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ORIGINAL ARTICLE

Three-Column Fixation for Complex


Tibial Plateau Fractures
Cong-Feng Luo, MD, PhD, Hui Sun, MD, Bo Zhang, MD, and Bing-Fang Zeng, MD

Special Surgery score, and lower-extremity measure at 24 months


Objectives: 1) To introduce a computed tomography-based ‘‘three- postoperatively were 89 (range, 80–98), 90 (range, 84–98), and 87
column fixation’’ concept; and 2) to evaluate clinical outcomes (by (range, 80–95), respectively. The average range of motion of the
using a column-specific fixation technique) for complex tibial plateau affected knee was 2.7° to 123.4° at 2 years after the operation.
fractures (Schatzker classification Types V and VI).
Conclusion: Three-column fixation is a new fixation concept in
Design: Prospective cohort study. treating complex tibial plateau fractures, which is especially useful
for multiplanar fractures involving the posterior column. The
Setting: Level 1 trauma center.
combination of posterior and anterior–lateral approaches is a safe
Patients: Twenty-nine cases of complex tibial plateau fractures were and effective way to have direct reduction and satisfactory fixation for
included. Based on routine x-ray and computed tomography images, such difficult tibial plateau fractures.
all the fractures were classified as a ‘‘three-column fracture,’’ which
Key Words: tibial plateau fracture, three-column fixation, combined
means at least one separate fragment was found in lateral, medial, and
approach, floating position
posterior columns in the proximal tibia (Schatzker classification
Types V and VI). (J Orthop Trauma 2010;24:683–692)
Intervention: The patients were operated on in a ‘‘floating
position’’ with a combined approach, an inverted L-shaped posterior
approach combined with an anterior–lateral approach. All three
columns of fractures were fixed. INTRODUCTION
Complex tibial plateau fracture management remains
Outcome Measures: Operative time, blood loss, quality of clinically challenging. These fractures are usually described as
reduction and alignment, fracture healing, complications, and Schatzker Type V and VI or as a C type injury when using the
functional outcomes based on Hospital for Special Surgery score AO/Orthopaedic Trauma Association classification.1,2 Bilat-
and lower-extremity measure were recorded. eral dual plating is usually recommended as the definite
Results: All the cases were followed for average 27.3 months fixation for this kind of fracture.3–6 However, this technique
(range, 24–36 months). All the cases had satisfactory reduction sometimes is not applicable to work in fractures with multi-
except one case, which had a 4-mm stepoff at the anterior ridge of the planar articular comminution. This is especially true when
tibial plateau postoperatively. No case of secondary articular depres- there is posterior shearing or a coronal fracture.7,8 Tradition-
sion was found. One case had secondary varus deformity, one case ally, the treatment for tibial plateau fractures is based on
had secondary valgus deformity, and two cases of screw loosening two-dimensional classification systems. Several authors have
occurred postoperatively. No revision surgery was performed. Two noted computed tomography (CT)-based three-dimensional
cases had culture-negative wound drainage. No infection was noted. consideration of the fracture pattern was important in the
The average radiographic bony union time and full weightbearing treatment of tibial plateau fractures.9–11 In recent years, we
time were 13.1 weeks (range, 11–16 weeks) and 16.7 weeks (range, developed a ‘‘three-column fixation’’ technique to treat the
12–24 weeks), respectively. The mean Short Form 36, Hospital for multiplanar complex tibial plateau fractures, which is based on
three-dimensional understanding of the fractures.
In this article, we report on the clinical results of using
a ‘‘three-column fixation’’ technique through combined
Accepted for publication January 14, 2010. approaches: the anterolateral and the posterior approaches.
From the Department of Orthopaedic Surgery, Shanghai Sixth People’s A special ‘‘floating position’’ was designed to perform the
Hospital, Shanghai Jiaotong University, Shanghai, China.
The authors did not receive grants or outside funding in support of their
surgery, which was based on a lateral decubitus, and the lower
research or preparation of this manuscript. leg was rotated to a prone position when the posterior
This study was presented in part as a poster presentation at the Annual approach to the tibial plateau was performed.
Meeting of the Orthopaedic Trauma Association, San Diego, CA, 2009.
Reprints: Cong-Feng Luo, MD, PhD, Department of Orthopaedic Surgery,
Shanghai Sixth People’s Hospital, Shanghai Jiaotong University, 600
YiShan Road, Shanghai 200233, China (e-mail: cong_fengl@yahoo.
PATIENTS AND METHODS
com.cn). The patients’ data were collected prospectively. Patient
Copyright Ó 2010 by Lippincott Williams & Wilkins demographics and the preinjury status were recorded at

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Luo et al J Orthop Trauma  Volume 24, Number 11, November 2010

admission. Preliminary management included distal bony articular depression with a break of the column wall is defined
skeletal traction or bridging external fixation where reduction as a fracture of the relevant column. Pure articular depression
needed to be maintained preoperatively. The external fixator (Schatzker Type III) was defined as a ‘‘zero-column fracture.’’
was used in emergency situations in which there was high- Most of the simple lateral split and split depression fractures
energy injury to the soft tissues. The fixation bridged across (Schatzker Types I and II) belong to a ‘‘one-column (lateral
the knee and the pin(s) in the tibial shaft were placed to avoid column) fracture.’’ However, when there is an anterolateral
the site of future operative incisions. All the patients had fracture and a separate posterior–lateral articular depression
definitive operative procedures after the soft tissue condition with a break of the posterior wall, the fracture is defined as
was stable. The mean time from presentation to definitive a ‘‘two-column (lateral and posterior column) fracture.’’
fixation was 8.5 days (range, 1–18 days). Articular depression in the posterior column with a break of
On admission, all the patients underwent a standard the posterior wall is also defined as a ‘‘one-column (posterior
radiologic protocol of x-rays and CT scans. The CT scans were column) fracture’’ (not included in any type of the Schatzker
performed after bony traction or bridging external fixation had classification). The other typical ‘‘two-column fracture’’ is the
been applied; this was much more informative for decision- anteromedial fracture with a separate posteromedial fragment
making. Besides Schatzker classification, all the fractures were (medial and posterior column fracture), which traditionally
also classified with a ‘‘three-column’’ concept (Fig. 1); on the belongs to Schatzker Type IV (medial condylar fracture). The
transverse view, the tibial plateau is divided into three areas, ‘‘three-column fracture’’ is defined as at least one independent
which are defined as the lateral column, the medial column, articular fragment in each column. The most common three-
and the posterior column. These three columns are separated column fracture is a traditional ‘‘bicondylar fracture’’
by three connecting lines, namely OA, OC, and OD. Point O is (Schatzker Type V or Type IV) combined with a separate
the center of the knee (midpoint of two tibial spines); Point A posterolateral articular fragment.
represents the anterior tibial tuberosity; Point D is the All the cases were assessed by different team leaders (we
posteromedial ridge of proximal tibia; and Point C is the have seven trauma teams). If the case was considered to need
most anterior point of the fibular head. Point B is the posterior the ‘‘three-column fixation’’ technique, he or she was
sulcus of the tibial plateau, which intersects the posterior transferred to the authors’ team. All of these 29 cases were
column into the medial and lateral parts. Besides the transverse operated on by the authors (C.F.L. and B.F.Z.).
view, the accurate classification usually was done with the help Postoperatively, anteroposterior x-rays of the knee were
of frontal view and three-dimensional reconstruction. taken in the immediate postoperative period, 6 weeks, 12
A ‘‘three-column classification’’ was used for decision- weeks, and every 6 to 8 weeks until bony union occurred and
making. According to this classification, one independent then 2 years after the index operation. Tibial plateau angle
(TPA), the femorotibial angle, and the medial and lateral
posterior slope angle (PA) were measured by one surgeon
(B.Z.). Malreduction was defined as intra-articular stepoff of
2 mm or more, a TPA $95°/TPA #80°, or PA $15°/PA #–5°.11
Secondary loss of reduction was defined as an increase of 5°
malalignment or an articular depression of 2 mm when
compared with the first postoperative radiograph at final follow
up. Bony union was defined as radiologically finding at least
three healed cortices. Full weightbearing was defined as the time
that patients could have painless walking without any aids.

Operative Technique
All patients were treated by open reduction and internal
fixation with the same surgical team. After induction of
general anesthesia and antibiotic prophylaxis, the procedure
was performed in the ‘‘floating position,’’ which was based on
a lateral decubitus, and the lower leg was rotated to a prone
position when the posterior approach to the tibial plateau was
performed (Fig. 2). A combined approach was used for all the
cases. The bridging fixator was removed before surgery
started.
A posterior inverted L-shaped approach was indicated to
deal with medial column and posterior column fractures
(Fig. 2). With the patient prone on a radiolucent table, the knee
was slightly flexed by a bump under the ankle. An inverted
L-shaped incision begins at the center of popliteus parallel to
Langers line superiorly and medial. Distally it turns at the
FIGURE 1. Three-column classification. medial corner of the popliteal fossa and is carried down to

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J Orthop Trauma  Volume 24, Number 11, November 2010 Three-Column Fixation for Complex Tibial Plateau Fractures

FIGURE 2. Combined approach:


reversed L-shaped approach +
anterior–lateral approach.

deep fascia. Full-thickness fasciocutaneous flaps were raised implant for posterior column fractures, an undercontoured
paying attention to protecting the sural nerve and short 3.5-mm LC-DCP, 3.5-mm T-plate, or a 3.5-mm cloverleaf plate
saphenous vein. The tendon of the medial head of the (Synthes, Oberdorf, Switzerland) with the central tip cut off
gastrocnemius was then visualized with blunt dissection and was used for posterior column fixation. For the posteromedial
then retracted laterally, protecting the neurovascular bundle fragment (between Points D and B in Fig. 1), the buttress plate
and displaying the back of the knee capsule (Fig. 3). To avoid was usually put in longitudinally (parallel to the medial ridge
injury to the neurovascular bundle in popliteal space, all the of the tibia). An oblique posterior plate (from proximal lateral
dissection from medial to lateral should be done beneath to the distal medial) was usually used to buttress the postero-
popliteus muscle in the proximal part. Overdissection laterally lateral fragment (between Points B and C in Fig. 1) (Fig. 5).
toward the tibial shaft should be avoided, because it is easy to To expose the anteromedial (medial column) fracture,
injure the posterior tibial recurrent artery (a branch from the anterior dissection can be done along the medial edge of this
proximal part of the anterior tibial artery and bifurcation of the incision. The fascia was incised between the medial
tibial arteries). gastrocnemius and the pes anserinus anteriorly. The medial
The popliteus and soleus origin are then elevated off the collateral ligament remains intact anteriorly and deep to the
posteromedial aspect of the proximal tibia from medial to pes anserinus. The semimembranosus insertion was released
lateral as needed to gain exposure of the fracture of posterior off the bone. Both pes anserinus and semimembranosus can be
column. In most situations, under general anesthesia, the entire reattached with nonabsorbable sutures after fracture fixation.
posterior aspect of the tibia can be exposed without cutting the A buttress plate (usually 3.5-mm LC-DCP) was put on the
medial head of the gastrocnemius. The articular surface was medial ridge of the proximal tibia to support the medial
elevated by working through the ‘‘fracture window’’ at the column. It is important to not put this plate too posteriorly or
fracture site by using a periosteum elevator (Fig. 4). The the buttress effect will decrease.
reduced articular surface was temporarily fixed with several A conventional anterior approach was used to reduce
subchondral Kirschner wires. From the posterior approach, it and fixate the fracture in the lateral column. The arthrotomy
is not easy to manipulate the anterolateral part of the articular was performed through a submeniscal approach. The articular
surface, which can only be reduced and fixed through the surface was elevated through the ‘‘fracture window’’ and fixed
anterolateral approach in the later stage of the operation. with a lateral plate (L-plate or LISS-PT; Synthes).
Flexing the knee to relax the posterior soft tissue can help The quality of reduction, the location of the plates, and
exposure; however, full reduction and buttress plate fixation of the length of the screws were confirmed under fluoroscopic
the articular surface in the posterior column can only be done guidance. The deep fascia was left open. Subcutaneous tissue
with the knee in extension. Because there is no standard and skin were closed over suction drainages.

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Luo et al J Orthop Trauma  Volume 24, Number 11, November 2010

FIGURE 5. Intraoperative photograph. The posterior column


was reconstructed and buttressed with two separate plates.

weightbearing was delayed until the fracture was healed and


callus appeared on radiographs.
Standard anteroposterior and lateral radiographs were
taken at follow up and were evaluated for fracture healing and
joint congruity. Bony union time and full weightbearing time
were recorded. Both TPA and PA on the radiographs
immediately postoperatively and 24 months postoperatively
FIGURE 3. Schematic diagram of the operative approach to the were measured and recorded. At 24-month follow up, patients
posterior aspect of the tibial plateau. were administered the Short Form 36 general health survey,
Hospital for Special Surgery, score and lower-extremity
Postoperative Management and Follow Up measure.
A continuous passive motion machine was used in the
Statistical Methods
hospital for 3 days after the surgery. Partial weightbearing
began at the fourth to sixth postoperative week. Full All data analysis was done using SPSS 11.0 (SPSS Inc.,
Chicago IL). Descriptive statistics were used to determine
ranges, means, and standard deviations. One-way analysis of
variance and Student t tests were used to determine the
difference between two means. Correlations were analyzed by
using the Pearson correlation coefficient. P , 0.05 was
considered statistically significant.

RESULTS
From December 2004 to July 2006, 266 cases of tibial
plateau fractures were operated on in our center. Among those,
there were 32 cases diagnosed as ‘‘three-column fractures,’’
which needed ‘‘three-column fixation.’’ Three patients were
excluded because they could not be contacted during follow
up, leaving 29 cases for the study. The patient demographics
and fracture types are shown in Table 1. There were six women
and 23 men with an average age of 46.8 years (range, 22–62
years). Thirteen fractures were on the left side and 16 on the
right. All fractures in this series were closed fractures without
FIGURE 4. Intraoperative photograph. Depressed posterolat- any distal neurovascular injury or compartment syndromes.
eral articular surface (arrow) can be seen from the ‘‘fracture The total mean operation time was 140 minutes (range,
window.’’ Direct reduction and fixation was performed 110–180 minutes). The mean blood loss was 327 mL (range,
through this window. 200–800 mL). Two cases had blood transfusion (No. 4 and

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J Orthop Trauma  Volume 24, Number 11, November 2010 Three-Column Fixation for Complex Tibial Plateau Fractures

TABLE 1. Patient and Immediate Postoperative Data


Time to Duration of Operation Blood
Age Surgery Schatzker Follow Up Time Loss Postoperative Postoperative Postoperative Postoperative Postoperative
Patient Sex (years) (days) Classification (months) (minutes) (mL) FTA (degree) TPA (degree) PAM (degree) PAL (degree) Stepoff (mm)
1 F 55 8 VI 24 115 200 174.3 87.0 6.8 5.2 0
2 F 59 18 VI 24 135 200 173.2 83.3 13.8 10.1 1
3 M 48 15 VI 26 130 200 170.4 86.4 5.7 3.6 2
4 M 45 11 VI 30 175 800 170.2 91.7 7.8 4.1 0
5 M 62 12 VI 27 150 800 170.4 86.3 13.5 1.1 1
6 M 41 12 V 26 145 200 169.9 91.2 4.9 2.9 0
7 M 56 9 V 25 160 300 170.3 92.0 10.2 8.5 1
8 F 59 11 VI 24 110 300 171.0 87.0 7.0 3.2 2
9 M 36 13 V 27 120 200 176.4 85.4 2.1 1.0 0
10 M 55 9 V 25 180 200 173.1 88.9 3.0 2.8 4
11 F 49 8 VI 30 140 800 173.1 86.6 6.8 5.1 2
12 M 49 5 VI 29 120 200 177.4 85.2 11.3 7.6 0
13 M 39 8 VI 26 170 300 178.3 88.3 3.3 1.8 2
14 M 44 19 VI 27 130 200 175.5 85.8 7.6 6.4 1
15 M 58 11 VI 28 120 200 170.1 88.4 3.2 2.6 0
16 M 59 14 VI 28 110 300 174.7 88.2 13.4 9.6 0
17 M 49 15 VI 29 130 400 172.3 87.4 10.2 8.1 0
18 M 45 12 VI 29 160 400 177.2 89.3 11.4 7.8 0
19 M 47 9 V 30 145 300 172.5 87.4 10.6 7.9 0
20 M 26 12 V 24 135 200 178.1 83.5 12.1 7.8 1
21 M 46 7 VI 24 120 400 177.4 87.2 9.4 8.2 1
22 M 42 9 V 29 150 200 172.6 86.5 12.1 12.9 1
23 M 39 11 VI 36 140 400 177.5 86.6 8.1 6.7 0
24 M 38 8 VI 27 115 500 173.2 90.8 10.7 7.7 0
25 M 25 14 VI 32 135 300 173.5 88.9 12.6 7.8 1
26 F 61 10 VI 27 170 300 172.3 89.8 7.3 6.5 2
27 F 44 9 VI 30 120 200 175.0 86.3 6.0 4.6 1
28 M 58 9 V 24 160 300 174.7 87.9 10.6 8.1 1
29 M 22 11 V 25 170 200 172.6 83.8 13.6 11.3 0
30 M 35 12 VI 0 140 300 174.2 86.3 9.9 5.8 0
31 F 46 10 V 0 120 400 175.0 85.2 12.0 7.8 0
32 M 39 8 V 1 135 400 172.3 88.8 11.6 8.9 1
FTA, femorotibial angle; TPA, tibial-plateau-angle; PAM, medial posterior-slope-angle; PAL, lateral posterior-slope-angle; F, female; M, male.

No. 5). All the cases were followed up for at least 24 months; (P = 0.840 for TPA, 0.060 for medial posterior-slope-angle,
the mean follow-up time was months 27.3 (range, 24–36 and 0.061 for lateral posterior-slope-angle) (Table 2).
months). The average radiographic bony union time was 13.1
weeks (range, 11–16 weeks) and the average full weightbear-
ing time was 16.7 weeks (range, 12–24 weeks). One case (No. DISCUSSION
21) had secondary varus deformity, one case (No. 26) had Most of the current classification systems for tibial
secondary valgus deformity, and two cases (No. 15 and No. plateau fractures use two-dimensional images, which usually
17) had screw loosening postoperatively. No revision surgery direct surgeons to pay attention to medial and lateral fixation
was performed for these complications. There were two cases without thinking of posterior fixation. With careful review
(No. 10 and No. 12) of wound drainage with negative bacterial and application of the CT scan for the evaluation for these
culture, and these healed with nonoperative wound manage- fractures,7,8,10–12 some surgeons have realized the importance
ment. No infection was noted. of considering posterior fixation in tibial plateau fractures,
Patient scores for the Short Form 36, Hospital for Spe- especially for the posteromedial fragment.8,13 In this article,
cial Surgery score, and lower-extremity measure at 24 months we reported on a column specific fixation concept: three-
postoperatively were 89 (range, 80–98), 90 (range, 84–98), column fixation, which is dependent on the understanding of
and 87 (range, 80–95), respectively. The average range of the fractures using CT scans. The authors believe this fixation
motion of the affected knees was 2.7° to 123.4°. There were no concept for tibial plateau fractures has been poorly reported
significant differences in either TPA or PA on the radiographs on in the English literature. Multiplanar complex tibial
immediately postoperatively and 24 months postoperatively plateau fractures, especially those involving the posterior

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Luo et al J Orthop Trauma  Volume 24, Number 11, November 2010

TABLE 2. 24-Month Postoperative Data


X-ray 2-Year 2-Year 2-Year 2-Year
Patient Union FWB 2-Year FTA TPA PAM PAL Stepoff 2-Year 2-Year 2-Year 2-Year 2-Year
No.* (weeks) (weeks) (degree) (degree) (degree) (degree) (mm) Extension Flexion HSS LEM SF-36
1 13 17 175.2 87.2 7.6 5.2 0 1 132 93 90 92
2 12 16 173.6 84.7 13.6 10.1 1 6 121 90 85 88
3 15 17 172.6 86.7 6.0 3.8 0 5 120 88 85 86
4 11 12 171.8 89.6 7.8 4.3 0 2 129 94 90 93
5 14 16 170.8 86.3 13.4 1.2 1 3 119 87 85 93
6 12 12 170.0 91.0 5.0 3.0 0 2 122 93 90 96
7 15 24 170.6 90.6 10.4 8.4 0 4 120 86 85 89
8 12 20 172.2 86.6 7.0 3.3 1 3 120 86 90 84
9 11 12 176.4 85.8 2.3 1.3 0 0 128 98 85 98
10 12 17 174.8 88.5 3.0 2.5 4 5 120 84 80 80
11 16 24 173.6 86.8 6.9 5.0 2 4 122 85 85 88
12 14 17 176.2 85.3 11.3 7.6 0 2 126 90 85 80
13 13 15 178.3 88.3 3.2 2.0 1 0 120 90 90 84
14 13 16 175.6 86.5 7.6 6.4 1 3 122 84 80 88
15 14 17 172.0 87.8 3.5 2.7 0 4 110 84 85 92
16 11 13 174.9 88.2 13.2 9.6 0 6 121 86 85 88
17 15 18 173.7 87.7 10.2 8.1 0 3 124 88 85 88
18 13 16 177.2 89.1 11.2 7.8 0 2 120 90 85 88
19 13 17 172.5 87.4 11.4 8.1 0 2 120 93 90 90
20 13 14 178.3 84.6 12.1 7.9 1 0 126 92 95 96
21 14 22 182.3 87.3 9.4 8.6 0 4 121 85 90 88
22 13 16 174.2 86.5 12.1 12.9 0 2 128 90 85 90
23 11 16 176.7 86.7 8.2 6.5 0 1 125 93 90 90
24 15 17 173.9 90.3 11.6 7.7 0 2 127 90 85 88
25 11 13 173.2 88.4 12.6 7.8 1 2 130 93 90 86
26 14 16 167.8 88.6 7.2 6.8 2 6 122 88 80 88
27 13 15 175.6 86.9 6.2 4.6 1 2 128 96 90 90
28 12 16 173.9 87.9 10.6 8.4 1 3 123 94 90 88
29 14 24 173.5 85.0 13.5 11.1 0 0 134 98 95 96
*Patients 30–32 were lost to followup.
FWB, full weightbearing; FTA, femorotibial angle; TPA, tibial plateau angle; PAM, medial posterior-slope-angle; PAL, lateral posterior-slope-angle; HSS, Hospital for Special
Surgery, LEM, lower-extremity measure; SF-36, Short Form 36.

column, are quite difficult to manage clinically. With our separately. As a result, 43% (18 of 42) of the fractures were
technique, posterior column fixation is stressed when the underevaluated by plain radiographs. On the other hand, such
fractures involve the posterior aspect of the plateau. Instead fractures can be difficult to fit into the classification systems
of classic bilateral (medial and lateral) approaches, a new currently used, which makes diagnosis and preoperative
combination of posterior and anterolateral approaches using planning difficult. Macarini et al15 studied 25 cases of tibial
careful patient positioning (the ‘‘floating position’’) is plateau fractures. After CT scan, only 48% of the cases had the
introduced to treat such a fracture. This new approach is same classification as before the CT scan and 60% of the cases
safe and effective in managing complex Schatzker V and VI had changes in the operative plan. Most authors agree that CT
tibial plateau fractures. scanning adds invaluable information to the treatment of tibial
Most complex tibial plateau fractures are a result of plateau fractures.7,8,16 We think the CT-based ‘‘three-column
high-energy injury. Resulting comminution makes interpreting concept’’ can help surgeons analyze these fractures three
of fracture patterns difficult. Fully understanding these dimensionally providing a better approach and fixation
fractures is the basis for successful treatment. Both the methods.
Schatzker and AO/Orthopaedic Trauma Association systems Although Khan et al12 had listed coronal splits at the
classify these fractures according to the appearance on posterior tibial plateau as a separate group in their classifica-
anteroposterior radiographs.14 Some of these fractures are tion system, this group of the fracture has been underappre-
easy to misunderstand, especially fractures involving the ciated in other commonly used classification systems.7,16 This
posterior aspect of the tibial plateau. Wicky et al11 reported is partly because this type of fracture usually appears con-
a cohort of 42 cases with tibial plateau fractures, which were fusing on initial radiograph and only can be clearly identified
assessed by plain radiographs and three-dimensional CT on a CT scan. For example, when the fracture involves the

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J Orthop Trauma  Volume 24, Number 11, November 2010 Three-Column Fixation for Complex Tibial Plateau Fractures

posterior–lateral aspect of the plateau, the fracture might be


visible through an anterior approach, but the reduction and
fixation are quite difficult, especially for those without an
intact posterior cortex (disruption of the posterior column).
Direct reduction through posterior approaches and posterior
buttress plating have been recommended by several authors.16–19
Other authors have also used this theory to produce better
clinical results than older less safe approaches.18,19
A bilateral dual plating technique using a posterior–
medial approach combined with an anterior–lateral approach
has been suggested by several authors.8,20 This posteromedial
approach, in the supine position, can deal with the poster-
omedial fragment,21 but it is impossible to obtain a direct
reduction when there is an articular depression in the lateral
part of the posterior column (between Points B and C in
Fig. 1). Posterior–lateral depressed fracture fragments are
impossible to deal with in the supine position and can only be
reduced and buttressed posteriorly in the prone position. The
amount of posterior dissection and the number of buttress
plates can be determined from preoperative CT.
Unilateral locking plates have also been used to treat
complex tibial plateau fractures. Some of the proximal tibial
locking plates have special design features with a ‘‘posterior–
medial fragment screw’’ aiming from anterolateral to poster-
omedial. Clinically, they are not strong enough to hold these
fragments and prevent secondary varus when compared with
a direct posterior–medial buttress plate.7,9,22 Barei et al8
investigated 57 bicondylar fractures with CT scans and found
the occurrence of the posteromedial fragment in approxi-
mately one third of the cases. The different shapes and
FIGURE 6. Female, 59 years of age, the victim of a traffic morphologic features of these fragments implicated supple-
accident, with a complex tibial plateau fracture of the right leg. mentary fixation when managing such a fracture. A com-
bination of the ‘‘reversed L-shaped’’ posterior approach and

FIGURE 7. Computed tomography


scan after emergent bridging exter-
nal fixator.

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Luo et al J Orthop Trauma  Volume 24, Number 11, November 2010

FIGURE 9. Sagittal computed tomography scan indicating


a posterior column fracture.

conventional bilateral dual plating techniques. It is important


to note that only a small percentage of tibial plateau fractures
need the ‘‘three-column fixation’’ technique in our series (12%
of fractures, or 33 of 266 of the cases). Without careful
FIGURE 8. Coronal computed tomography scan indicating planning, these ‘‘three-column fractures’’ usually proceed to
both medial and lateral column are involved. failure of reduction and fixation.
In our technique, through the ‘‘reversed L-shaped’’
the anterior–lateral approach is recommended by the authors posterior approach, both posterior–lateral and posterior–medial
for those fractures that have a bicondylar fracture, but also for fragments can be directly reduced and buttressed (reconstruction
those that have a separate fragment/articular depression in the of posterior column) (Figs. 6–9). In the authors’ opinion, this
posterior column. Such fractures will not reduce well with approach also obviates the use of a second posterolateral

FIGURE 10. Postoperative x-ray after


a combined approach with three-
column fixation.

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J Orthop Trauma  Volume 24, Number 11, November 2010 Three-Column Fixation for Complex Tibial Plateau Fractures

FIGURE 12. One-year follow-up function.

plateau and it can be placed in an oblique fashion (from


proximal posterolateral to distal posteromedial) (Fig. 10).
As the last step, the anterior–lateral aspect of proximal
tibia (the lateral column) is approached through an anterolateral
incision, which can be performed on a patient in the ‘‘floating
position’’ without a second draping (Fig. 2). The lateral column
FIGURE 11. One-year follow-up x-ray.
fracture is usually manipulated with minimal invasive techni-
ques; the small proximal incision is used to reduce the articular
surface and the metaphyseal area is plated percutaneously.
incision as advocated by Carlson.23 The posterolateral approach Because ‘‘three-column fractures’’ are usually quite commi-
creates problems around the exposure of the common peroneal nuted and the fragments are small, 3.5-/4.5-mm systems instead
nerve and management of posterior tibial recurrent artery (a of the conventional 4.5-/6.5-mm systems are recommended for
branch from the proximal part of the anterior tibial artery). fixation. To the authors’ understanding, this is the first time that
Through the inverted L-shaped posterior approach, the re- this ‘‘floating position’’ for the combined approach has been
duction of the posterolateral articular surface can be achieved reported in the English literature.
with an elevator through a posterior ‘‘fracture window.’’ We The weaknesses of this article include the fact that this is
recommend application of a buttress plate to the posterolateral a small series of patients and it represents a single center’s

FIGURE 13. One-year follow-up function. FIGURE 14. Posterior ‘‘reversed L-shaped’’ approach.

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Luo et al J Orthop Trauma  Volume 24, Number 11, November 2010

experience. There is no postoperative CT scanning to 8. Barei DP, O’Mara TJ, Taitsman LA, et al. Frequency and fracture
accurately quantitate articular reductions. We also feel that morphology of the posteromedial fragment in bicondylar tibial plateau
fracture patterns. J Orthop Trauma. 2008;22:176–182.
a full length standing x-ray is necessary for more precise 9. Luo CF, Jiang R, Hu CF, et al. Medial double-plating for fracture
alignment at long-term follow up (Figs. 11–14). dislocations involving the proximal tibia. Knee. 2006;13:389–394.
10. Hackl W, Riedl J, Reichkendler M, et al. Preoperative computerized
tomography diagnosis of fractures of the tibial plateau. Unfallchirurg.
CONCLUSIONS 2001;104:519–523.
The ‘‘three-column concept’’ is a new and useful sup- 11. Wicky S, Blaser PF, Blanc CH, et al. Comparison between standard
plement to the present classification systems for tibial plateau radiography and spiral CT with 3D reconstruction in the evaluation,
classification and management of tibial plateau fractures. Eur Radiol.
fractures. ‘‘Three-column fixation’’ seems to be an effective 2000;10:1227–1232.
and a safe way for the treatment of multiplanar complex tibial 12. Khan RM, Khan SH, Ahmad AJ, et al. Tibial plateau fractures. A new
plateau fractures. classification scheme. Clin Orthop Relat Res. 2000;375:231–242.
13. Lobenhoffer P, Gerich T, Bertram T, et al. Particular posteromedial and
posterolateral approaches for the treatment of tibial head fractures.
ACKNOWLEDGMENT Unfallchirurg. 1997;100:957–967.
We thank Dr. Richard Buckley from Calgary, Canada, 14. Schatzker J, Tile M. The Rationale of Operative Fracture Care, 2nd ed.
Berlin: Springer-Verlag; 1996:390–391.
for his kind review of our paper. 15. Macarini L, Murrone M, Marini S, et al. Tibial plateau fractures:
evaluation with multidetector-CT. Radiol Med. 2004;108:503–514.
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