Accepted Manuscript

Title: Algorithmic Treatment of Busch-Hoffa Distal Femur

Fractures: A Technical Note Based on a Modified Letenneur
Classification

Authors: Robinson E. Pires, Vincenzo Giordano, Fabricio

Fogagnolo, Richard S. Yoon, Frank Liporace, Mauricio Kfuri

PII: S0020-1383(18)30279-1
DOI: https://doi.org/10.1016/j.injury.2018.06.008
Reference: JINJ 7710

To appear in: Injury, Int. J. Care Injured

Accepted date: 2-6-2018

Please cite this article as: Pires RE, Giordano V, Fogagnolo F, Yoon RS, Liporace
F, Kfuri M, Algorithmic Treatment of Busch-Hoffa Distal Femur Fractures: A
Technical Note Based on a Modified Letenneur Classification, Injury (2018),
https://doi.org/10.1016/j.injury.2018.06.008

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Algorithmic Treatment of Busch-Hoffa Distal Femur Fractures:A Technical Note Based
on a Modified Letenneur Classification

Robinson E. Pires1,2, Vincenzo Giordano3, Fabricio Fogagnolo4, Richard S. Yoon5, Frank

Liporace5, Mauricio Kfuri4,6

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1 Department of the Locomotive Apparatus. Federal University of Minas Gerais, Belo
Horizonte (MG), Brazil
2 Department of Orthopedics. Felicio Rocho Hospital, Belo Horizonte (MG), Brazil

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3 Orthopaedic Trauma Department. Miguel Couto Hospital, Rio de Janeiro (RJ), Brazil
4 Department of Biomechanics, Medicine and Rehabilitation of the Locomotor

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Apparatus, School of Medicine of Ribeirão Preto, University of São Paulo
5 Division of Orthopedic Trauma & Adult Reconstruction, Department of Orthopedic

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Surgery, Jersey City Medical Center – RWJ Barnabas Health Jersey City, New Jersey,

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United States N
Missouri Orthopedic Institute, University of Missouri, Columbia, United States
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Corresponding author:
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Robinson Esteves Santos Pires

E-mail: robinsonestevespires@gmail.com
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Federal University of Minas Gerais - Av. Alfredo Balena, 190 - Belo Horizonte – MG,
Brazil. Phone: +55 31-3409-9757.
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Abstract
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Treatment of distal femur fractures in the coronal plane can be challenging. Depending on
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fracture line orientation, topography and associated comminution, decision-making regarding

approach and fixation is not straightforward and can result in complications. Therefore,

treatment of coronal plane distal femur fractures (Busch-Hoffa fractures) should be

approached in a systematic manner, leading to efficient planning and operative execution.

Here, we offer a proposed treatment algorithm, guiding treatment, approach and fixation

based on the modified Letenneur classification of coronal plane distal femur fractures.

Keywords: Knee fracture; Distal femur fracture; Articular fracture; Coronal plane fracture;

Hoffa fracture; Busch-Hoffa fracture; Surgical approach; Internal fixation; Fracture fixation;

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Open reduction.

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Introduction

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In 1869, Fredrich Busch was the first author to describe a coronal plane fracture of the

lateral femoral condyle1. In 1888, Albert Hoffa, using Busch’s original drawing in his book

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was credited with discovering the ‘Hoffa fracture’, a coronal plane distal femur fracture.
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Recently reviewing the history of femoral condyle fractures and noting the aforementioned
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evolution in discovery, Bartoníček and Rammelt recommended renaming coronal plane
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fractures of the distal femur “Busch-Hoffa fractures” to give appropriate credit to the original

author.1
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Busch-Hoffa fractures are caused by high-energy trauma. Nork et al. reported over
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80% occurred as a result of either motor vehicle or motorcycle accidents.2 Mechanistically,

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the injury results from axial shearing forces applied to the femoral condyles with the knee

joint in flexion.3 However, not all Busch-Hoffa fractures are the same. The Letenneur
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classification, aiming to characterize those injuries with higher likelihood of avascular

necrosis, takes into consideration the distance of the fracture line to the posterior cortical of
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the femur, and also the orientation of the fracture line (Figure 1).4

Type I depicts a fracture line, which is in line with the posterior cortex and, therefore,

yields a large fragment of the femoral condyle. Type I may also be associated with articular

comminution, adding a Type I variant to the Letenneur classification. Type II is an

osteochondral fracture, as the main fracture plane is away from the posterior cortical of the

femur. The fragment may, therefore be deprived from vascular supply. Depending on the size

of the osteochondral fragment, a type II may be subcategorized in IIa, IIb, and IIc. Letenneur

Type III has an oblique orientation, which intersects the articular surface anteriorly.

Based on the modified Letenneur classification, an algorithmic treatment protocol is

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proposed, offering preferred surgical approach to allow for facile, mechanistic, principle-

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based fixation strategies. Here, we outline each Letenneur fracture type associated with a

case-example to highlight the proposed strategy.

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Letenneur Type I

The procedure is performed under general anesthesia. The patient is placed prone on a

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radiolucent table with bump under the thigh allowing for fluoroscopic control in multiple
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projections. A longitudinal incision measuring approximately 10cm in length is placed on the
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posterolateral aspect of the knee, in line with the lateral head of the biceps tendon. A careful
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blunt dissection is carried out aiming to identify the peroneal nerve, which is located medially
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to the head of the biceps tendon. A number 2 Penrose drain is passed around the nerve, for its

protection and mobilization. Deep dissection is performed in between the lateral head of the
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biceps tendon and the iliotibial band. (Figure 2)

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The reduction is obtained with the knee in full extension. The distal fragment may be

mobilized with a ball spike pusher or with a Weber clamp. Provisional fixation is
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accomplished with Kirschner wires, under fluoroscopic control in multiple projections. A

3.5mm small fragments plate is contoured to buttress the posterolateral surface of the lateral
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condyle. Additionally, lag screws may be considered from posterior to anterior, avoiding the

penetration of the cartilage anteriorly. (Figure 3)

Letenneur Type I Variant

 In cases of posterolateral shearing with an impacted or comminuted osteochondral

fragment in the articular surface (Letenneur type I variant), the standard posterolateral

approach may be insufficient to provide adequate exposure and reduction of the articular

surface. Thus, we prefer to have our patient laying oblique on the operative table, with a

small foam under the ipsilateral hip, so we may perform an extended lateral approach to the

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knee joint with an osteotomy of the Gerdy tubercle. The osteochondral fragment is reduced

anatomically and fixed with headless screws. (Figure 4).

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Alternatively, an anterolateral parapatellar approach may be selected with the patient

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in supine position. The main drawback of this approach is the difficulty achieving fracture

reduction of the posteriorly sheared fragment with the flexed knee. We routinely use a Weber

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clamp to address fracture reduction and K-wires to provide provisional fixation. Lag screws
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from anterior to posterior are used to fix the fracture, and a horizontal plate increases
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construction stability (Figure 5).
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Letenneur Type II

For Letenneur types IIa, IIb, and IIc, our treatment preference is the posterolateral
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approach between the biceps tendon and the peroneal nerve (Figure 6) with the patient in
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prone position.

Performing this approach, one can fix small fragment fractures of the lateral condyle
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using screws from posterior to anterior (Figure 7). Depending on fragment location and size,
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one may consider approaching the fracture medially to the peroneal nerve. We strongly

recommend avoiding anterior to posterior fixation in Letenneur type II fractures, because it is

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very difficult to get a hold of small osteochondral fragments, which in this scenario would be

controlled by few screw threads.

Letenneur Type III

 For Letenneur type III, as we are dealing with a fracture that results in a large

posterolateral fragment we normally perform an anterolateral parapatellar approach, fixing

the fracture using anterior to posterior lag screws, accompanied with a horizontal

neutralization belt plate.

Medial coronal plane fractures

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Coronal plane fractures of the medial condyle are rare. Our treatment protocol

includes posteromedial subvastus approach with the patient in prone or supine-oblique

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position. When in supine-oblique position, a pad applied under the hip on the contralateral

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limb makes the approach easier, with the surgeon positioned on the opposite side of the

fracture.

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Fracture reduction is performed with the knee in extension. Provisional fixation is
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obtained using K-wires. A buttress reconstruction, DCP, or LCP plate can be placed on the
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posteromedial surface of the distal femur to fix the fracture. Lag screws are used from
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posterior to anterior to fix small fragments (Figure 8). Medial fracture patterns with proximal

extension present challenges related to implant choice. A pre-contoured proximal humerus

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plate turned upside down can fit well and offer several locking screws with ideal trajectory of
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fixation (Figure 9).

Figure 10 summarizes our treatment protocol according to the modified Letenneur

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Classification.
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Discussion

Busch-Hoffa fractures are rare, and treatment methods are based on the few reports in
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the literature. High suspicion index is required to prevent overlooking of coronal plane

fractures. Computed tomography scan should be obtained for an adequate preoperative

planning. Generally, Busch-Hoffa fractures are treated using the principle of absolute

stability to provide early range of motion and satisfactory functional outcomes.

 Several treatment possibilities were described to provide adequate reduction and

fixation, including anterior to posterior or posterior to anterior lag screws, posterolateral and

posteromedial plates, as well as horizontal plates7,8,9,10,11. However, clinical results remain

unsatisfactory in terms of complications. Recently, Onay et al. reported a 54% incidence of

osteoarthritis and a mean Knee Society Score of 78.4 (range, 53-95points)6.

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The Letenneur classification is the most cited system for coronal plane fractures of the

distal femur. To the best of our knowledge, we are unaware of any studies showing a

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treatment algorithm based on the Letenneur classification system, therefore providing a

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rationale for management of Busch-Hoffa fractures. Moreover, we identified the type I

variant, a modification to the original Letenneur classification, when an intercalary articular

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fragment is associated with type I fracture. In terms of Busch-Hoffa fractures, type I variant
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is relatively frequent, and the standard posterior approach developed for type I is inefficient
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to address the intercalary fragment. Thus, introducing the type I variant to the original
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classification, one can more adequately address the intercalary and the vertically sheared

fragments. Posterolateral approach with the Gerdy osteotomy, as well as the parapatellar
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approach using anterior to posterior lag screws plus a horizontal belt plate are very efficient
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treatment options for this fracture pattern.

Our preference for posterolateral buttress plates in Letenneur type I fractures is based
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on the biomechanical study of Sun et al8. The authors reported that plate fixation patterns
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implanted in the posterior or lateral position were shown to provide higher overall axial load

to failure and stiffness, and less vertical displacement than anterior to posterior or posterior to
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anterior screws fixation.

The main limitation of the present study is the lack of long-term outcomes using

validated functional scores to evaluate the presented treatment protocol. Since this is the first

presentation of the modified Letenneur classification, more data is needed to validate our
algorithm; in these rare fractures, a multi-center, international trauma registry may offer the

best data in determining an ideal approach and fixation protocol.

Conclusion

Busch-Hoffa fractures are challenging injuries and an accurate preoperative assessment of the

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injury, determining the exact plane of the fracture and the size of the osteochondral fragment

in the femoral condyle are key elements of the decision-making process. Our goals were to

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group the three most typical fracture patterns and bring awareness to a new variant of

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Letenneur classification. Future studies with series of cases using this algorithm should be

considered to validate our algorithm of treatment.

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Conflict of interest: The authors declare that they have no conflict of interest related to this
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manuscript.
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References

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femoral condyles. Int Orthop. 2015 Jun; 39(6): 1245-50.

2. Nork SE, Segina DN, Aflatoon K, et al. The association between supracondylar-

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intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg [Am]

2005; 87-A: 564–569.

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3. Dhillon MS, Mootha AK, Bali K, et al. Coronal fractures of the medial femoral

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condyle: a series of 6 cases and review of literature. Musculoskelet Surg. 2012; 96: 49–54.

4. Letenneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV. Hoffa’s fractures: report of

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20 cases (author’s transl). Ann Chir 1978; 32: 213–219

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Arastu MH, Kokke MC, Duffy PJ, Korley REC, Buckley RE. Coronal plane partial
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J 2013;95-B:1165–71.
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6. Onay T, Gülabi D, Çolak I, Bulut G, Gümüştaş SA, Çeçen GS. Surgically treated
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Hoffa Fractures with poor long-term functional results. Injury, Int. J. Care Injured. 2018; 49:

398–403.
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7. Gavaskar AS, Tummala NC, Krishnamurthy M. Operative management of Hoffa

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fractures - A prospective review of 18 patients. Injury, Int. J. Care Injured. 2011; 42: 1495–

1498.
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8. Sun H, He QF, Huang YG, Pan JF, Luo CF, Chai YM. Plate fixation for Letenneur

type I Hoffa fracture: a biomechanical study. Injury, Int. J. Care Injured. 2017; 48: 1492–

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9. Hill BW, Cannada LK. Hoffa Fragments in the Geriatric Distal Femur Fracture: Myth

or Reality? Geriatric Orthopaedic Surgery
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osteoporotic Hoffa fracture. Knee Surg Sports Traumatol Arthrosc. 2010; 18: 784–786.

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11. Pires RES, Giordano V, Santos JK, Labronici PJ, Andrade MAP, Lourenço PRBT.

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Figure 1: Modified Letenneur Classification System for Busch-Hoffa Fractures. Type I

depicts a fracture line which is longitudinal and in-line with the posterior cortex. If with

associated comminuted, we propose the Type I variant. Type II is purely osteochondral with

IIa, IIb, and IIc subclassification moving more posteriorly. Letenneur Type III has an oblique

orientation, which intersects the articular surface anteriorly.

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Figure 2 – (A): Posterior view of a knee specimen. The dotted horizontal line depicts the

popliteal crease. P: Proximal; D: Distal; L: Lateral; M: Medial. A longitudinal line is drawn

on the posterolateral aspect of the knee. (B): An interval between the lateral head of the

biceps tendon and the iliotibial band is developed to gain exposure to the posterolateral

aspect of the distal femur.

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Figure 3: A: Radiograph in lateral projection showing a coronal plane fracture of the lateral

condyle of the distal femur. B, C, D, and E: computed tomography scan in sagittal, axial, and

3D reconstruction showing the Busch-Hoffa fracture. F: Drawing of the posterolateral

approach (P: Proximal; D: Distal; L: Lateral; M: Medial; FH: Fibular head). G: Perioperative

image of the posterolateral approach showing the posterolateral anti-gliding plate and a

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Kirschner wire from posterior to anterior. H: Perioperative image in lateral view showing

fracture reduction and provisional fixation with the Kirschner wire. I and J: Post-operative

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images in anteroposterior and lateral views showing fracture reduction and fixation with a

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posterolateral plate and a partially threaded 4.0 mm cancellous lag screw.

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Figure 4: A and B: Radiographs in anteroposterior and lateral projections depicting a Busch-

Hoffa fracture of the lateral femoral condyle. C and D: Computed tomography scan in

coronal and sagittal series showing the intermediary fragment, which characterizes the

Letenneur type 1 Variant. E: Perioperative image showing the Gerdy osteotomy and the

fracture fixation using an anti-gliding plate and Herbert screws for the central fragment. F

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and G: Postoperative images in anteroposterior and lateral views showing anatomic reduction

and fixation with an anti-gliding plate and Herbert screws. H: Clinical outcomes after

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complete wound healing revealing a very satisfactory range of motion.

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Figure 5 - A and B: Computed tomography 3D reconstructions depicting a type 1 Variant

with central comminution. C: Perioperative image of the anterolateral approach showing the

fracture reduction and provisional fixation with K-wires. D and E: Postoperative images in

anteroposterior and lateral views showing fracture fixation with anterior to posterior screws,

complemented with a horizontal belt plate. F: Perioperative image of the anterolateral

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approach showing the fracture fixation with a horizontal belt plate.

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Figure 6 – (A): Posterior view of a knee specimen. For Letenneur type II our preference is a

posterolateral approach using the interval between the biceps femoris and the peroneal nerve.

(B): Alternatively, the lateral condyle can be addressed medially to the peroneal nerve, being

careful not to cross the midline of the knee, avoiding the vascular bundle.

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Figure 7 - A and B: Preoperative anteroposterior and lateral X-rays showing a lateral Type IIa

Busch-Hoffa fracture (open arrows). Note the associated fracture of the posterior tibial

plateau, including the insertion of the PCL (closed arrow). C: Preoperative CT-Scan axial

images showing the lateral Type IIa Busch-Hoffa (open arrows) and the posterior tibial

plateau (closed arrow) fractures. Also note an associated lateral sleeve fracture of the distal

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pole of the patella (ball-spiked arrow). D: Fractures were directly reduced and provisional

fixed with multiple smooth 1.2 mm K-wires. E and F: Postoperative anteroposterior and

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lateral X-rays showing the Type IIa Busch-Hoffa fracture fixation with multiple posterior to

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anterior 2.7 mm lag-screws screws; the posterior tibial plateau fracture was fixed with a

small-fragment plate with a hook. The fragmented small pieces of the distal pole of the

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patella were resected from the patellar ligament.
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Figure 8: A and B: Anteroposterior and lateral radiographs showing a coronal fracture of the

medial condyle. C and D: Coronal plane fracture of the medial condyle shown in CT scan. E

and F: Fracture fixation using 2 lag screws and a buttress reconstruction plate in

anteroposterior and lateral views. G: Sub-vastus approach and buttress plate. F and G: H and

I: Three months postoperative images showing proper fracture reduction without evidences of

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hardware failure.

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Figure 9: A and B: Distal femur in anteroposterior and lateral views after a gunshot injury,

presenting a comminuted articular fracture of the medial condyle. C, D and E: Sagittal, axial,

and 3D computed tomography reconstruction views showing a Busch-Hoffa fracture with

diaphyseal and intercondylar involvement, medially. F and G: Independent cannulated screws

support the fixation of the articular components. A proximal humerus plate used upside down

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improves fixation and allows for locking screws crossing the fracture line, therefore

purchasing into the lateral condyle. H and I: Anteroposterior and lateral views after healing,

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exhibiting a well-maintained joint line.

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Figure 10: Treatment algorithm for c 

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