Name:
Hoffa Fracture Letenneur Type II
Description:
Hoffa Fracture Letenneur Type II
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Duration:
T00H07M29S
Embed URL:
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Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/16449e20-4c09-4314-81fb-353f2de93ca7/Hoffa fracture Letenneur type II.mp4?sv=2019-02-02&sr=c&sig=%2FEaTKkJCLrT2538ktr%2BdA%2Fmv2chL5ADeLz%2FvgYcJkuc%3D&st=2024-11-21T17%3A10%3A10Z&se=2024-11-21T19%3A15%3A10Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: Good evening, everyone. My talk would be on how I approach and fix a Letenneur type 2 or four fracture. Letenneur type 2 of a fracture is signified by a fracture line that runs almost parallel to the posterior femoral condyle. It is further classified in two types a, b, and c, depending on the location of the fracture line.
ASHOK GAVASKAR: Type two C tends to have no soft tissue attachment whatsoever, whereas types A and B might have the collateral and the properties on the lateral side attached to it sometimes. So how do I approach and fix it? So what exposure I use, how do I reduce and what kind of fixation I use? So this practice can be done in supine, lateral or prone position, and it will depend on what side you want to approach, what kind of surgical approach you want to use, and also the fracture pattern and the extent of commination and impaction that you want to address.
ASHOK GAVASKAR: Conversely, we tend to use anterior based surgical approaches to address fractures. On the lateral side, you can use a swashbuckler or a lateral parapatellar, on the medial side, a middle parapatellar or a medial Sub vastus is often sufficient. So this is true for most type I and three fractures, but for type 2 injuries you may need something more most of the time. So my go to approach for a lateral type 2 or four would be a Gerdy tubercle osteotomy combined with the swashbuckler or a lateral parapatellar approach.
ASHOK GAVASKAR: It gives you excellent posterial lateral access and also allows you to plate along the rim of the lateral condyle. So this is a 37-year-old male who had a comminuted Hoffa, a type II injury, as you can see on the CT with some comminution anteriorly. So we addressed this by using a Gerdy tubercle osteotomy with a swashbuckler approach.
ASHOK GAVASKAR: We used three five AP screws, combined them with two four mini fragment rim plate along the lateral condyle. And the osteotomy was fixed with 3.5 millimeter cortical screws. Another similar case in a 90-year-old male with a bicondylar hoffa type 2 lateral injury and a type III medial injury. So since this required access to both condyles, we used the latteral parapatellar and then use a Gerdy turbercle osteotomy to address the lateral type II injury.
ASHOK GAVASKAR: So this is what it looks like intraoperatively and at the end of fixation where we could achieve anatomical reduction and a stable fixation in this 90-year-old gentleman. On the medial side, a subversive vastus approach is our go to approach. as it gives you great posterial middle axis. You can plate it posteriorly also if you need, but if you want to position posterior to anterior screws, it is often difficult for this.
ASHOK GAVASKAR: If you want to do it, you can do it better by using a posterial medial approach in a prone position. So this was a Letenneur type IIa fracture in a 59-year-old female. We approached her by using a medial sub varsus approach, reduced the fracture and then fixed it with AP lag screws and then neutralized it by using a proximal tibial lock plate. And this is how it looks like postoperatively
ASHOK GAVASKAR: at 14 months, once the implants were removed. For type 11c injuries on the lateral side, none of the approaches that I described before may be very useful. These fractures tend to be too small and too posterior, and it often requires a posterolateral approach and you might have to combine it with a lateral epicondyle or osteotomy most of the time. So this is a 44-year-old female, the type IIc injury on the lateral side.
ASHOK GAVASKAR: We use a posterolateral approach in a lateral position. The plane posterior to the biceps is developed after protecting the common peroneal nerve. This gives you greater access to the posterolateral condyle. You can reduce and fix it with posterior to anterior screws, but if you have more anterior fracture fragments especially impacted articular segments, then a lateral epicondyle osteotomy if you're actual epicondyle is not already broken.
ASHOK GAVASKAR: Comes in really handy and this is how we go about and fix it by using varisation screws and then the osteotomy is fixed with a 6/5 screws. What about fracture reduction type IIc fractures? I have no soft tissue attachment, so they reduce easily. Type IIa, and b require flexions. So most often these fractures reduce easily in a third degree of flexion. Supra-lateral are lax, it also negates the posterior tibial slope, and you might require a joystick in the intact femur to re-rotate it and reduce the fracture to the posterior chondral fragment.
ASHOK GAVASKAR: You also have to be wary about articular impaction. It is rare, but when it is present it is often seen between the transition at ephemeral and femoral articulations. So this is a young male with a poly trauma. He had a shaft and a neck of femur fracture and a type II lateral off of distal impaction. And this is what it looks like intraoperatively and after this impaction and this is all we went again and fixed it using AP lag screws and then with a ring plate and then the osteotomy was fixed as well.
ASHOK GAVASKAR: What about fixation? As I said, AP screws are rarely sufficient for these injuries and you might require something more most of the times. So our go to technique would be to combine AP screws with a plate along the rim or in rough mode for most type 11 a and b injuries. And for type II c injuries, you will require posterior to anterior screws and you can use PA screws for also b and a type injuries.
ASHOK GAVASKAR: So this is an example of a case where we have used posterior to anterior screws in type IIB over on the lateral side, which was approached by using a posterolateral approach using a lateral epicondyle osteotomy. Another example to show a ring plate on the lateral side is a young male who had a type IIa lateral Hoffa and avulsed fibular head. And this is all we've got is Gerdy tubercle osteotomy with a swashbuckler.
ASHOK GAVASKAR: Here we use the pelvic reconstruction plate in a rim fashion and this is how it looks like postoperatively and after healing at three months. There's a young male. We got a C3 fracture of the distal femur with bincondylar Hoffa, he had a type II injury on the medial side, as you can see and so this is how we went ahead and fixed it. After using a lateral lock plate, we used a small three 5t plate in a raft mode using a raft of screws into the posteromedial condyle to stabilize it.
ASHOK GAVASKAR: And this is how we healed up at one year without any problems. So in summary, Letenneur type II injuries tend to be more posterior and distal. You have less soft tissue attachment, so you have to be careful about devascularizing them more in type II A and B injuries type swashbuckler and parapatellar approaches on the lateral side combined with the Garty tubercle osteotomy will do great. For the medial side.
ASHOK GAVASKAR: subvastus approach is often sufficient for type IIc injuries, on the lateral side, it will require a posterolateral approach, plus or minus a lateral chondrial osteotomy and on the medial side, for such a fracture you will require to go prone using a posteromedial approach. For fixation, AP screws plus a plate is sufficient for a type A and B fractures.
ASHOK GAVASKAR: For types IIC fractures, you will often require posterior to anterior countersunk or headless screws. Thank you.
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