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- PreOp Planning
    - most important step in reconstruction of any intra articular frx, is to expose the fracture w/o devasclarizing the fragments;
    - treatment plan:
           - open reduction;
           - elevation of the depressed plateau;
           - bone grafting of metaphysis;
           - fixation of the fracture with cancellous screws
           - butress plating of the lateral cortex;
    - position:
           - for optimal exposure, consider supine position, w/ a bolster under thigh, & table broken so that the knee is flexed 90 deg;
           - this position allows increased exposure submeniscally;

- Surgical Approach:
      - consider a longitudinal lateral parapatellar approach;
      - elevate anterior compartment muscles off proximal tibia, exposing tibial flare and split frx;
      - trace frx is to joint line and enter joint thru transverse sub-meniscal interval;
             - if needed, transect attachment of anterior horn of meniscus;
             - elevate meniscus superiorly to expose intra-articular frx segment;
      - if the anterior compartment is tight, consider limited fasciotomy to avoid compartment syndrome;

- Exposure of Depressed Segment:
    - split frx is hinged open anteriorly (like a book) to expose depressed joint surface;
    - insert an osteotome below the subchondral cancellous fragments and gently tap the osteotome until it comes to rest along the posterior 
          tibial cortex;
    - use the posterior cortex as a fulcrum for the osteotome and lever it upwards to lift all of the frx fragments "en mass" until they are 
          congruent with the joint line;
          - the mistake to avoid is to attempt to individually disimpact frx fragments, since this results in multiple separate pieces which cannot be 
                 held congruent at the joint line;
    - elevated segment may be supported w/ K wires (consider biodegradable);
          - metal wires can be inserted from the opposite (medial) condyle in order to maintain the elevation of the depressed fragment 
                 temporarily, until the split fragment is firmly reduced;
          - absorable K wires can be inserted from both the medial and lateral sides, to form a carpet configuration;
    - apply bone graft from below;
          - this surface is elevated to appropriate level & defect is filled w/or local cancellous bone or allografts;

- Implants:
    - at this point, the frx has essentially been turned into a type I frx;
    - w/ minimal comminuation and good bone stock, consider 6.5 mm cancellous screws w/ or w/o washers;
           - if cannulated screws are used, these are inserted over K wires;
           - if split fragment is not comminuted, 2 or 3 cancellous screws are inserted parallel to & > 1 cm distal to articular surface;
           - an additional, cortical anti-glide scrw w/ washer is inserted distally;
    - in older patients, w/ osteoporotic bone, one cannot rely on lag screws alone to prevent redisplacement of fragments;
           - a butress plate is almost a must;
           - a comminuted frx, requires an L or T shaped buttress plate;
           - another indication, for butress plating is assoc subcondylar frx;

     

- Case Example:
    - 30 year old male who fell during a soft ball game.
    - as the axial view clearly shows, there are several intra-articular fragments which are impacted into the metaphyseal bone;
    - as expected, complete anatomic restoration of these multiple articular fragments could not be achieved