Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table, with the leg prepared for both posteromedial and anterolateral surgical access.

Anatomical surgical approach:  The surgical procedure commenced with a posteromedial approach to the tibia, allowing for buttress plating of the medial condyle. This was followed by an anterolateral approach, involving a longitudinal incision and subperiosteal dissection to expose the lateral tibial plateau. A submeniscal arthrotomy was performed to facilitate direct reduction of the articular surface.

Operative remarks: 

Intraoperative imaging of the contralateral knee was obtained to assist in anatomical reconstruction of the articular surface. The posteromedial approach allowed for effective buttress plating, while the anterolateral approach facilitated reduction and fixation of the lateral condyle. A distractor was utilized to aid in visualization and reduction, with tamping employed to achieve optimal articular congruity before definitive fixation.

In accordance with the key principles of periprosthetic fracture management, several essential questions were addressed preoperatively:

1) Was the prosthesis functioning well prior to the injury?

2) Is the tibial component well-fixed or loose?

In this patient, the implant had been well-functioning with no prior pain, and advanced imaging (CT) confirmed that the tibial baseplate was well-fixed, not loosened by the injury. These findings strongly supported the decision for surgical fixation.

A critical intraoperative step was obtaining imaging of the contralateral knee, which served as a reference for anatomic articular reconstruction—this should be considered standard practice in complex periarticular injuries.

Factors contributing to success in such cases include:

– A well-functioning prosthesis pre-injury

– Absence of arthritis in the remaining compartments

– A well-fixed implant despite the fracture

– Careful surgical planning respecting prior incisions

– Anatomic reduction and stable fixation of both the medial and lateral columns

– Adherence to fundamental fracture principles, treating the injury “as if the implant were not there,” as emphasized in expert commentary.

Postoperative protocol:   Postoperative rehabilitation included initial touch weight-bearing (TWB) for 4 weeks, progressing to partial weight-bearing (PWB) from week 5, and full weight-bearing (FWB) by week 6 post-surgery.

Follow up:   Not specified.

Orthopaedic implants used:   Buttress plate, distractor, submeniscal arthrotomy instruments.