Reconstructing a shattered knee: A case study in complex intra-articular fracture management

When a 58-year-old active farmer suffered a catastrophic knee injury, an orthopedic surgeon in Gujarat, India, undertook a rare and challenging surgical reconstruction. Here, Dr. Kashyap Ardeshna provides a first-hand account of the surgical approach, decision-making, postoperative strategy, and long-term outcome of a severe multi-fragmentary fracture of the knee joint.

Dr Kashyap Ardeshna's case presented in this Guest Blog was the winner of the myAO Case Competition 2025.

I have been practicing orthopedic surgery for over 25 years in Gujarat, India, with a primary focus on general trauma cases. As orthopedic surgeons we often say, “every fracture is a different fracture,” but this particular case stood out due to its severity and the resilience required both by the surgery team and the patient.

A 58-year-old farmer, the patient had always been physically active despite some age-related degenerative changes in his knees. His injury occurred from a fall in which he landed directly on his knee, resulting in a highly comminuted fracture. On initial inspection, the fracture resembled a shattered stone, with seven to eight individual fragments within the knee joint. These fragments included articular surfaces critical for knee function, making the restoration of joint congruity both urgent and exceptionally challenging.

What made this case significant was not only the extent of the injury but also the context: this was a man who relied almost entirely on his ability to perform physical labor. A poor outcome could have meant permanent disability, severely affecting not just his quality of life but jeopardizing his entire livelihood.

The complexity of the injury required a structured, multi-step approach, starting with comprehensive imaging. While X-rays provided an initial overview, it was the CT scan that delivered the critical 3D visualization of the fracture pattern. This enabled precise identification of each fragment and helped enormously in preoperative planning.

Such advanced imaging is essential for joint injuries where the accuracy of reduction dictates functional outcome. It allowed me to mentally reconstruct the knee and consider the tools and implants I would need. A detailed plan was then developed with contingencies in place—Plan B, and Plan C etc—including alternatives for fixation devices that might not conform to standard knee fracture patterns.

Equally important was patient counseling. I met with the patient and his family to explain the gravity of the injury, the surgical complexity, and all the possible outcomes, including the chance he might never regain full function. He was made aware of the possible need for job modifications and restrictions in his daily activities. After thorough discussions and obtaining informed consent, we proceeded with surgery.

The operation: piecing together a broken puzzle

Given the patient’s age and the extent of the fracture, a full pre-anesthetic workup was completed, and he was cleared for surgery. I assembled a surgical team of two orthopedic surgeons and four support staff, because I favored a team-based approach due to the anticipated technical challenges.

The joint was exposed via an open procedure similar to that used in total knee arthroplasty, allowing us full visibility. What we encountered were multiple fragments, many of which were too small to individually identify without proper sequencing – much like solving a jigsaw puzzle. The first step was to reconstruct the articular surface using temporary fixation with Kirschner wires (K-wires). Fragment by fragment, we identified and aligned them to reform the joint’s surface. Once reconstructed, this block of bone was then aligned with the diaphysis of the tibia.

One of the critical intraoperative challenges was the presence of a void within the area, a consequence of both osteoporosis and the impact of the fall. Anticipating this, we had prepared to perform bone grafting. Autologous bone was harvested from the patient’s iliac crest and packed into the cavity to provide structural support and facilitate fracture healing.

Permanent fixation was then achieved using two plates and multiple screws. Due to the unavailability of a dedicated plate for this particular fracture configuration, we used a shoulder locking plate, which fitted anatomically well for medial and lateral support. This unorthodox but carefully considered decision underscores the importance of improvisation when conventional tools fall short.

Some people may also ask why we did not perform a knee replacement from the outset, given the extent of damage. The answer lies in the nature of the fracture. In a primary knee replacement, only the articular surface is replaced, resting on structurally sound bone. In this case, the bone itself was destroyed.

Had we chosen replacement initially, we would have needed a tumor prosthesis – a bulky, costly, and complex option with a relatively short lifespan and considerable functional restrictions. By reconstructing the native bone, we preserved the possibility of a more standard primary knee replacement in the future, should it become necessary.