Surgical Discussion

Patient positioning:  Supine positioning was utilized, with the leg prepared for both posteromedial and anteromedial surgical access.

Anatomical surgical approach:  The surgical approach commenced with a posteromedial incision, slightly anterior to the typical line, allowing exposure of the posteromedial fragment. Dissection proceeded anterior to the MCL. Anteromedial access was also established for additional fragment manipulation and fixation. Submeniscal arthrotomies were performed vertically at fracture sites for direct visualization of articular reduction.

The surgeon noted the absence of a standard algorithm for reduction in this complex fracture pattern. Manipulation of fragments was performed through created windows, followed by provisional wiring. A significant bone defect beneath the articular fragments was addressed by avoiding autograft use due to the need for structural support. A custom-fabricated blade from a bent 1/4 or 1/3 tubular plate was employed as a fixed-angle device for fragment-specific fixation and support. Posteromedial and direct medial buttress plating was performed, along with an anteromedial "baby blade" construct to maintain articular slope.

Postoperative protocol:   Postoperative rehabilitation included early mobilization with weight-bearing as tolerated, progressing based on clinical and radiographic healing over approximately three months.

Follow up:   Not specified.

Orthopaedic implants used:   External fixator, 1/4 or 1/3 tubular plate (custom-bent), posteromedial buttress plate, direct medial buttress plate, anteromedial blade construct.