Fragment size of lateral Hoffa fractures determines screw fixation trajectory: a human cadaveric cohort study

Abstract

Background and purpose: Recommendations regarding fragment-size-dependent screw fixation trajectory for coronal plane fractures of the posterior femoral condyles (Hoffa fractures) are lacking. The aim of this study was to compare the biomechanical properties of anteroposterior (AP) and crossed posteroanterior (PA) screw fixations across differently sized Hoffa fractures on human cadaveric femora. Patients and methods: 4 different sizes of lateral Hoffa fractures (n = 12 x 4) were created in 48 distal human femora according to the Letenneur classification: (i) type I, (ii) type IIa, (ii) type IIb, and (iv) type IIc. Based on bone mineral density (BMD), specimens were assigned to the 4 fracture clusters and each cluster was further assigned to fixation with either AP (n = 6) or crossed PA screws (n = 6) to ensure homogeneity of BMD values and comparability between the different test conditions. All specimens were biomechanically tested under progressively increasing cyclic loading until failure, capturing the interfragmentary movements via motion tracking. Results: For Letenneur type I fractures, kilocycles to failure (mean difference [∆] 2.1, 95% confidence interval [CI] –1.3 to 5.5), failure load (∆ 105 N, CI –83 to 293), axial displacement (∆ 0.3 mm, CI –0.8 to 1.3), and fragment rotation (∆ 0.5°, CI –3.2 to 2.1) over 5.0 kilocycles did not differ significantly between the 2 screw trajectories. For each separate subtype of Letenneur type II fractures, fixation with crossed PA screws resulted in significantly higher kilocycles to failure (∆ 6.7, CI 3.3–10.1 to ∆ 8.9, CI 5.5–12.3) and failure load (∆ 275 N, CI 87–463 to ∆ 438, CI 250–626), as well as, less axial displacement from 3.0 kilocycles onwards (∆ 0.4°, CI 0.03–0.7 to ∆ 0.5°, CI 0.01–0.9) compared with AP screw fixation. Conclusion: Irrespective of the size of Letenneur type II fractures, crossed PA screw fixation provided greater biomechanical stability than AP-configured screws, whereas both screw fixation techniques demonstrated comparable biomechanical competence for Letenneur type I fractures. Fragment-size-dependent treatment strategies might be helpful to determine not only the screw configuration but also the surgical approach.

Keywords

• fragment size-dependent screw trajectories
• Hoffa fracture
• individualized surgical strategies
• Letenneur classification