Clinical decision algorithm for managing Hoffa's fat pad: Preservation, partial resection, or complete excision?

The management of Hoffa's fat pad during knee arthroscopy remains controversial. Resection is frequently performed to improve visualization or address inflammation, yet standardized criteria guiding the extent of excision are lacking, often leading to inconsistent postoperative outcomes. The purpose of this study was to develop a clinically applicable decision algorithm integrating clinical presentation, MRI characteristics, and intraoperative findings to guide the choice between preservation, partial resection, and complete excision of Hoffa's fat pad.

A retrospective single-center review of 60 patients undergoing arthroscopic procedures involving the infrapatellar fat pad between 2016 and 2021, with follow-up completed through 2024, was performed. Patients were categorized by surgical management: preservation, partial resection, or complete resection. Demographic, clinical, and MRI parameters were correlated with functional outcomes (VAS, Kujala scores) at a minimum follow-up of 36 months. Results from the cohort were combined with evidence from a focused literature review to develop the final clinical decision algorithm.

All groups improved postoperatively, but preservation was associated with superior outcomes (VAS 2.1 ± 1.0; Kujala 92 ± 8) compared with partial (3.0 ± 1.3; 86 ± 10) and complete resection (3.8 ± 1.6; 82 ± 12; p < 0.05). MRI patterns correlated with surgical findings: diffuse edema favored conservative care, localized fibrosis benefited from partial resection, and nodular fibrosis required complete excision. The algorithm correctly classified 90% of satisfactory outcomes.

The proposed algorithm provides a reproducible, evidence-informed approach for managing Hoffa's fat pad. Preservation should be prioritized to maintain biomechanical and synovial function, reserving resection for clearly defined fibrotic or mechanical lesions.

IV (retrospective therapeutic cohort study).