, in turn, causes screw
displacement. Thus, this technique requires a high level of
arthroscopic expertise. With this method access to some extra-
articular areas is limited, so intraoperative fluoroscopy still plays
an important role in verifying the reduction outcome.
A model of the surgical visibility of each approach mapping the
visible areas of the distal femoral condyle is shown in Fig. 5. This
model can help surgeons select the appropriate approach. A review
of case series of Hoffa fracture treatments classified by surgical
approach, including the advantages and disadvantages of each
technique, is provided in Table 1. Indications and contraindications
for each technique are highlighted in Table 2.
Guidelines for determining surgical approach
First step: determine the fracture size
Fracture size is a key determinant of the appropriate surgical
approach. The first question to be answered is, “Can we adequately
appraise the fracture line using a single surgical approach, either
anterior or posterior, or do we need to use a combination of
approaches?” Most large simple Hoffa fractures can be treated by
anatomical reduction using PPA. Using the percentage of Hoffa
fragment size to the AP condylar width as a guideline, we
recommend PPA if the Hoffa fracture size is more than 28.7% of the
medial condyle AP diameter or 19.9% of the lateral condyle AP
diameter. If the fragment size is less than 28.7% of the medial
condyle or 19.9% of the lateral condyle, we recommend DMA or PLA
as the initial approach [7].
Fig. 5. Map of surgical approach visibility. Colors indicate visible area with different approaches; there is some overlapping. A, D - medial view; B, E - distal view; C, F - lateral
view; G, H - posterior view).
2307
Second step: determine the approach for reduction
To achieve an anatomical fracture reduction, at least two sides
of the bony surfaces which compose the articular surface and non-
articular surface, either the outer side (LCL or MCL side) or the
inner side (cruciate ligament side), have to be identified. Xie et al.
demonstrated CT mapping of Hoffa fractures and reported that the
frequency of comminution which is more common in lateral than
in medial Hoffa fractures [2]. Using this mapping together with the
percentage of the visible area of the Hoffa fracture as described by
Orapiriyakul et al. [7], the fracture size, the fracture plane, and the
area of comminution together will indicate the proper approach
(Fig. 6). If the comminution is in the intermediate zone, i.e.,
between the anterior and posterior approach, use of a combination
of those approaches should be considered. In cases of medial Hoffa
fracture with comminution, a combination of MPPA and DMA or
extended MSVA (MSVA and DMA in a single incision) can be
performed in a supine position with the contralateral leg dropped
down in order to access both PPA and DMA simultaneously. In
complex lateral Hoffa fractures, the floating position, flipping the
affected leg over with the patient in the supine or prone position is
an option for gaining concurrent access from the anterior, lateral or
posterior approach.
Third step: select the proper fixation technique
Many fixation options can provide adequate stability in large
Hoffa fractures using 6.5 mm A–P cancellous screws with the
thread crossing the fracture to allow interfragment compression;
however, the Hoffa fragment should be larger than 16 or 32 mm to
permit adequate thread length. In small Hoffa fragments, we
2308 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311

Table 1
Advantages and disadvantages of available surgical approaches with references.

Condyle Approach Advantages Disadvantages Fragment Fixation Letenneur References

size technique classification
Medial Medial - Surgeon familiarity - Poor visualization and difficult re- >28.7% A-P screw I, III Holmes et al. [5]
parapatellar - Suitable for large fragments duction of small Hoffa Ocguder et al.
- Can access both condyles - P-A screw may be impossible with [34]
small fragments Cheng et al. [35]
Dhillon et al. [6]
Xu et al. [17]
Singh et al. [36]
Crossed I, II, III Xu et al. [20]
screw Xu et al. [17]
A-P, P-A I, II, III Gavaskar et al.
screw [19]
Medial - Preserves quadriceps muscle - Difficult to evert patella >28.7% A-P screw I Nandy et al. [37]
subvastus - Preserves vascular supply of patella - Proximity to vascular structures plus plate

Extensile - Access to both anterior and posterior - Large skin incision <28.7% A-P screw NM Viskontas et al.
medial aspect of condyle with one incision. - Risk to extraosseous fragment blood comminu- [28]
subvastus - Possible comminution fracture supply tion
(Hoppenfeld - Risk to infrapatellar branch of sa-
and deBoer phenous and saphenous nerves
medial
approach)
Direct medial - Suitable for small Hoffa fragments - Occasionally requires medial gas- <28.7% P-A screw I Yucel et al. [38]
(Henderson - Biomechanical advantage of P-A trocnemius incision Borse et al. [18]
approach) screw - Risk to extraosseous fragment blood Screw I, II, III Gao et al. [29]
- Plating possible supply plus plate Trikha et al. [22]
- Risk to infrapatellar branch of sa-
phenous and saphenous nerves

Arthroscopy - Minimally invasive - Technically demanding >28.7% A-P screw I Goel et al. [39]
- Direct fracture visualization - Limited P-A screw trajectory
- Quick recovery through arthroscopic portal/ surgi-
- Decreased blood loss cal window

Lateral Lateral - Surgeon familiarity - Poor visualization and reduction of >19.9% A-P screw I, III Papadopoulos
parapatellar - Suitable for large fragment small Hoffa et al.
- Can access both condyles - P-A screw maybe impossible in Xu et al. [17]
- Can combine with distal femoral small fragment Singh et al.
locking plate (Swashbuckler)
[36]
P-A screw III Borse et al. [18]
Lee et al. [40]
Crossed I, IIc, III Lewis et al. [3]
screw Xu et al. [20]
Xu et al. [17]
Posterolateral - Biomechanical advantage of P- A - Occasionally lateral gastrocnemius <19.9% Suture IIc Tan et al. [30]
screw incision required
- Plating possible - Neurovascular risks (if access medial
to lateral gastrocnemius needed)

Direct lateral - Access lateral to posterolateral as- - Requires IT band insertion incision >19.9% A-P screw – Kumar et al. [41]
(Henderson pect of condyle - Risk to extraosseous fragment blood P-A screw I Neogi et al. [42]
approach) - Plating possible supply Egol et al. [43]
- Risk of common peroneal nerve Screw I, II, III Lin et al. [44]
injury plus plate Tetsunaga et al.
[45]
Shi et al. [11]
Zhao et al. [13]
Jordan et al. [46]
Trikha et al. [22]
Lian et al. [12]
Arthroscopy - Minimally invasive - Technically demanding >19.9% A-P screw I Ercin et al. [33]
- Direct fracture visualization - Limited P-A screw trajectory P-A screw III Wagih [32]
- Quick recovery through arthroscopic portal/ surgi-
- Decreased blood loss cal window

A–P = Anterior to posterior screw trajectory; IT = iliotibial band; P A = Posterior to anterior screw trajectory.

recommend P-A headless screw fixation via the posterior Summary

approach, e.g., DMA or PLA (Fig. 7A, B). Antiglide plates can be
augmented in large fractures with metaphyseal extension, and in Fracture size is the most important factor guiding the selection
case that screw fixation stability remains doubtful (Fig. 7C). of surgical approach and fixation technique. We have summarized
 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311 2309

Table 2
Indications and contraindications of available surgical exposures for Hoffa fracture treatment.

Condyle Approach Indications Contraindications

Medial MPPA Large fragment (Letenneur type I, III or size > 28.7%) Small fragment (Letenneur type IIc or Hoffa fracture size <18.3%)
Medial Similar to MPPA Similar to MPPA
subvastus - Fracture with metaphyseal extension needed to buttress
approach
Extensile Large to moderate size (Letenneur type IIa, IIb, or size 28.7-18.3%) with Small fragment (Letenneur type IIc or Hoffa fracture size <18.3%)
subvastus articular comminution requiring further visualization from posterior
approach aspect
DMA Small to very small fragment (Letenneur type IIc, Hoffa size <18.3%) Large fragment
requiring P-A screws (Letenneur I, III or
Hoffa fracture >28.7%)
Knee flexion contracture

Lateral LPPA - Large fragment (Letenneur type I, III or Hoffa fracture size > 19.9%) Small fragment
- Concurrent distal femoral fracture (Letenneur type IIc or Hoffa fracture size <10.1%)

DLA - Moderate to small size fracture - Large fragment (Letenneur I, III or Hoffa fracture size >28.7%)
- (Letenneur type II or Hoffa fracture size <19.9%) requiring A-P screw fixation
- Fracture with articular comminution at middle third of the condyle - Knee flexion contracture
- Fracture with metaphyseal extension

PLA Small fracture - Large fragment (Letenneur type I, III or Hoffa fracture size
(Letenneur type IIb, IIc or Hoffa fracture size <19.9%) >19.9%)
- Knee flexion contracture

Fig. 6. The comminution mapping by Xie et al and the surgical approach visibility. Decision making of the surgical approach for Hoffa fracture with comminution. Blue area
indicate the comminution area.
2310 W. Orapiriyakul et al. / Injury, Int. J. Care Injured 49 (2018) 2302–2311

Fig. 7. Surgical approach and fixation strategy. A. With a large Hoffa fragment (>28.7% of MC or 19.9% of LC), at least two A–P screws can be used through PPA. B. With a small
Hoffa fragment (< 28.7% of MC or <19.9 of LC), fixation with headless screws through DMA or PLA is recommended. C. With Hoffa fractures requiring a posteromedial or
posterolateral buttress plate, PLA, DLA or MSVA is recommended. (LC = lateral condyle, MC = medial condyle).

Fig. 8. Fragment size and treatment selection. Flow chart of surgical approach selection and treatment options. (L = letenneur classification; S = size; MC = medial condyle;
DLA = direct lateral approach; DMA = direct medial approach: MPPA = medial parapatellar approach; MSVA = medial subvastus approach; LC = lateral condyle; LPPA = lateral
parapatellar approach; PLA = posterolateral approach.

the available surgical approaches and illustrated the fragment
visibility in each approach. Better understanding of the relation-
ship between fragment size and treatment approach as summa-
rized in Fig. 8 can help surgeons achieve successful treatment
outcomes.
Conflict of interest
The authors declare that they have no conflict of interest related
to this manuscript.
Acknowledgement
This reseach work was partially supported by Chiang Mai
University. We wish to thank Prof. Pasuk Mahakkanukrauh, for
providing the cadaver as well as Dr. G. Lamar Robert, Ph.D. for
reviewing our paper.
[10] Reddy AS, Frederick RW. Evaluation of the intraosseous and extraosseous
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