A Hoffa fracture is an uncommon intra-articular coronal shear fracture of the distal femoral condyle, accounting for less than 1% of all femur fractures (Zhou et al., 2019). The lateral condyle is predominantly affected due to the natural physiological valgus alignment of the knee during axial loading (Patel & Tejwani, 2018). Because the fracture line is intra-articular and subjected to intense shear forces during knee flexion, conservative management routinely fails. Anatomical reduction and rigid internal fixation are mandatory to restore joint congruity and prevent post-traumatic osteoarthritis (Viskontas, n.d.). Surgeons deploy multiple implants to stabilize these fractures, predominantly relying on partially threaded cannulated cancellous screws (CCS), headless compression (Herbert) screws, and lateral or posterior buttress plates (Maheshwari et al., 2019). Traditional headed CCS can cause cartilage irritation if not perfectly countersunk, whereas Herbert screws can be buried beneath the subchondral bone, providing excellent compression without joint impingement (Agarwal et al., 2021). Alternatively, buttress plates offer superior biomechanical stability against vertical shear forces, especially in severely comminuted fractures, but they necessitate extensive soft tissue stripping (Shawky et al., 2023). The purpose of this prospective study conducted at SCB Medical College and Hospital (Cuttack) is to critically evaluate and compare the functional outcomes, union rates, and complication profiles of these three distinct fixation modalities over a one-year follow-up period.

This prospective comparative study was conducted at the Department of Orthopaedics, SCB Medical College and Hospital (SCB MCH), Cuttack, between March 2025 and March 2026. A total of 112 adult patients presenting with isolated Hoffa fractures were enrolled. Inclusion criteria: Closed coronal shear fractures of the distal femur (Hoffa fractures), age over 18 years, and presentation within two weeks of injury. Exclusion criteria: Open fractures, associated ligamentous knee injuries, pathological fractures, and polytrauma cases. Fractures were classified using the Letenneur classification system based on CT imaging (Chen, n.d.). Patients were sequentially assigned to one of three surgical interventions based on fracture morphology and surgeon discretion: 1. Group A (n=38): Fixation with 4.0 mm or 6.5 mm Cannulated Cancellous Screws. 2. Group B (n=39): Fixation with headless compression Herbert Screws. 3. Group C (n=35): Fixation with a pre-contoured Buttress Plate (frequently augmented with lag screws). Postoperatively, patients underwent a uniform rehabilitation protocol consisting of static quadriceps exercises on day one, followed by active-assisted range of motion (ROM) as tolerated. Strict non-weight bearing was maintained for 6 weeks, progressing to full weight bearing by 10 to 12 weeks upon radiographic confirmation of bridging callus. Functional evaluations were conducted at 3, 6, and 12 months using the Knee Society Score (KSS).

The study population comprised 112 patients, predominantly young males involved in high-energy road traffic accidents. The baseline demographics and fracture characteristics were uniformly distributed across all three treatment arms without any statistically significant disparity (Table 1). Table 1: Patient Demographics and Fracture Characteristics Parameter CCS (n = 38) Herbert Screws (n = 39) Buttress Plate (n = 35) p-value Mean Age (Years) 38.2 ± 11.4 36.9 ± 10.8 40.1 ± 12.1 0.45 Gender (M:F) 26:12 29:10 24:11 0.81 Mechanism of Injury - Road Traffic Accident 28 31 25 0.58 - Fall from Height 10 8 10 Letenneur Classification - Type I 14 16 12 0.76 - Type II 15 17 10 - Type III 9 6 13 Intraoperative metrics varied significantly depending on the implant chosen. The buttress plate group required significantly longer operative times and experienced greater intraoperative blood loss due to the necessity of wider surgical exposure. Time to bony union remained comparable across all modalities (Table 2). Table 2: Intraoperative and Postoperative Parameters Parameter CCS (n = 38) Herbert Screws (n = 39) Buttress Plate (n = 35) p-value Mean Surgical Time (min) 62.4 ± 14.2 58.6 ± 12.5 88.3 ± 18.1 < 0.01* Mean Blood Loss (mL) 145 ± 35 130 ± 28 260 ± 55 < 0.01* Time to Union (weeks) 12.6 ± 2.1 12.1 ± 1.8 12.8 ± 2.4 0.34 *Indicates statistical significance. Postoperative complications (Table 3) were predominantly related to hardware irritation and soft tissue stiffness. The CCS group reported the highest rate of hardware prominence (irritation), occasionally requiring implant removal. The buttress plate group experienced a higher rate of knee stiffness, whereas Herbert screws recorded the lowest overall complication profile. Table 3: Complication Profiles Complication CCS (n = 38) Herbert Screws (n = 39) Buttress Plate (n = 35) p-value Superficial Infection 2 1 4 0.21 Hardware Irritation 6 0 3 < 0.05* Knee Stiffness 4 2 7 < 0.05* Delayed Union 1 0 1 0.88 Functional outcomes evaluated via the Knee Society Score (KSS) demonstrated that patients treated with Herbert screws mobilized faster, achieving significantly higher KSS scores at the 3-month mark. By 12 months, the functional disparity neutralized, and all groups exhibited similar clinical outcomes (Table 4). Table 4: Functional Outcome (Knee Society Score) over 12 Months Follow-up CCS (n = 38) Herbert Screws (n = 39) Buttress Plate (n = 35) p-value 3 Months 68.4 ± 7.2 75.2 ± 6.8 65.1 ± 8.5 < 0.01* 6 Months 81.2 ± 6.4 85.6 ± 5.9 79.8 ± 7.4 0.08 12 Months 89.5 ± 5.1 91.2 ± 4.8 88.4 ± 5.6 0.42 Final clinical grading at 12 months (Table 5) categorized outcomes into excellent, good, fair, or poor. Over 80% of patients across all groups achieved excellent to good functional restoration. Table 5: Final Range of Motion and Clinical Grading at 12 Months Parameter CCS (n = 38) Herbert Screws (n = 39) Buttress Plate (n = 35) p-value Mean ROM (degrees) 118.5 ± 12 124.2 ± 10 114.6 ± 14 0.06 Excellent (>85 KSS) 22 28 19 0.28 Good (70-84 KSS) 11 9 11 Fair (60-69 KSS) 4 2 4 Poor (<60 KSS) 1 0 1

Hoffa fractures are notoriously challenging to manage due to their intra-articular nature and the intense deforming shear forces exerted by the gastrocnemius muscle (Bagaria et al., 2019). The primary goal of intervention is absolute anatomical reduction to prevent early onset post-traumatic arthritis and to allow aggressive early rehabilitation (Zhou et al., 2019). Our findings indicate that headless compression (Herbert) screws offer a distinct advantage during early recovery. Because these screws can be safely countersunk beneath the articular cartilage, they eliminate the hardware irritation commonly associated with headed cannulated cancellous screws (Mushtaq et al., 2022). Consequently, patients in the Herbert screw cohort exhibited significantly better Knee Society Scores at 3 months and achieved a slightly broader final range of motion, echoing the findings by Maheshwari et al. (2019). However, screw fixation alone may fail in osteoporotic bone or severely comminuted Letenneur Type III variants (Vairagade, n.d.). In such scenarios, buttress plating serves as a vital structural backstop, neutralizing vertical shear and preventing proximal fragment migration (Rampurwala, n.d.). While plating introduces a higher risk of knee stiffness due to extensive periosteal stripping (Neumann-Langen et al., 2023), its structural rigidity is unmatched for complex fracture patterns. Ultimately, all three fixation methods converge on similar functional endpoints at 12 months, provided anatomical reduction is achieved intraoperatively.

For isolated, non-comminuted Hoffa fractures, Herbert screws are the implant of choice. They provide exceptional interfragmentary compression, minimize articular profile disruptions, and facilitate rapid postoperative mobilization compared to traditional CCS. Buttress plates, despite their association with increased surgical time and soft tissue stiffness, remain indispensable for highly comminuted or multi-fragmentary Hoffa fractures where screw purchase alone is insufficient.

1. Agarwal, S., Krishna, L. G., Agarwalla, A., Talwar, J., & Rustagi, A. (2021). Lateral buttress plate along with cancellous screw fixation for Hoffa fracture using Swashbuckler approach. Indian Journal of Orthopaedics, 55, 780-785. https://doi.org/10.1007/s43465-020-00312-2 2. Bagaria, V., Sharma, G., Waghchoure, C., Chandak, R. M., Nemade, A., Tadepelli, K., & Pawar, P. (2019). A proposed radiological classification system of Hoffa's fracture based on fracture configuration and consequent optimal treatment strategy along with the review of literature. SICOT-J, 5, 18. https://doi.org/10.1051/sicotj/2019016 3. Chen, H. (n.d.). Novel CT-based classification of Hoffa fracture and optimal. 4. Maheshwari, V., Sharma, S. L., Goyal, D., Qureshi, P., & Hussain, Z. (2019). Clinical experience with management of Hoffa fractures using headless compression screw and headed screw. Journal of Clinical Orthopaedics and Trauma, 10, 934-940. https://doi.org/10.1016/j.jcot.2018.10.011 5. Mushtaq, M., Dhar, S. A., Bhat, T. A., & Dar, T. A. (2022). A case report of the Hoffa fracture and a review of literature. Chinese Journal of Traumatology, 25, 293-301. https://doi.org/10.1016/j.cjtee.2022.01.002 6. Neumann-Langen, M. V., Eggeling, L., Glaab, R., von Rehlingen-Prinz, F., Kösters, C., & Herbst, E. (2023). Hoffa fractures are associated with concomitant soft tissue injures and a high postoperative complication rate. Archives of Orthopaedic and Trauma Surgery, 144, 747-754. https://doi.org/10.1007/s00402-023-05133-0 7. Patel, P. B., & Tejwani, N. C. (2018). The Hoffa fracture: Coronal fracture of the femoral condyle a review of literature. Journal of Orthopaedics, 15, 726-731. https://doi.org/10.1016/j.jor.2018.05.027 8. Rampurwala, A. (n.d.). Role of distal femur anatomical plate in fracture of... 9. Shawky, M., Abdel Karim, M., Samir Mohamed Farahat, A., & Goda El-Hamalawy, A. (2023). Management of distal femoral fractures: A review article. Journal of Clinical Orthopaedics and Trauma, 46, 102291. https://doi.org/10.1016/j.jcot.2023.102291 10. Vairagade, P. (n.d.). Medial Hoffa's fracture treated with subvastus approach. 11. Viskontas, D. G. (n.d.). Technique of reduction and fixation of unicondylar medial Hoffa. 12. Wagih, A. M. (2015). Arthroscopic management of a posterior femoral condyle (Hoffa) fracture: Surgical technique. Arthroscopy Techniques, 4, e299-e303. https://doi.org/10.1016/j.eats.2015.03.005 13. Xiao, Y. (n.d.). Results of surgical treatment of Hoffa fractures in pediatric population. 14. Zhou, Y., Pan, Y., Wang, Q., Hou, Z., & Chen, W. (2019). Hoffa fracture of the femoral condyle. Medicine, 98, e14633. https://doi.org/10.1097/md.0000000000014633.