Lego-like reconstruction of a complex floating knee using osteotomy-assisted exposure: A case report

Floating knee injuries involving distal femoral articular fractures with concomitant segmental tibial fractures are uncommon but challenging high-energy injuries. Optimal outcomes depend on individualized fixation strategies, adequate exposure during the procedure, and preservation of soft-tissue biology. We reported a 52-year-old male sustained a road traffic accident resulting in an AO 33-C3 distal femur fracture with intra-articular extension and an ipsilateral AO 42-C2 segmental tibial fracture, classified as modified Fraser type IIb. A fragment-specific approach was undertaken. Tibial tuberosity osteotomy via the Swashbuckler approach provided improved visualization of the distal femur. Articular reduction was secured with an anteroposterior lag screw and a medial locking compression plate applied in bridging mode. The proximal tibial segments were stabilized with percutaneous lag screws, and the displaced distal shaft fragment was fixed using a limited contact dynamic compression plate through a minimally invasive percutaneous plate osteosynthesis technique. The osteotomized tuberosity was reattached with a cannulated cancellous screw. Postoperative recovery was uneventful. Early non-weight-bearing mobilization began on postoperative day 2, with protected weight-bearing allowed by 2 months and full weight-bearing by 3 months. At 6 months, radiographs confirmed solid union without implant-related complications and the patient achieved near pain-free knee motion and independent ambulation. This case highlights the value of tailored fixation and selective tibial tuberosity osteotomy to achieve anatomic reduction and stable reconstruction in complex floating knee injuries. Coordinated rehabilitation further contributed to favourable functional and radiological outcomes.