Systematic Review and Meta-Analysis Medicine ®

OPEN

Hoffa fracture of the femoral condyle

Injury mechanism, classification, diagnosis, and treatment
∗
Yabin Zhou, MDa,b, Ying Pan, MDc, Qingxian Wang, MDa, Zhiyong Hou, MDa, Wei Chen, MDa,

Abstract
Background: Hoffa fractures are coronal-plane fractures of the femoral condyle, which are rarer than sagittal-plane condylar
fractures. This study aimed to systematically review the clinical knowledge base of Hoffa fractures to facilitate the diagnosis and
management of such injuries.
Methods: We searched Medline, Embase, Cochrane Library, Google Scholar, China National Knowledge Infrastructure, and China
Biology Medicine disc, using the terms “Hoffa fracture” and “coronal fracture of femoral condyle.”
Results: One hundred five articles on Hoffa fractures were reviewed, and the clinical knowledge base was summarized. High-
energy trauma is a common cause of a Hoffa fracture, although low-energy trauma and iatrogenic injury can also lead to these
fractures. Commonly used classifications include the Letenneur classification, a computed tomography (CT) classification, the AO
classification, and modified AO classification. Radiography can reveal fracture lines. If radiographic findings are negative in
questionable cases, CT and magnetic resonance imaging (MRI) should be performed. Nondisplaced fractures can be managed
conservatively; however, they involve a high risk of redisplacement. Open reduction and internal fixation are preferred. For young
patients with good compliance, simple medial or lateral condylar fractures can be treated via a medial or lateral parapatellar approach.
After fracture exposure, headless compression screws can be inserted perpendicularly to the fracture line from posterior to anterior.
For bicondylar fractures, a median parapatellar incision can be used. For complex fractures in patients with osteoporosis or a high
body mass index, cannulated screws with antigliding plate fixation should be used.
Conclusion: Here, we summarized the injury mechanism, diagnosis, classification, and treatment options of Hoffa fractures.
Abbreviations: CT = computed tomography, MRI = magnetic resonance imaging.
Keywords: classification, diagnosis, Hoffa fracture, injury mechanism, treatment

1. Introduction fracture of the femoral condyle but did not indicate the source of
the previous reference. Following Letenneur classification of
Fractures of the distal femur typically occur in the axial and
coronal fractures of the femoral condyle in the 1970s and the
sagittal planes.[1] A Hoffa fracture, a rare fracture confined to the
publication of the second version of the “Manual of Internal
coronal plane of either femoral condyle, accounts for 8.7% to
Fixation,” the Hoffa fracture has become more widely recognized
13% of distal femoral fractures.[2] This fracture type was 1st
by orthopedists. With rapid developments in transportation,
described by Busch in 1869.[3,4] In 1888, Hoffa described coronal
construction, and industry, the incidence of Hoffa fractures has
gradually increased. This article reviews the mechanism,
Editor: Yan Li.
diagnosis, classification, and treatment of Hoffa fractures.
YZ and YP contributed equally to this work.
This study was supported by the National Natural Science Foundation of China
(grant no: 81401789) and the Top Young Talents for Hebei Province (2016–
2. Method
2018). The funding sources have no role in study design, literature collection,
review, data analysis, and manuscript preparation. Medline, Embase, the Cochrane Library, Google Scholar, the
The authors have no conflicts of interest to disclose. China National Knowledge Infrastructure, and the China
a
Department of Orthopedic Surgery, The Third Hospital of Hebei Medical Biology Medicine disc were searched for relevant articles. We
University, Orthopedic Research Institution of Hebei Province, Key Laboratory of used the key words “Hoffa fracture” and “coronal fracture of
Biomechanics of Hebei Province, b Department of Orthopedic Surgery,
femoral condyle” for the knowledge. One hundred five relevant
Shijiazhuang The Third Hospital, c Department of Pharmacy, The Third Hospital of
Hebei Medical University, Shijiazhuang, China. articles were reviewed, and the clinical knowledge base was
∗
Correspondence: Wei Chen, The Third Affiliated Hospital of Hebei Medical
summarized.
University, Shijiazhuang, Hebei Province 050051, China Our hospital’s institutional review board waived the need for
(e-mail: [email protected]). ethical approval for this review paper.
Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC- 3. Injury mechanism
ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially The main cause of a Hoffa fracture is a high-energy injury such as
without permission from the journal. those sustained in traffic collisions (80.5% of cases) and falls
Medicine (2019) 98:8(e14633) (9.1% of cases).[5–9] For children and individuals with osteopo-
Received: 11 March 2018 / Received in final form: 24 January 2019 / Accepted: rosis, low-energy trauma can also lead to a Hoffa fracture.[10]
30 January 2019 Werner and Miller[11] reported that iatrogenic injury is a cause of
http://dx.doi.org/10.1097/MD.0000000000014633 Hoffa fracture that cannot be ignored.

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3.1. High-energy trauma 4. Classification of Hoffa fracture

The specific mechanism of a Hoffa fracture is not well The Letenneur classification, computed tomography (CT)
understood.[12,13] Most researchers[2,7,14] currently believe that classification, the AO classification, and the AO classification
when the knee is in ≥90° of flexion and emergency braking is with supplement are widely used in clinics to categorize Hoffa
performed while driving a car, an axial force in either a varus or fractures.
valgus direction is transferred from the proximal femur to the
femoral condyle. At the same time, forces on the distal tibia are
4.1. Letenneur classification
transferred to the tibial plateau, resulting in great shear stress
between the femoral condyle and the tibial plateau.[15,16] These The widely known Letenneur classification not only clarifies the
forces cause gross displacement of the condyle, which can not relationships between the fracture line and ligaments and soft
only rupture the quadriceps tendon but also perforate the skin, tissue, but also has significance for clinical treatment and
resulting in an open injury. With a lower degree of knee flexion, prognosis. The Letenneur classification[31] divides fractures into 3
the extensor mechanism is damaged below the patella (patellar types (Fig. 1). Type I, the most common classification, is a vertical
tendon); at higher angles, the quadriceps tendon is torn. fracture line parallel to the posterior cortex of the femur and
Furthermore, a Hoffa fracture is associated with cruciate involves the entire condyle. Fracture lines are often located where
ligament injury. In these cases, avulsion of the anterior cruciate the anterior cruciate ligament and lateral collateral ligaments
ligament along with a large chunk of bone at its insertion[17] can attach. In these fractures, the popliteus tendon and the lateral
lead to a Hoffa fracture. When high-energy trauma involves the head of the gastrocnemius muscle remain attached to the
distal femur, the lateral condyle is often damaged[18] before the fragment. Type II is a fracture horizontal to the base of the
medial condyle because of the physiologic genu valgum of the posterior condyle with fracture lines located posterior to the
knee joint.[19] Therefore, lateral condyle fracture is significantly attachment point of the lateral collateral ligament. Type III is an
more common than medial condyle fracture.[15,17–20] The oblique fracture of the femoral condyle with the fracture line
fracture line its inclination angle of a Hoffa fracture depend located anterior to the joint capsule, anterior cruciate ligament,
on the degree of knee joint flexion at the time of trauma[18]; as the lateral collateral ligament, popliteal tendon, and the lateral head
angle of knee flexion increases, the fracture line will occur farther of the gastrocnemius muscle. Types I and III Hoffa fractures
from the posterior cortex of the femoral-condyle.[21] In contrast usually have a good prognosis because the soft tissue remains
to unicondylar Hoffa fracture, a bicondylar Hoffa fracture is attached to the fragment, ensuring an adequate blood supply. In
caused by a posterior and upward directed force and is not contrast, type II fractures have a high risk of nonhealing or
associated with knee valgus.[21,22] delayed healing because of poor adhesion and poor blood supply.
In some patients, a Hoffa fracture is associated with a patellar However, Gavaskar et al[2] argued that no evidence confirms this
fracture. In these cases, the associated patellar fracture results correlation.
from a combination of forces: direct trauma causing the Hoffa
fracture and possible indirect injuries from sudden contraction of 4.2. CT classification
the quadriceps muscle causing a vertical patellar fracture.[23]
The CT classification[32] uses the anatomic femoral axis and a line
parallel to the posterior cortex of the femoral condyle to divide
3.2. Low-energy trauma the femoral condyle into a, b, and c regions. Three types of
Low-energy trauma can cause Hoffa fractures in people with fracture are defined based on the coronal fracture line (Fig. 2). For
skeletal immaturity[24] as well as in those with low bone mass, such example, a fracture line dividing the femoral condyle surface into
as patients with osteoporosis.[10] Some of these patients may have a 2 parts is classified as type I; 2 fracture lines dividing the femoral
history of poliomyelitis that predisposes individuals to osteoporo- condyle surface into 3 parts is type II; and 3 or more fracture lines
sis.[25] Loss of bone matrix results in brittle, weaker bones that dividing the femoral condyle surface into 4 or more parts is type
break rather than bend with external force. In addition to changes III. This system allows the classification of comminuted femoral
in bone mineral composition and a reduced proportion of bone condyle fractures.
matrix in patients with osteoporosis, changes in bone microstruc-
ture, thinning of bone cortex, and reduction in the number and size 4.3. AO classification and supplement
of bone trabeculae result in a decreased bone load capacity[26] and
an increased risk of a Hoffa fracture with low-energy trauma. In the AO classification, Hoffa fracture is classified as type
B3.2.[33] Dua and Shamshery[34] proposed a classification
method that supplements the AO classification with proper
3.3. Iatrogenic injury surgical planning to optimize outcomes. In the type I, an isolated
Reconstruction of the anterior cruciate ligament of the knee joint fracture is confined to the coronal plane of 1 condyle (medial or
can lead to iatrogenic Hoffa fracture. In anterior cruciate lateral). Two or 3 cancellous screws (4 or 6.5 mm) can be used to
ligament reconstruction, an anterior medial approach to the fix the fracture in an anterior-to-posterior direction. In the type II
femoral tunnel allows restoration of the position of the tendon (bicondylar Hoffa fracture), both condyles are fixed with
graft and increases rotation stability when an expanded bone anteroposterior screws. Medial and lateral buttressing may be
tunnel is used for the graft. However, if the tunnel is too close to required if either fracture extends proximally in the same plane.
the distal femoral articular surface and too little cartilage-covered In types III and IV (unicondylar coronal plane fracture with
bone is retained, either the passage of the tendon through the supracondylar or intercondylar distal femoral fractures, respec-
bone tunnel or fixation of the tendon can lead to a Hoffa tively), fixation is needed as for isolated Hoffa fracture in
fracture.[11] The presence of a thick ligament in a relatively small addition to stabilization with a metaphyseal bridging implant or a
femur is also a risk factor for a Hoffa fracture.[27–30] fixed-angle device.

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Figure 1. Letenneur classification of Hoffa fracture. The dotted lines represent fracture lines. In Type II fracture, the dotted lines are horizontal to the base of the
posterior condyle. For fractures located posterior to dotted line a, the popliteal tendon or gastrocnemius muscle attached to the fragment. For those located
posterior to dotted line b, only a part of popliteal tendon or gastrocnemius muscle attached to the fragment. There is no soft tissue attachment to the fracture
fragments located posterior to dotted line c.

5. Diagnosis knee pain and limited knee mobility.[10,38] Local manifestations

Making the diagnosis of a Hoffa fracture is challenging.[34] The of a Hoffa fracture include knee swelling, pain, skin color changes
clinical diagnosis of a Hoffa fracture relies on trauma history, (with or without skin defects), limited knee mobility, and a
physical examination, imaging, and other objective indicators as positive floating patella test.[7,10] The finding of medial or lateral
well as increased suspicion based on the history and positive stress test and anterior and posterior drawer test were reported to
signs.[35,36] be positive in some patients.[39,40] Wagih[41] reported that, under
general anesthesia, patients with Hoffa fracture have instability at
30° of flexion but not with leg straightened.
5.1. Medical history and local examination
5.2. Imaging examination
Hoffa fractures are most commonly caused by traffic accidents,
especially motorcycle accidents.[12,37] Orthopedic surgeons A radiographic examination should include anteroposterior,
treating these patients should be vigilant in diagnosing a Hoffa lateral, oblique, and stress views of the knee. In the ante-
fracture; patients with undiagnosed injuries experience long-term roposterior radiograph of the femoral condyle, the trabecular

Figure 2. Computed tomography classification of Hoffa fracture. The anatomical femoral axis (the right dotted line) and the line parallel to the posterior cortex of the
femoral condyle (the left dotted line) divided the femoral condyle into three regions (a region locates anterior to the right dotted line; b region locates between both
dotted lines and c region locates posterior the left dotted line). The solid line represents fracture line.

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bone structure of the femoral condyles is disordered, with poor 6.3. Surgical approach
continuity of the cortex. On lateral radiographs, the normal An appropriate surgical approach allowing full fracture exposure
femoral condyles overlap, and bone cortex interruption may not is selected based on fracture type. For simple lateral condylar
be visible.[7] Nondisplaced Hoffa fractures are difficult to Hoffa fractures, a patellar anterolateral approach is most
visualize on anterior and lateral radiographs of the knee.[42] commonly used. This approach fully exposes the fracture and
Compared with anteroposterior and lateral films, oblique does not risk damaging the nerves and blood vessels,[67] making
radiographic views can show minimally displaced fractures the operation simple and safe. A lateral incision plus Gerdy
better[14] and can, therefore, be used as a routine examination tubercle osteotomy provides full exposure[68] especially in cases
method for a Hoffa fracture. In addition, the Hoffa fracture line of coronal fracture of the lateral condyle. This approach can also
can be seen on stress films taken with the patient under general be used to treat comminuted fractures or complex Hoffa
anesthesia.[43] If radiographic examination is not diagnostic but a fractures.[18]
Hoffa fracture is suspected, a CT scan, which is the gold standard For simple fractures of the medial condyle, a medial
for diagnosis of a Hoffa fracture, should be performed.[17,18] parapatellar surgical approach is most commonly used. The
Magnetic resonance imaging (MRI) should be performed when advantage of this approach is that it does not compromise future
injury is suspected to the meniscus, cruciate ligament, collateral arthroplasty surgery; however, it does not allow visualization and
ligament, or other soft tissues to determine the extent of injury,[32] treatment of any posterior comminution.[5] Viskontas et al[69]
develop appropriate surgical plans, and accurately assess reported an extensile medial subvastus approach that allows
prognosis. better exposure of the surgical field and protects the blood supply
of the bones comparing with the medial parapatellar approach.
5.3. Misdiagnosis Gao et al[70] reported a “medial to medial-posterior distal femur
A high-energy injury resulting in a Hoffa fracture of the medial approach” in which the fragments were exposed through the
condyle is often associated with a tibia fracture,[18] a bicondylar interval space between the gracilis muscle and medial head of the
Hoffa fracture,[44,45] a dislocation of the patella,[14] a knee gastrocnemius and the medial collateral ligament can be clearly
dislocation,[46] intercondylar and supracondylar fractures,[9,47] exposed and protected.
and pelvic[48,49] and femoral shaft fractures.[50,51] An open For bicondylar Hoffa fractures, it is necessary to simulta-
supracondylar- intercondylar distal femoral fracture has a 2.8 neously expose both condyles[71] to allow proper reduction. Lee
times more chance of a Hoffa fracture than a closed distal femoral et al[13] reported that Gerdy osteotomy combined with an
fracture.[9] The pain due to these combined injuries often exceeds anterior lateral parapatellar approach provides appropriate
that caused by the Hoffa fracture, which can lead physicians to exposure for bicondylar Hoffa fractures. Fixation with an
miss the latter.[52] This fact reminds us that a Hoffa fracture anti-glide plate on the lateral condyle and tibial osteotomy with
evaluation should be a routine part of the lower-limb and pelvis two 4.5-mm screws is ideal. A swashbuckler approach[34,72] can
examination with or without injury.[53] In addition, partial be used to treat bicondylar Hoffa fractures because it protects the
nondisplaced Hoffa fractures are difficult to diagnose on Quadriceps femoris abdomen during surgery, allowing quick
anteroposterior and lateral views of the knee because the fracture postoperative recovery of muscle strength and range of
lines often overlaps the side or lateral condyle, which can result in motion.[73] This approach is suitable for the treatment of Hoffa
a missed diagnosis in as many as 30% of cases.[9,18] fracture with patella dislocation.
Among the various types of Hoffa fractures, the Letenneur II is
unique because the fragments are small and difficult to fix, and
6. Treatment poor blood supply to the fragments impairs its healing. Kapoor
et al[74] recommended a direct posterior approach and a lazy S-
6.1. Conservative treatment
shaped incision to expose the fracture. In some cases, the
Nondisplaced Hoffa fractures can be treated with cylindrical Letenneur II fragment is small but essential for the knee join when
plaster cast immobilization with the knee in 10° of flexion.[54] flexed at 90° because it ensures the articular surface integrity. This
However, popliteal and gastrocnemius muscle traction and foot method is beneficial for reducing small and rotating fragments.
or ankle movement can lead to fracture redisplacement,[55–57] Tan et al[75] recommended an improved posterolateral approach
which can cause delayed fracture healing, nonunion, traumatic starting from the space between the peroneal nerve and the biceps
arthritis, knee dysfunction, and other complications.[6,45,48,58–63] femoris. The risk of blood vessel damage when using this
Therefore, we must strictly control the indications for conserva- approach is minimal but the common peroneal nerve should be
tive treatment. isolated first.

6.2. Surgical treatment 6.4. Surgical considerations

Anatomic reduction of the articular surface, stable fixation, and For Letenneur II and some Letenneur III fractures close to the
early mobilization should be the aims of treatment.[64] Open posterior cortex of the femoral condyle, cannulated lag screw
reduction and internal fixation is the 1st choice for the treatment fixation is commonly used. The exposed fracture line is initially
of displaced Hoffa fractures, and it is also suitable for the fixed with a k-wire and screws are placed perpendicular to the
treatment of nondisplaced Hoffa fractures. The knee joint is fracture surface. The use of several 3.5-mm-diameter screws is
placed in flexion during surgery,[65,66] placing the joint capsule recommended to fix the fractures. A biomechanical study[5]
and gastrocnemius in a relaxed state, which reduces the traction shown that several smaller-diameter screws cause less damage to
on the fracture and is conducive to fracture repair. The the joint cartilage than larger-diameter screws but that both have
appropriate surgical plan is chosen based on the location of the same tensile force.[76,77] Fixation with 2 or more screws can
the Hoffa fracture, characteristics of the fracture line, fracture prevent rotation and rotational displacement.[78] Previous studies
severity, and associated injuries. showed the use of many screws to fix the Hoffa fracture, such as

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cancellous, cannulated, and headless used in a lag technique. fracture line prevents reduction, arthroscopy can distinguish
Cancellous screws cannot achieve adequate compression[55] and the tissues and the degree of damage to assist restoration.[93] The
require more surgical time to countersink. Headless compression biggest challenge in the treatment of Hoffa fractures under
screws are self-compressing and can be positioned beneath the arthroscopy due to the patella is dissecting the fragments for
outer cortex resulting in significantly greater axial compression, a reduction[94] and placing screws perpendicularly into the fracture
higher load limit, and increased fracture stability.[65,67] More- line.[95] Because Hoffa fractures are intra-articular, the success of
over, headless compression screws can prevent soft tissue anatomical reduction and firm internal fixation is closely related
irritation and do not need an additional countersinking to postoperative complications like traumatic arthritis. There-
procedure.[55] Onay et al[79] performed a long-term follow-up fore, further studies are needed to improve the quality of Hoffa
study of Hoffa fracture patients treated with screws and observed fracture reduction under arthroscopy.
that the screws provided sufficient biomechanical stability until Lax patellar attachments are thought to place adolescent boys
the fractures were healed. Somford et al[65] showed that the repair at higher risk of patellar dislocation.[96,97] Thus, closed reduction
strength of absorbable screw fixation is weak, knee joint activity is recommended when Hoffa fracture is accompanied by patella
produces greater shear stress, and there is a risk of screw dislocation. A patella that is stuck between the tibia and femur
breakage; thus, careful selection of the surgical plan is can be relocated naturally by flexing of the hip joint with the knee
recommended. in 110° of flexion under local anesthesia. Some patellar
Screw insertion direction differs among operative approaches. dislocations are difficult to treat with closed reduction because
Screws inserted from anterior to posterior induce less soft tissue the patella is attached to the intercondylar fossa by the quadriceps
dissection and carry no risk of damaging the posterior neuro- femoris[98] and rotational or vertical displacement is present.
vascular structures.[80] From a biomechanical point of view, Valgus strain on the knee and the continuous pull of the
when the load is in the vertical direction, posteroanterior screw quadriceps causes the patella to ride against the femoral condyle,
placement has a lower risk of shifting than anteroposterior resulting in rotation around its vertical axis.[99] The patella may
placement.[2,77] The heads of screws placed through the articular become incarcerated in the intercondylar fossa, wedged between
cartilage are countersunk to prevent damage to the cartilage. the femoral condyles, or even rarely incarcerated in the Hoffa
Fixation with headless screws can reduce the degree of cartilage fracture. In such cases, the forces necessary for closed reduction
injury.[81] For patients who require a longer healing time, such as can result in cartilage injury or a small avulsion fracture of the
those with a higher body mass index or poor compliance, the patella.[100,101] To avoid damaging the cartilage in these cases, it
simple application of a cannulated screw is insufficient to counter is important to reduce the patella early and restore the
the great shearing force between condyles and the tibial plateau patellofemoral joint stability by repairing the damaged medial
when the knee is in flexion.[25] A cannulated screw combined with soft tissues.[102] Therefore, open reduction and internal fixation is
a plate is recommended in these cases. This method is also recommended to minimize cartilage damage and allow appro-
recommended for patients with osteoporosis, metaphyseal priate treatment of the bone and soft tissues. Tsai et al[103]
extension, or comminuted Hoffa fractures.[82,83] A biomechani- reported that surgical treatment is the 1st choice for Hoffa
cal study by Li et al[84] demonstrated that plates combined with fracture accompanied by traumatic patella dislocation; if
screws more firmly fixed the femoral condyle, reducing the conservative treatment is adopted, the redislocation rate is as
probability of fracture displacement. Lian and Zeng[85] and Zhao high as 40%.[104] To prevent habitual patellar dislocation, repair
et al[86] treated Hoffa fracture patients with plates combined with of the medial retinaculum complex or a combination of lateral
screws and achieve good results. Based on plate position, screws retinacular release[14,105] and simultaneous patellar ligament
can be combined with a lateral antigliding plate[84] or a posterior insertion on the tibial tubercle is recommended. For tibial
antigliding plate.[55,87] fractures, the use of bone plates or intramedullary nails is
Hoffa fractures are caused by shear stress between the femoral recommended if the condition of the local soft tissue is suitable.
condyle and tibial plateau. According to the internal fixation For local soft-tissue injuries, external fixation can be used, but
principle, the antiglide plate should be fixed in the posterior this may delay the time to mobility restoration and affect
position. However, the latest biomechanical study[88] showed therapeutic efficacy.
that lateral antiglide plate has greater anti-shearing strength than
posterior fixation. Moreover, the placement of a posterior
6.5. Postoperative management
antiglide plate with screws strips more soft tissue, especially the
insertion of the gastrocnemius heads, and may destroy the blood On The 1st postoperative day, the injured limb should be
supply to the fragments. In addition, the lateral antiglide plate can mobilized on a continuous passive motion device. Partial weight
provide stable support, and in combination with autologous bone bearing with crutches is started at 6 to 8 postoperative weeks.
grafting can promote fracture healing,[38,55,89] which is especially Weight bearing is allowed with radiographic evidence of healing,
useful for treating old Hoffa fractures. which usually occurs by 10 weeks of the postoperative period.[55]
Hoffa fracture with cruciate ligament, lateral collateral
ligament, or meniscus injuries can be treated with arthroscopic
7. Summary
surgery,[90] which has the advantages of minimal invasion, less of
an effect on blood supply, early postoperative return to Improving the accuracy and timeliness of Hoffa fracture
functional exercise, and effective prevention of nonunion and diagnosis and improving minimally invasive treatment outcomes
joint stiffness.[53,91] However, some Hoffa fractures combined remain the focus of orthopedic surgeons. Familiarity with the
with a tear of the posterolateral horn of the lateral meniscus are characteristics of Hoffa fracture on various imaging modalities
identified intraoperatively, and tear of the lateral meniscus can be and an understanding of the mechanism and likelihood of
repaired with suture anchors. Suture anchors are drilled into the combined injuries contribute to the timely and accurate diagnosis
posterolateral tibia to repair the meniscus to the meniscosynovial of Hoffa fracture and avoiding misdiagnosis. According to the
junction.[92] Moreover, if soft tissue embedded within the severity of Hoffa fracture and combined injuries, a reasonable

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treatment plan can be developed. Further improvements in [22] Calmet J, Mellado JM, Garcia Forcada IL, et al. Open bicondylar
Hoffa fracture associated with extensor mechanism injury. J Orthop
arthroscopic-assisted reduction and other minimally invasive
Trauma 2004;18:323–5.
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medial Hoffa fracture associated with ipsilateral vertical patella
fracture. J Clin Orthop Trauma 2013;4:102–5.
Author contributions [24] Potini VC, Gehrmann RM. Intra-articular dislocation of the patella
with associated hoffa fracture in a skeletally immature patient. Am J
Funding acquisition: Wei Chen.
Orthop 2015;44:E195–8.
Project administration: Wei Chen. [25] Chang JJ, Fan JC, Lam HY, et al. Treatment of an osteoporotic Hoffa
Supervision: Qingxian Wang, Zhiyong Hou, Wei Chen. fracture. Knee Surg Sports Traumatol Arthrosc 2010;18:784–6.
Writing – original draft: Yabin Zhou. [26] Wu P, WB , Kong LC, et al. Oral application of Qiangguyin Keli and
Writing – review & editing: Ying Pan. alendronate sodium vitamin D3 tablets in postoperative anti-
osteoporosis treatment in patients with primary osteoporotic hip
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