Surgical Discussion

Patient positioning:  The patient was positioned in the lateral decubitus position. Due to body habitus, a 2mm Steinmann pin was placed under fluoroscopic guidance to accurately identify the femoral shaft and facilitate correct limb alignment intraoperatively.

Anatomical surgical approach:  A standard Kocher-Langenbeck approach was performed. The incision was made along the posterior aspect of the coxa, centered over the greater trochanter and extending distally along the femoral shaft. Subcutaneous adipose tissue was dissected to expose the fascia lata, which was incised in line with the skin incision. The gluteus maximus was split in line with its fibers, and the short external rotators (piriformis, obturator internus, gemelli) were identified and retracted or released as necessary to expose the posterior column and wall of the acetabulum. The sciatic nerve was identified and protected throughout. The fracture site was exposed, and the wedged chondrocancellous fragment was retrieved from the region adjacent to the incisura ischiadica major. Anatomic reduction of the articular fragment, posterior column, and posterior wall was achieved, followed by fixation with contoured plates and screws.

Morbid obesity significantly complicated intraoperative exposure, anatomical landmark identification, retraction, and fluoroscopic imaging. A 2mm pin placed under C-arm guidance facilitated accurate identification of the femoral shaft for limb positioning. Retrieval of the intra-articular chondrocancellous fragment required careful dissection near the greater sciatic notch. After reduction of all fragments, contoured plates and screws were applied to maintain stability. Postoperative imaging confirmed accurate reduction and appropriate implant placement. Wound management strategies were employed to mitigate increased risk of complications associated with obesity.

Postoperative protocol:   Early passive range of motion exercises were initiated postoperatively. Toe-touch weight bearing was maintained for 8-12 weeks, with progression to partial and then full weight bearing as radiographic healing permitted. Wound care protocols were intensified due to increased risk of dehiscence and infection in morbid obesity.

Follow up:   Not specified

Orthopaedic implants used:   Contoured reconstruction plates; cortical screws