Surgical Discussion

Patient positioning:  The patient was positioned supine, with the leg supported under the distal thigh with a carbon roll, allowing intraoperative flexion of approximately 30 degrees.

Anatomical surgical approach:  A two-incision approach with a semi-suspended lower limb allowed approximately 270-degree access around the joint, which made possible a Lobenhoffer approach and direct plating of the posterior column. This minimized the need to reposition the patient from prone to supine intraoperatively, thus saving around 40 minutes of operative time.

Following the preoperative plan, the posteromedial approach to the posterior column allowed for the unremarkable plating of the posterior shear coronal fracture with a modified distal tibial locking plate. This distal tibial plate has multiple distal screw options, and the curvature and angulation of the locking screw trajectories fitted this fracture pattern appropriately. After the installation of the posteromedial plate, we shifted to the anteromedial side to provide support for the medial column, using deliberately short anteromedial subchondral screws. This prevented the screw positions from interfering with the reduction and fixation of the lateral condyle.

The length of the medial plate was chosen such that the external fixator pins distally were adequately bridged, thus avoiding stress risers and concentration at this previously operated level. The lateral side was intriguing; following soft tissue mobilization and exposure of the lateral condyle fragment, the lateral condyle spontaneously extruded itself from the wound, as visualized in the intraoperative images. This included a visible fibular articular facet as a single free fragment, allowing excellent visualization of the lateral meniscus, which was longitudinally torn. This facilitated direct open suture repair of the meniscus before the reinstallation and fixation of the condyle piece.

Interestingly, following reduction of condyle height and coronal plane alignment of the limb, the crush injury to the fibula head was reduced under indirect ligamentotaxis. While a reconstruction of the posterolateral corner was fully anticipated, the tension of the lateral sided structures following column height reduction was excellent with no residual valgus instability demonstrable intraoperatively. Consequently, no further surgical fixation or reconstruction of the posterolateral corner was required.

Postoperative protocol:   The postoperative rehabilitation protocol mandated the patient to remain non-weight-bearing for eight weeks postoperatively. Given the coronal plane stability and lack of injury to the medial and lateral collateral ligaments, no orthotic bracing was necessary. Partial weight-bearing was commenced at eight weeks, gradually increasing to total weight-bearing between 10 and 12 weeks postoperatively. Encouragement of full range of motion started from day one. The postoperative images provided at 12 months postoperatively showed consolidation of the fracture and maintained varus-valgus alignment. Unfortunately, the radiographic projection did not clearly demonstrate the lateral joint surface. However, a minimal loss of height can be appreciated in the lateral projection, while some loss of height in the sagittal plane remains acceptable. The clinical images at 12 months demonstrated no clinically relevant varus-valgus alignment deformity. The patient had a complete pain-free range of motion with full active extension, no extension lag, and active flexion of 130 degrees comparable to the non-operative side.