International Journal of Surgery 19 (2015) 95e102

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International Journal of Surgery

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Original research

Surgical treatment and rehabilitation of medial Hoffa fracture fixed by

locking plate and additional screws: A retrospective cohort study
Mingjie Gao a, Jie Tao a, *, Zihui Zhou a, Qingbin Liu a, Lin Du a, Jieming Shi b
a
Department of Orthopaedics, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, 100, Haining Road, Shanghai 200080,
China
b
The First Clinical Medical College, Nanjing Medical University, 140, Hanzhong Road, Nanjing, Jiangsu 210029, China

h i g h l i g h t s

 Evaluate our strategy of treatments for the medial Hoffa fracture.

 A locking plate combined additional scerws were used for fixing the medial Hoffa fracture.
 Early active rehabilitation should be taken after steady fixation.
 Fixation with a locking plate and additional scerws combined early rehabilitation might give satisfactory functional results.

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Hoffa fracture fixed by only using a single plate or lag screws might be not strong enough to
Received 25 January 2015 achieve direct stability. The goal of this study is to determine the functional outcome of the surgical
Received in revised form treatment and rehabilitation of medial Hoffa fracture by a locking plate combined with cannulated or lag
6 May 2015
screws.
Accepted 15 May 2015
Available online 26 May 2015
Methods: A total of 13 patients suffering isolated medical Hoffa fractures were identified during the
study period (2005.February-2013.February) and retrospectively analyzed. All the fractures were treated
by open reduction via the medial approach, and internal fixation by a locking plate combined with
Keywords:
Medial Hoffa
cannulated or lag screws. Early active rehabilitation including tele-rehabilitation for rural patients with
Rehabilitation restricted weight bearing was instituted after the surgical treatment. The radiological and functional
Locking plate outcome analysis was performed by using Knee Society Score (KSS), the range of movement (ROM), and
Screw the stability of fixation of the patients during 24 month follow-up.
Results: The bone union of medial Hoffa fractures was achieved in all patients. The articular surface of
medial femoral condyle was anatomically reduced. There was no loss of reduction and fixation. All pa-
tients achieved satisfactory knee joint function and regained their walking ability with good clinical
results through early postsurgical rehabilitation. Ten patients (77%) had 0 e130 range of motion with
full extension; two patients (15%) had 0 e115 range of motion; one patient (8%) had 0 e110 range of
motion. The KSS of all the patients were more than 80, and the scores of seven patients (54%) were more
than 85.
Conclusion: Fixation with a locking plate and cannulated or lag screws for medial Hoffa fracture seemed
to be effective and reliable for achieving anatomical reduction, and gave satisfactory functional results
when coupled with aggressive rehabilitation.
© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Solitary coronal shear fractures of femoral condyle, known as

Hoffa fractures, are usually associated with supracondylar or
intercondylar fractures of the femur [1]. It has been reported that
* Corresponding author. Hoffa fracture is seldom seen in isolated condylar and usually
E-mail address: taojie123@sjtu.edu.cn (J. Tao).

http://dx.doi.org/10.1016/j.ijsu.2015.05.027
1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
96 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102

involves the lateral condyle [2]. Isolated coronal fracture of medial
Hoffa fracture is extremely rare, and little is described in literatures
about the surgical approach, fixation methods and rehabilitation in
such fractures [3e5].
The purpose of the treatment of this kind of articular fracture is
to achieve anatomical reduction of the articular surface. Early open
reduction and internal fixation are mandatory for good long-term
recovery in patients with such fractures. But there are many diffi-
culties associated with internal fixation in treating Hoffa fracture,
especially the medial Hoffa fracture. It was shown that the internal
fixation by only using a single plate or lag screws was not enough to
achieve enough stability of Hoffa fracture, and as a result, fragment
displacement, non-union, and even bone absorption could happen
[6,7].
Except for the steady fixation on medial Hoffa fracture, early
effective rehabilitation is also essential to achieve the satisfactory
functional recovery of knee. A review of available data suggests that
a combination of both two exercises is helpful when appropriate
precautions are taken to protect the healing fragments and avoid
excessive stress to the patellofemoral joint [8,9]. However, there
were few researches concerning the rehabilitation on this kind of
fracture.
In this study, we reported our experience of surgical treatment
and rehabilitation of medial Hoffa fracture in patients fixed by a
locking plate and cannulated or lag screws through the medial
approach, which could provide rigid stability and earlier active
rehabilitation.
modified the medial distal-femur approach as a “medial to medial-
posterior distal femur approach”, and it was easy to explore the
vastus medialis muscle, sartorius muscle and sapheneus nerve,
which was retracted forward to the anterior to explore the gracilis,
semimembranosus and semitendinosus muscles. After that, the
semimembranosus and semitendinosus were retraced to the pos-
terior and we could go through the interval space between the
gracilis muscle and caput medial of the gastrocnemius to expose
the fragment, and then the origin of the medial collateral ligament
could be clearly exposed and protected. The intact fragment of
Hoffa fracture was reduced and fixed with one or two cannulated or
lag screws from the medial-posterior to the lateral-anterior
condyle, and meanwhile a locking plate (Synthes) was anatomi-
cally contoured and used for fixing with angular stability and also
preventing from the vertical gliding of the fragment. No external
fixation was used after operation.
Several pitfalls should be alerted and avoided during operation.
Firstly, the operation should be carried out gently to protect the
nutrient artery and soft tissue, including the insertion of medial
collateral ligament, especially in the Type II Hoffa fracture; Sec-
ondly, the procedure of fixation should be avoided operating
repeatedly, in order to prevent surgical failure, if the fracture
fragment is small; The third, the plate and cannulated or lag screws
should be placed correctly. The locking plate (Synthes) was placed
on the medial-posterior side of the femur condyle and the cannu-
lated or lag screws were placed by the side of the locking plate in
our research.

2. Materials and methods

2.3. Rehabilitation
2.1. Patients
To obtain a good function of the injured knee joint, a systematic
From February 2005 to February 2013, a total of 13702 patients program of earlier active rehabilitation was carried out. The func-
with bone fractures were admitted in our institute, and there were tional outcome analyses were performed by using Knee Society
728 (5.3%) patients with distal femur fractures among all the cases. Score (KSS), range of movement (ROM), and the stability of fixation
In this cohort study, we retrospectively analyzed 82(0.6%)patients of the patients.
with Hoffa fractures admitted in the institute, including 13 patients
(0.9‰), who had isolated medial Hoffa fracture (OTA type 33-B3.2)
without associated supra-condylar or inter-condylar fracture
2.4. One week to 4 weeks postoperatively
components (Table 1). Our work was compliant with the STROBE
criteria [10].
In the early medial Hoffa fracture postoperative rehabilitation,
one of the most important goals was to control the pain and
2.2. Surgical managements swelling, thus the elevation of the leg and non-steroidal anti-in-
flammatory drugs had been suggested. Reducing the pain and
The operation was conducted under the guidance of profes- swelling was helpful to improve ROM and the function of quadri-
sional surgeons. All the fractures were treated by open reduction ceps, and additionally decreased the risk of limited ROM and
through the same modified posteromedial approach (Fig. 1). We muscle contracture. It could also avoid the delay in the progression
to the next stage. After the management of pain and swelling,
continuously passive motion (CPM) system was used for knee joint
Table 1
Patients data, type of fracture. flexion and extension exercises in all patients 3 days post-
operation. The patients acquired 0 e20 the range of knee mo-
Case Gender Age Mechanism Type of fracture
tion with no or slight pain. According to the different degree of pain
1 Female 52 motor vehicle accident I in patients, the flexion amplitude was increased gradually form
2 Male 45 motor vehicle accident IIa 20 e40 by the CPM system. Degree of knee flexion was achieved
3 Male 58 motor vehicle accident IIb
4 Male 33 motor vehicle accident IIb
from 40 to 60 at the seventh day postoperatively. At the begin-
5 Female 60 motor vehicle accident III ning of second week, the exercise was carried out 2 to 3 times to
6 Male 55 high-velocity fall IIc increase l0 to 15 range of knee flexion every day. After each CPM
7 Female 48 motor vehicle accident III practice, the patients should sit on the bed with the injured leg
8 Male 56 high-velocity fall III
reaching the floor without bearing weight. As a landmark, the pa-
9 Female 47 motor vehicle accident I
10 Male 49 high-velocity fall I tients were freely encouraged to attain approximately 100e130 of
11 Male 40 motor vehicle accident IIc flexion by the end of the third week postoperatively. Then, 3e4 min
12 Male 43 motor vehicle accident III for a full range of motion was allowed, and the exercise should be
13 Female 51 high-velocity fall IIb performed 30 mine45 min at a time, 2 to 3 times a day, and be
Type of fracture was classified according to Letenneur classification. lasted for a week.
 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102 97

Fig. 1. a) The incision passed over the surface of vastus medialis muscle and sartorius muscle,and the medial femoral condyle was exposed by being mobilized and retracted. b)-c)
Full exposure of the fragment of the medial condyle of the left femur by a modified approach was achieved and a locking plate and cannulated screw was placed.

2.5. Six weeks to 10 weeks postoperatively
In 6e8 weeks after surgery, the patients began practicing non-
weight-bearing walking with the help of crutches. The patients
were allowed partial weight-bearing at around 10 weeks post-
operatively. For the discharged patients, they gradually increased
the bearing weight under the guidance of the clinician via tele-
rehabilitation [11].
2.6. Fourteen weeks to 28 weeks postoperatively
When the sign of bone union was showed in radiographs and
the patients were allowed for full weight-bearing from 14 weeks to
28 weeks postoperatively.
2.7. Follow up
The patients after discharge were followed up by taking X-ray or
CT scanning every month in the first 3 months, every 3 months in
the following 9 months, and then at the 12th and 24th months.
3. Results
All the patients were compliant and the data were collected
without missing. To evaluate the healing of the fracture, the X-ray
or CT scanning were used. We found that the bone union in 10
patients (77%) were seen at 3 months, bone union of 2 patients
(15%) were seen at 5 months, and 1 patient (8%) got bone union at 6
months. At the end of 24-month follow-up, all the fractures were
united.
Following open reduction and internal fixation (ORIF), gradual
range of motion exercises of knee were initiated. At four weeks
postoperatively, 9 patients (69%) had 0 -130 range of motion with
full extension, 3 patients (23%) had 0 -115 range of motion, 1 pa-
tient (8%) had 0 e110 range of motion, and there was no varus-
valgus instability. Functional outcome of knee measurements
98 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102

Table 2
Follow-up and outcomes.

Patient Diagnostic modality Knee ROM (degrees) Knee Society score (points) Bone union time(month) Follow-up (months) Non-union Stability

1 X-ray 0 to 130 84 3 23 None Stable

2 X-ray 0 to 115 81 3 23 None Stable
3 X-ray, CT 0 to 130 87 6 24 None Stable
4 CT 0 to 130 89 3 24 None Stable
5 X-ray, CT 0 to 130 81 3 22 None Stable
6 X-ray 0 to 130 90 5 23 None Stable
7 CT 0 to 110 83 3 23 None Stable
8 X-ray 0 to 130 87 3 24 None Stable
9 CT 0 to 130 91 3 24 None Stable
10 CT 0 to 110 80 5 24 None Stable
11 X-ray, CT 0 to 115 82 3 24 None Stable
12 X-ray 0 to 130 88 3 23 None Stable
13 X-ray 0 to 130 90 3 24 None Stable

(ROM of knee, KSS, stability of fixation) were performed during the
24 months’ follow up (Table 2). Additionally, there was no limb-
length discrepancy, postoperative infection, un-union, secondary
displacement, or bone resorption, and the distal femoral physis had
started to fuse on both sides. All the patients were pain free and
ambulatory without walking aids.
In this study, the patient of case 3 (a 58-year-old male) got the
left medial Hoffa fracture (type IIb) from a motor vehicle accident
(Fig. 2a and b). A locking plate and one cannulated screw were
placed at the medial-posterior distal femoral condyle (Fig. 3). The
patient could acquire nearly 90 range of motion through active
rehabilitation at the tenth day (Fig. 4). 3 months after the operation,
0 e130 range of motion was obtained in the patient (Fig. 5). Six
months after the operation, the fracture line was obscure at the 3D-
CT, and there was no secondary displacement (Fig. 6).The patient
was allowed to have full weight-bearing at home 9 months post-
operatively. A stable and functional knee was achieved after 13
months, and the patient was fully recovered, loaded, and back to
work as a physical worker after 24 months follow-up.
4. Discussion
In 1904, the coronal plane fractures of the distal femoral condyle
were officially described for the first time by Hoffa [1]. Hoffa

Fig. 2. a)-b) AP/Lateral radiograph of right knee showed a type IIc medial Hoffa fracture. c)-d) 3D-CT of right knee showed a type IIc medial Hoffa fracture.
 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102 99

Fig. 3. AP/Lateral radiograph of right knee showed that the fracture was reduced and fixed with a locking plate and one cannulated screw.

fracture refers to the single or double femoral condyle fracture on
the coronal plane. Since the patients with Hoffa fracture usually
suffer from high-energy injury, many cases are missed unfortu-
nately at the first assessment [12]. Unicondylar Hoffa fracture has
been reported in several studies [2,13]. However, few reports about
medial Hoffa fracture were shown in the literature [3,14,15].
Hoffa fracture was classified into three types by Letenneur [16].
Type I is a vertical fracture involving the entire condyle parallel to
the posterior cortex of the femur; Type II is a fracture of variable
size, horizontal to the base of the condyle; Type III is a fracture

Fig. 4. The patient could acquire nearly 90 range of motion through active rehabilitation at the tenth day.

Fig. 5. The patient obtained 0 e130 range of motion in 3 months after the operation.
100 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102

Fig. 6. 3D-CT of the left knee showed that there was no secondary displacement and the fracture line was obscure ten months after the operation.

oblique to the femur, originally described for lateral Hoffa fractures
(Fig. 7). Compared to type I and type III fractures, the type II Hoffa
fracture fragment was relatively small and most likely to nonunion
for the lack of soft tissue attachment. Type II Hoffa fracture has
worse blood supply bone union than the other two types. Most of
the nutrient arteries for medial condyle were provided by superior
medial genicular artery and arteriae genu descendens, and a few
blood supply was from the soft tissue, medial collateral ligament
attachment sites. Compared to type I and type III fractures, the
fragment in type II Hoffa fracture was relatively small and most
likely to induce nonunion due to the lack of soft tissue attachment.
Accordingly, injury of these nutrient artery and soft tissues should

Fig. 7. Letenneur Classification of Hoffa fracture.

 M. Gao et al. / International Journal of Surgery 19 (2015) 95e102
be prevented during the operation.
Hoffa fractures are usually caused by motor vehicular accidents.
Until now, the injury mechanisms of this fracture pattern have not
been clearly described. To detect the coronal fractures more accu-
rately, CT scanning is necessary to these fractures that might be
easily overlooked on plain radiographs. On the other hand, CT
scanning or MRI examination is essential to find out a potential
fracture and other accompanying structure injuries [17]. Ozturk
[18] recorded a case of neglected medial Hoffa fracture that was
initially missed because of seemingly normal anteroposterior (AP)
radiographs of the knee.
The medial Hoffa fracture is a kind of intra-articular fracture,
and most of these cases need operation [3,13]. Conservative man-
agement often leads to nonunion or loss of knee function [18]. The
surgical approaches are usually parapatellar approaches (ante-
romedial), or combined with posterior approaches, depending on
the fracture classification and fixation methods.
As far as we know, there was no clinical comparison of different
fixation methods on Hoffa fracture in the literatures. Most of Hoffa
fractures were treated with cannulated screws or cancellous screws
from anterior to posterior or the opposite direction, and the clinical
outcomes were different [2,15,18e20]. It is generally accepted that
the screw heads are recessed beneath the articular surface. Some-
times, internal fixation assisted with arthroscopy could be helpful
to restore the article surface [21]. A biomechanical study showed
that cannulated screws placed from posterior to anterior provided
more stable fixation of Hoffa fractures in embalmed femurs than
anteroposteriorly placed cannulated screws [22]. However, there
was also a report of screw fixation failure in osteoporotic Hoffa
fracture [15].
The key factors for Hoffa fracture healing contain blood supply
and fixation stability. Therefore, the firmness of fixation is partic-
ularly important. Favorable biomechanical and clinical results had
shown that the locking plate with a fixed-angle design could pro-
vide angular stability of the fracture if applied appropriately
[23,24]. It was shown that two screws with cross direction were
sufficient for the fixation of Hoffa fractures [6,25]. Shi [26] reported
12 cases of lateral Hoffa fractures treated with a locking plate and
cannulatedor lag screws. According to Knee Society Score, 6 pa-
tients got an excellent result, and 6 got good. Bone Unions were
achieved in all patients. No loss of reduction and fixation appeared.
There was no evidence of deep infection after 3 years follow-up.
In this study, we used additional locking plate device to fix the
fragment providing stronger support after compression with one or
two cannulated screws. On the other hand, the locking plate was
used as an anti-sliding plate to avoid secondary displacement,
especially at vertical displacement. As a result, instantly biome-
chanical stability was achieved, patients were allowed active knee
movement immediately after the operation without any external
brace or cast. Meanwhile, bone union was all found three to six
months after the fixation and earlier good knee function was
achieved.
For correcting knee flexion and extension deficits, the rehabili-
tation protocol is necessary. The therapeutic goals such as con-
trolling pain and edema, preserving quadriceps function, achieving
more than 90 of knee flexion and functional knee, and returning to
activity and sports, often need to be addressed by rehabilitation
methods [27]. During the period of hospitalization, the rehabilita-
tion program of patients was implemented with the help of phy-
sicians, but due to the special conditions in China, like economic
condition, health care system, bed conversion and farmer-workers’
migration, it is hard for the Chinese patients to take rehabilitation
exercise in hospital. Tele-rehabilitation is a promising alternative to
traditional face-to-face therapies after discharge from open
reduction and internal fixation, especially for those patients who
101
have difficulty with transportation to rehabilitation center [11]. The
advantages of rehabilitation could reduce the rate of the post-
operative complications, which include lowering the odds of
acquiring Deep Vein Thrombosis (DVT), joint loosening and post-
operative infection [28]. The rehabilitation of patients after surgery
refers to start to train based on the preoperative instructions from
the third day of post-operation, and keeps on physical therapy post-
discharge by tele-rehabilitation. In our study, all the patients were
compliant and received positive rehabilitation according to our
personalized and professional instructions during the follow-up
period. The plan of rehabilitation excise in this study was on the
basis of previous researches and combined with the internal fixa-
tion methods we did here, which allowed the patients with Hoffa
fracture to carry out earlier, more active and safer post-operative
rehabilitation excise, and our results were satisfactory. Up to now,
the rehabilitation program should be considered on a case-by-case
basis, and its implementation and coordination should be executed
by professional physician and surgeon.
In this retrospective cohort study, the lack of controls and the
limited number of patients was due to that the medial Hoffa frac-
ture is extremely rare. The managements of medial Hoffa fracture
applied in our study need to be evaluated deeply in further study.
In summary, it suggests that cannulated or lag screws combined
with a locking plate provided an adequate stability and earlier
active rehabilitation for the patients with medial Hoffa fracture to
estore knee function. Our surgical treatment of the medial Hoffa
fracture seems to present good clinic results while combined with
early active rehabilitation.
Conflict of interest
The authors declare no conflicts of interest.
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