Three-Column Fixation for ComplexTibial Plateau Fractures

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

J Orthop Trauma Volume 24, Number 11, November 2010

DR. LOKESH SHAROFFOrthopaedic Surgeon, Mumbai, India

JOT – JOURNAL OF ORTHOPAEDIC TRAUMA• Objectives:

1) To introduce a computed tomography-based ‘‘three column fixation’’ concept; and

2) to evaluate clinical outcomes (by using a column-specific fixation technique) for complex tibial plateau fractures (Schatzker classification Types V and VI).

STUDY DESIGN• PROSPECTIVE COHORT STUDY

PATIENTS• From December 2004 to July 2006, 266 cases of tibial plateau

fractures were operated.• 32 cases diagnosed as ‘‘three-column fractures,’’• 3 patients - excluded because they could not be contacted during

follow-up.• So, 29 cases included for the study.

SURGICAL TEAM• All patients were operated by 2 surgeons belonging to 1 surgical

team.

EXTERNAL FIXATORIt was applied in patients, - who required pre –operative reduction,

- high energy injury to the soft tissues.

INVESTIGATIONS- XRAYS,

- CT- SCANS -- WERE PERFORMED AFTER EX-FIX as it gave more information.

THREE-COLUMN CONCEPT

1 COLUMN-- 1 COLUMN – is 1 independent articular depression with break of the column is defined as a fracture of the relative column.

-- Pure articular depression (S-type 3) was defined as a Zero Column Fracture.-- anterolateral fracture and a separate posterior–lateral articular depression with a break of the posterior wall, the fracture is defined as a ‘‘two-column (lateral and posterior column) fracture.’’

-- Antero-Medial + Postero-medial = 2 column

THREE COLUMN FRACTURE• The ‘‘three-column fracture’’ is defined as at least one independent

articular fragment in each column.

POST OPERATIVE PROTOCOL-- AP & LATERAL XRAYS were done – immediate post- op , every 6 weeks till union and then 2 years after the index operation.

-- TPA, FTA, MEDIAL AND LATERAL POSTERIOR SLOPE ANGLE – MEASURED

MALREDUCTION – intra-articular step-off 2 mm, TPA > 95*OR < 80, PA > 15 OR <-5

SECONDARY LOSS OF REDUCTION- > 5* MALALIGNMENT OR 2MM ARTICULAR DEPRESSION

SF-36 FORM – FILLED AT 2 YRS.

OPERATIVE TECHNIQUE-- Floating position- prone and lateral position

- prone – posterior, postero medial and antero-medial columns

3.5 mm plates were used (lcdcp, t-plate, cloverleaf plate)

POSTERIOR APPROACH

OPERATIVE TECHNIQUE

OPERATIVE TECHNIQUE-- ANTERO-LATERAL APPROCH – LATERAL COLUMN FIXATION – SUB-MENISCAL APPROACH

-- L-PLATE or LISS PLATE applied

POST-OPERATIVE PROTOCOL--CPM – 3 DAYS

--PARTIAL WEIGHT BEARING- BEGIN FROM 4TH-6TH WEEK

-- FULL WEIGHT BEARING – AFTER BONY UNION

STASTICAL METHODS-- SPSS 11.0

-- CORRELATION – BY PEARSON CORRELATION COEFFICIENT

RESULTS-- 32 CASES

-- 3 CASES LOST TO FOLLOW UP

-- 23 MEN AND 6 WOMEN

-- AVERAGE AGE – 46.8

-- 13 LEFT , 16 RIGHT

ALL WERE CLOSED FRACTURES WITH NO DNVD

-- TOTAL MEAN OPERATION TIME- 140 MINS

-- MEAN BLOOD LOSS – 327 ML

-- AVERAGE XRAY BONY TIME FOR UNION- 13.1

--AVERAGE FULL WT BEARING TIME – 16.7 WEEKS

RESULTS• 1 case 2* varus and valgus deformity each, 2 cases had screw loosening• 2 cases had wound drainage with negative bacterial culture• Patient scores for the Short Form 36, Hospital for Special Surgery score,

and lower-extremity measure at 24 months postoperatively were 89 (range, 80–98), 90 (range, 84–98) and 87 (range, 80–95), respectively. • Average ROM of the affected knees was 2.7 to 123.4.• NO significant differences in either TPA or PA on the radiographs

immediately postoperatively and 24 months postoperatively• (P = 0.840 for TPA, 0.060 for medial posterior-slope-angle and 0.061 for

lateral posterior-slope-angle)

CONCLUSION• The ‘‘three-column concept’’ is a new and useful supplement to the

present classification systems for tibial plateau fractures.• ‘‘Three-column fixation’’ seems to be an effective and a safe way for

the treatment of multiplanar complex tibial plateau fractures.

THANK YOU