Case presentation
A 46 years old man was admitted to the emergency department after falling from a building, which had been under construction, and after his fall he was injured by a falling brick in his right knee. A bicondylar Hoffa fracture was observed on the right knee based on radiographic examination (Figure 1) and computed tomography (Figure 2). Both the lateral and medial were displaced (Figure 3). The patient’s radiographs and CT scans also revealed avulsions of the medial and lateral collateral ligaments. Upon examination after anesthesia, both varus and valgus were unstable. Therefore, we decided to do a double approach since we could fix collaterals as well as fractures. An open reduction and internal fixation were performed two days after the accident. The patient was positioned supine with exsanguinated right limb. We used both medial and lateral approaches to the distal femur by incision on both sides. A lateral parapatellar arthrotomy was performed in order to discharge the joint hematoma. A flexed knee was used to deliver the Hoffa fragments manually from the anterior. As a result of anatomical reduction and the placement of multiple Kirschner wires of 2 mm to stabilize and reduce the temporal defects (Figure 3), the fragments were then anatomically reduced. After that, a large, pointed reduction clamp was used to compress the fragments. A direct visual evaluation of the articular surface and fluoroscopy confirmed anatomical reduction. In the deep flexion position at the posterior articular surface, six (three per fragment) 6/5 cannulated screw were inserted over 1.4 mm Kirschner wires and directed anteriorly perpendicular to the fracture plane to compress the fractures (Figure 4). Just below the cartilage-bone interface, these screws were driven in. In the final step, 3.5 mm reconstruction plate as an anti-Glide were applied in order to fix the fractures of the medial wall of the medial condyle and we used transosseous nonabsorbable suture to fix the medial and lateral collateral ligaments. We took post-operation radiograph after the surgery (Figure 4). We have visited the patient in 2, 4, 8, 12 weeks after the surgery. In the first month post operation, intermittent knee mobilization and isometric muscle strengthening exercises were prescribed and he was also allowed to have toe-touch weight bearing. The sutures were removed two weeks later post-operation. In the 4th week after the surgery, the patient switched from a walker to a cane, and after 8 weeks, the patient was allowed to have full weight-bearing. According to the latest follow-up, the patient was able to do all her daily and work activities without discomfort at 3 months after surgery and the knee range of motion had a range of 0–100∘. (Figure 5).