Fixation Strategies in Hoffa Fractures: A Systematic Review and Meta-Analysis of Surgical Outcomes.

Abstract

Hoffa fractures are rare, unstable coronal plane injuries of the distal femur. Optimal fixation strategies remain debated, particularly in cases complicated by medial voids or nonunion. We performed a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, and the Cochrane Library were searched from January 2000 to March 2025 using predefined keywords. Eligible studies included randomized and observational clinical studies reporting outcomes of operative fixation for Hoffa fractures. Data extracted included union rate, time to union, functional scores, complications, and fixation method. Risk of bias was assessed with the ROBINS-I tool, and certainty of evidence was rated using GRADE. Pooled estimates were calculated using fixed- or random-effects models depending on heterogeneity, with subgroup analyses for fixation strategy and medial voids. Publication bias was assessed using funnel plots and Egger's test, where ≥ 10 studies were available. Seventeen studies (<i>n</i> = 432 patients) were included: 246 treated with screw/single-plate fixation and 186 with dual plating.<i>Union rate</i>: 99.2% (95% CI 97.4-99.9; <i>I</i> ² = 12%).<i>Time to union</i>: Weighted mean 15.4 weeks across 12 studies; most did not report variance data, precluding pooled meta-analysis. Healing was delayed by ~ 5.5 weeks in studies describing medial voids.<i>Functional outcomes</i>: Eight studies reported scores using various systems (KSS, IKDC, Neer, and Letenneur). Results clustered around a weighted mean of ~ 84/100. Variance data were inconsistently reported; therefore, outcomes were summarized descriptively. Dual plating groups tended to show higher scores (~ 87) than screw/single-plate fixation (~ 81).<i>Complications</i>: 7.1% (95% CI 5.5-9.3; <i>I</i> ² = 15%), based on ten studies. Dual plating was associated with fewer reported complications (2.1% vs. 7.10%).Funnel plots showed no major asymmetry. Certainty of evidence was moderate for union, moderate-high for complications, and low for time to union and function. Both screw/single-plate and dual plating achieve high union rates in Hoffa fractures. Dual plating was associated with fewer complications and higher reported functional outcomes, particularly in fractures with medial voids or comminution. While these findings support dual plating in complex cases, the evidence base is limited by small sample sizes and incomplete variance reporting. Prospective multicenter trials with standardized outcome measures are needed to refine fixation strategies. The online version contains supplementary material available at 10.1007/s43465-025-01650-9.