Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Partial articular fracture, frontal/coronal, posterior condyle(s)

ORIF - anterior screws for large fragments

1. Principles

Hoffa fractures involve important load-bearing areas of the knee joint surface, and the principles of anatomical reduction and absolute stability of fixation apply.

Fixation can be achieved indirectly with 3.5 mm or 4.5 mm screw systems. It is advantageous to use cannulated screw systems.

In small fragments direct fixation is required through a posterior approach.

At least two screws should be used, in order to prevent fragment rotation and to achieve satisfactory compression.

No implant is allowed to violate on the articular surface.

Similar principles apply if both condyles are fractured.

3. Approaches

For this procedure the following approaches may be used:

These difficult fractures can be approached for reduction and fixation from the anterior aspect. If the posterior condylar fragments are large, the fracture lines will usually be accessible by the parapatellar approach.

For shallower fragments the standard lateral/anterolateral approach is necessary to gain more posterior access: alternatively, a posterior approach should be considered.

For the medial side, a straight medial approach can be used, taking care to avoid injury to the infrapatellar branch of the saphenous nerve.

4. Reduction

Achieve reduction using periosteal elevators and a large pointed reduction forceps. The joystick technique, in which a small Schanz screw is inserted from the extraarticular surface, is also useful (as illustrated).

5. Fixation

Guide-wire insertion

Insert the guide wires as perpendicularly as possible to the fracture plane.

Check guide-wire placement

Check the correct guide-wire insertion under fluoroscopic image intensifier control. The condylar surface must not be perforated.

Countersinking

Countersink manually, deeply enough to allow for fully buried screw heads.

Pitfall: countersinking too deeply
Be aware of countersinking too deeply into the cancellous bone, which often happens using a power tool.

Do not perform countersinking when planning the use of headless compression screws.

Screw length determination

Determine the appropriate screw lengths, inserting the dedicated measuring device into the countersunk hole.

Screw insertion

Insert the screws using the cannulated screw driver and check under image intensifier control in the lateral and oblique views that the screw length was chosen correctly.

X-ray

X-ray showing the completed osteosynthesis.

Appendix

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v1.0 2008-12-03