Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent operating table with a carbon roll under the proximal thigh to allow 30 degrees of knee flexion and 270-degree circumferential access to the tibial plateau.

Anatomical surgical approach:  A dual-window approach was utilized with longitudinal incisions over the medial and lateral aspects of the knee. The medial approach was larger due to distal fracture extension, while a limited lateral approach involved an osteotomy window at the inferior aspect of Gerdy's tubercle for indirect reduction of the central lateral articular surface using a bony tamp.

Intraoperatively, indirect reduction of the central lateral articular surface was challenging but achieved by elevating the depressed fragment to its approximate articular height through lateral window osteotomy and medial intrafocal manipultaion before being provisionally secured to the medial block with K-wires. This reduced articular surface and medial condylar block were then reduced en bloc to the intact lateral column. The restored, now intermediate, lateral articular fragment did lose some reduction during this en block manouver. Medial column height was restored by reducing the large intermediate fragment at the metaphyseal-diaphyseal transition, which included the superficial medial collateral ligament insertion, restoring valgus stability. A large bone reduction clamp compressed the femoral condyles before introducing two 6.5mm cannulated rafting screws laterally to medially, engaging the medial block fragment. An anteriomedial 3.5mm buttress plate with locking rafting screws was used to support the medial column and to secure medial collateral integrity.

Postoperative protocol:   Postoperatively, the patient was managed in a knee orthosis to reduce valgus stress, with immediate encouragement of free range of motion. Non-weight bearing was maintained for eight weeks, progressing to full weight bearing by ten weeks.

Follow up:   At 18 months follow-up, the patient demonstrated a pain-free range of motion from 0 to 140+ degrees, with a slight valgus axis compared to the contralateral side and no clinically identifiable ligamentous instability. No impedement of activity reported.

Orthopaedic implants used:   Two 6.5mm cannulated screws (lateral to medial) - Anterior medial 3.5mm buttress plate with locking rafting screws