Column Tibial Plateau Fractures Research Articles

Functional and union outcome of combined column tibial plateau fracture treated with hybrid external fixator.

To determine the combined column tibial plateau fracture treated with a hybrid external fixator in terms of knee functionality, union outcome and complications. The quasi-experimental study was conducted at the Department of Orthopaedic Surgery, Mayo Hospital, Lahore, Pakistan, from July 5, 2019, to December 31, 2021, and comprised patients of either gender aged 20-50 years who presented with 2-column or 3-column fractures of proximal tibia classified according to the 3-column classification system after being diagnosed using radiographs and three-dimensional computed tomography scan. Knee function, union and complications, like neural, vascular, infection, delayed union, nonunion, malunion and implant failure, were evaluated. The Knee Society Score was used to assess knee function, and modified Rasmussen score for the union, while complications were assessed clinically on the 2nd, 6th, 12th, 16th, 24th, 36th weeks and one year post-operatively. Data was analysed using SPSS 26. Of the 113 patients, 91(80.53%) were males and 22(19.47%) were females. The overall mean age was 35.56±9.00 years. From the 12th week to the 24th week 45(39.83%) patients had good and 59(52.21%) patients had excellent functional outcomes. Union outcome in the 16th and 24th week was good in 57(50.44%) patients and excellent in 47(41.59%) patients. No neurovascular injury was observed. Superficial pin tract infection was observed in 21(18.6%) cases that healed with wound debridement and antibiotics. No delayed union, malunion and implant failure was observed. Good to excellent functional and union outcomes with minimum complications were observed with the hybrid external fixator.

The prone posteromedial approach to the knee revisited: a safe and effective strategy for posterior tibial plateau fractures.

To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach. A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing. All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7min vs. 82.3min; P = 0.015). The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

Free subchondral screws in tibial plateau fractures: do they hinder a total knee arthroplasty? Strategies to prevent complications.

Open reduction and internal fixation of extended lateral column tibial plateau fractures through a tibial condyle osteotomy and limited arthrotomy with the use of free subchondral locking screws is a straightforward and safe technique. However, these free subchondral screws are enclosed in the subchondral bone and therefore virtually impossible to remove after bone healing. The question arises whether these free subchondral screws might hinder a future total knee arthroplasty. In order to refute this, we retrospectively reviewed all surgically managed tibial plateau fractures in our tertiary center during one year and assessed the number, position and configuration of these in situ subchondral screws and K-wires. In addition, we performed a cadaver study, wherein we prepared 7 tibial plateaus for a total knee arthroplasty tibial component placement with free subchondral screws in situ. In this experiment, we demonstrated that free subchondral screws do not interfere with total knee arthroplasty, but they can increase operative time in some cases. We also provide recommendations to avoid difficulties and potential complications.

Solving the enigma of posterolateral tibial plateau fractures, the clue protocol

The study aim is to evaluate functional and radio- logical outcomes following a suggested protocol based on the four-column classification for management of posterolateral column tibial plateau fractures. A prospective cohort study was performed in level I academic center on 42 patients with mean age of 36 years (22-59). Eleven patients had isolated posterolateral column fractures whereas 31 patients had associated columns fractures. According to the suggested protocol, all cases of isolated posterolateral column fracture started treatment via arthroscopic evaluation of soft tissue injuries (menisci and liga- ments), arthroscopically assisted reduction and inter- nal fixation by rafting screws followed by ORIF if plating was needed. If associated with other columns fractures, columns were fixed sequentially in an anti-clockwise direction starting from anteromedial column. Average follow up was 26 months. Mean time to union was 16.3 (12-22) weeks. No radiological evidence of loss of coronal or sagittal alignment was detected at final follow up. Five patients had an average depression of 5 millimeters that did not need further intervention at this short-term follow up. Mean KOOS was 81 (72- 88). The average knee range of motion was (0° - 127°). One patient had temporary common peroneal nerve injury, one patient had deep infection and two had superficial wound infection. implementing the suggested protocol gives good to excellent radiological and functional results as regard posterolateral tibial plateau fracture. A larger study group with longer follow up is needed.

Anterior Midline Incision is a Safe and Effective Approach for High-energy Medial Shear Fractures of the Tibial Plateau

Objective: We present a technical trick for surgical treatment of with (Schatzker IV) medial tibial plateau fractures treated with a standardized operative protocol with early radiographic and clinical outcomes. Methods: Skeletally mature patients with a medial tibial plateau fracture (Schatzker IV) admitted to an academic level 1 trauma center between 2002 and 2017 were identified by institutional database review. Screening of operative reports selected patients treated with a single anteromedial approach following a standard surgical protocol by a single surgeon. Data relevant to initial injury characteristics, patient comorbidities, operative management, and follow-up were extracted by chart review. Preoperative and postoperative clinical documentation and radiographs were examined to measure specific injury and outcome variables. Radiographic and clinical outcomes were validated by one fellowship-trained orthopedic trauma surgeon and 2 orthopedic trauma fellows. Results: Review of 335 patients with tibial plateau fractures during the study period identified a series of 17 high-energy, medial partial articular fractures that met the inclusion criteria. Injury pattern included articular depression in all patients, meniscal injury in 59%, ligamentous injury in 65% and none had compartment syndrome. Immediate radiographic analysis showed restoration of the articular surface, condylar width, and mechanical alignment for all patients. No patient experienced wound healing complications, soft tissue infection or skin necrosis. Median time to radiographic fracture consolidation was 12.9 weeks and ambulation without achieved at 18.9 weeks. Conclusions: The use of a standard anteromedial approach to the knee via medial parapatellar arthrotomy with full-thickness medial skin flap for isolated high-energy medial column tibial plateau fractures offers improved visualization and facilitates reduction and fixation of the lateral and anterior articular impaction while enabling immediate repair or reconstruction of associated meniscal and ligamentous (anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament) pathology. Short-term and mid-term follow-up demonstrates good clinical and radiographic patient outcomes. This approach is a safe and reliable option for treatment of this unique and challenging injury pattern.

Column specific fixation for complex tibial plateau fractures – Midterm prospective study in South - Indian population

BackgroundTibial plateau fractures involving two or more columns were routinely assessed by two-dimensional radiography in the past. This often misled surgeons and attention was given only to the medial and lateral column without consideration of the posterior column, especially the postero-medial corner. Luo in 2010 introduced the new three-column classification system based on multiplanar computed tomography images. This study was conducted to assess the outcome after internal fixation of tibial plateau fractures involving two or more columns in our centre based on the column specific approach. Materials and MethodsThis was a prospective study conducted at our institute, between 2011 and 2016. Total of 183 patients with tibial plateau fractures involving two or more columns were admitted during this study period of which 123 patients were satisfied our inclusion criteria. 8 patients were lost to follow up. Hence 115 patients with tibial plateau fractures involving two or more columns were classified based on the new three column classification system. Dual column fixation (Anterolateral +Anteromedial) was done in 76 patients, (Anterolateral+Posteromedial) fixation in 25 patients and triple column fixation (Anterolateral + Anteromedial + Posteromedial) in 14 patients. Post operatively patients were assessed by Modified Rasmussen functional and radiological scoring system. ResultsBased on Modified Rasmussen functional scoring system, 73 patients (63.5%) had excellent results, 37 patients (32.2%) had good results and 5 patients (4.3%) had fair results. Based on Modified Rasmussen radiological scoring system, 71 patients (61.7%) had excellent results, 38 patients (33.1%) had good results, 6 patients (5.2%) had fair results. 3 patients had deep infections. ConclusionBased on our study, we like to conclude that we had good outcomes utilizing this modern column specific approach to the treatment of these two or more column tibial plateau fracture injuries, which includes assessment of three columns.

A combined prone and supine approaches for complex three column tibial plateau fracture with posterolateral articular injury

IntroductionUpdated three column fixation of tibial plateau fractures (TPFs) arouse the importance of posterior column articular reduction. Complex TPFs with posterolateral (PL) articular injury is difficult to manage. We presented a strategy of combined positions and approaches to treat these injuries. Surgical technique was described and outcome of these were reported. Materials and MethodsFrom 2014 Jan to 2016 Dec, there were 132 patients of TPFs treated in our institute. Preoperative evaluation included plain films and 2D/3D CT scan to evaluate the involvement of articular surface and associated columns. Inclusion criteria were three column TPFs with PL corner injury. We put patients in prone position first with reverse L incision to manage PL articular impaction and posteromedial (PM) fractures. Then we repositioned the patients in supine to treat anterolateral fixation. Postoperative radiographic analysis, physical examination findings, and patient reported outcome scores from the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire were recorded. ResultsPatient demographic information was retrospectively reviewed with a mean follow-up time of 34.4 months (range 24–48 months). The average time to union was 5.2 months (range 4-8months). 13/16 (81%) of patients had satisfactory articular reduction by plain films (less than 2 mm articular step off). All patients demonstrated healed without secondary displacement or infection. All patients demonstrated satisfactory coronal (medial proximal tibia angle 84.68 degrees) and sagittal alignment (posterior proximal tibia angle 84.75 degrees). Condylar width averaged 3.93 mm. 3/16 (19%) of cases required posterolateral columnar plating in addition to posteromedial columnar plating. The knee range of motion averaged 115 degrees (ranged from 0 degrees of extension to140 degrees flexion). The average KOOS score was 83/100 (range 76–90). 3 patients in the series developed a surgical site superficial infection and resolved after debridement and oral antibiotics use. No patient eventually received total knee arthroplasty at the last follow up. ConclusionsOur strategy provides an effective method to treat three column tibial plateau fractures with PL articular injury.

A Modified Direct Posterior Midline Approach for the Treatment of Posterior Column Tibial Plateau Fractures.

The purpose of this study was to introduce a modified surgical approach for the treatment of posterior column tibial plateau fractures. Fifteen patients with posterior column fractures with or without other column fractures were included and treated with this approach between July 2015 and June 2016. The patients were followed up for 18 to 24 months (20.9 ± 1.8 months). Outcomes included neural or vascular injuries, wound complications, nonunion, plate loosening or breakage, and Hospital for Special Surgery (HSS) scores. Bone union was observed in all cases, and the average time for bone union was 13.5 ± 1.4 weeks (11-16 weeks). No neurovascular injuries, malunion, nonunions, or plate loosening or breakages were observed. The average HSS score was 94.7 ± 4.1 (range: 84-100). The modified direct posterior midline approach can provide excellent exposure and facilitate reduction and internal fixation of posterior column fractures of the tibial plateau, including split and depressed fractures. We expect that this approach can be used as a new effective method for managing complex posterior tibial fractures.

Limited value of the column concept in the operative management of posterior column tibial plateau fractures.

The three-column concept has been proposed as tool in surgical decision-making for treating tibial plateau fractures. Recent studies have underscored the negative effect of posterior column tibial plateau fractures on clinical outcome. The purpose of this study was to assess the value of the three-column concept and posterior plating in posterior column fractures. We hypothesized that treating patients according to the three-column concept improves functional outcome. 111 consecutive tibial plateau fractures, treated between January 2009 and December 2016, with at least a posterior column fracture were included. Relevant demographic and treatment variables were studied. Applied treatment was retrospectively evaluated according to the three-column concept. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Median follow-up was 43.1 months (IQR 29.0-63.3) with a response rate of 80.2%. Outcome scores were markedly lower compared to the general population. 22.5% patients were treated according to the three-column concept and 27% was treated with posterior plating. Predominantly combined fractures of posterior and lateral columns were treated without fixation of the posterior column. Neither treatment according to the three-column concept and/or with posterior plating was found to significantly influence outcome. The outcome of posterior column fractures was equal, regardless of whether these fractures were treated or not. This indicates that the three-column concept seems insufficient and gives rise to further debate on surgical strategies of posterior column fractures. The implementation of trauma mechanism-based fracture morphology in the three-column concept might be important to consummate the three-column concept as guiding tool. 3.

Extended lateral column tibial plateau fractures. How do we do it?

We describe the operative management of extended lateral column fractures according to the revised three-column classification approach in a step-by-step fashion. We show that direct reduction and stable fixation of extended lateral column tibial plateau fractures via a limited arthrotomy and tibia condyle osteotomy, with the use of free subchondral 2.7 mm locking screws is a reliable technique. Subsequently, diverging VA-LCP locking screws further improve the structural properties. It is a straightforward technique and the single lateral approach (Lazy-S) facilitates direct reduction of the articular surface and stable fixation of the fracture fragments under direct vision with good radiological and fair functional outcome.

Combined Posteromedial and Anterolateral Approach in the "floating position" - Two Column Fracture of the Tibia Head

Background The posterior tibial plateau is often affected in intra-articular tibial fractures. Moreover, treating these posterior fractures is recognised as an important prognostic factor. Open reduction and internal fixation of lateral and posterior two column tibial plateau fractures can be achieved via a combined reversed L-shape approach and an anterolateral approach in the floating position without intraoperative repositioning of the patient. Material and Methods The operative procedure starts in the posterior position with visualisation of the posterior column after lateral retraction of the medial head of the M.gastrocnemius. The posterior fragment is then reduced and fixated. This is followed by reversed patient tilt, and slight flexion and varus stress on the knee. An anterolateral approach is performed with visualisation of the lateral column, direct reduction and internal fixation of the lateral tibia plateau. Results Since June 2014, 14 two column tibial plateau fracture patients with posterior and lateral column involvement have been treated according to this technique. The median follow-up was 306 days (IQR 194 - 438); 1 patient was lost to follow-up. During the last outpatient visit, 7 patients reported pain to some extent. At a median of 110 days (IQR 96 - 181), 10 patients showed a full range of motion. One deep infection was noted postoperatively. At the 3 to 4 month postoperative CT control, 10 of 14 patients showed successful reduction with restored alignment, whereas in 8 of 14 patients there was a congruent articular surface without significant articular steps (< 2 mm). Conclusion We have demonstrated that the surgical treatment of two column fractures of posterior and lateral tibial plateau fractures is technically possible via a combined posterior reversed L-shaped and anterolateral approach in a floating position without the necessity of intraoperatively repositioning of the patient. Although the number of patients was limited, the clinical and radiographic outcome was rather good.

Newly designed anterolateral and posterolateral locking anatomic plates for lateral tibial plateau fractures: a finite element study

BackgroundLateral column tibial plateau fracture fixation with a locking screw plate has higher mechanical stability than other fixation methods. The objectives of the present study were to introduce two newly designed locking anatomic plates for lateral tibial plateau fracture and to demonstrate their characteristics of the fixation complexes under the axial loads.MethodsThree different 3D finite element models of the lateral tibial plateau fracture with the bone plates were created. Various axial forces (100, 500, 1000, and 1500 N) were applied to simulate the axial compressive load on an adult knee during daily life. The equivalent maps of displacement and stress were output, and relative displacement was calculated along the fracture lines.ResultsThe displacement and stresses in the fixation complexes increased with the axial force. The equivalent displacement or stress map of each fixation under different axial forces showed similar distributing characteristics. The motion characteristics of the three models differed, and the max-shear stress of trabecula increased with the axial load.ConclusionsThese two novel plates could fix lateral tibial plateau fractures involving anterolateral and posterolateral fragments. Motions after open reduction and stable internal fixation should be advised to decrease the risk of trabecular microfracture. The relative displacement of the posterolateral fragments is different when using anterolateral plate and posterolateral plate, which should be considered in choosing the implants for different posterolateral plateau fractures.

Outcome of Posterior Tibial Plateau Fixation.

Isolated posterior tibial plateau fractures are rare injuries that encompass a wide variety of fracture patterns. Based on the variation in fracture pattern, the surgical approach varies, with both anterior and posterior approaches described for surgical fixation. Postoperative protocol also varies among studies. The aim of this article is to summarize the outcomes related to posterior column tibial plateau fractures. The papers reviewed, primarily small retrospective case series, showed functional knee range of motion is preserved, a low incidence of wound complications, and patient outcome scores comparable to other reported lower extremity injury outcome scores.

A combined posterior reversed L-shaped and anterolateral approach for two column tibial plateau fractures in Caucasians: A technical note.

Open reduction and internal fixation of two column posterior and lateral tibial plateau fractures through a combined posterior reversed L-shaped and anterolateral approach in floating position in Caucasians. Two column posterior and lateral tibial plateau fractures. Tibial plateau fractures that do not involve the posterior and lateral column. The patient is positioned in floating position, a reversed L-shaped skin incision is made, the posterior column after lateral retraction of the medial head of the gastrocnemius muscle is exposed, and the posterior fragments are reduced and fixed. Subsequently, flexion and varus stress on the knee is applied, an anterolateral skin incision is made, the lateral column is exposed, and the lateral fragments are reduced and fixed. Despite a different physique as Asians, a combined posterior reversed L-shaped and anterolateral approach in a floating position for the surgical treatment of two column posterior and lateral tibial plateau fractures is technically possible in Caucasians. In our experience, this combined approach is an excellent strategy in most patients for surgical treatment of two column posterior and lateral column fractures.

Voie d’abord postérieure directe en décubitus ventral dans la chirurgie de la colonne postérieure des fractures du plateau tibial

IntroductionThe three-column fixation concept is becoming popular in orthopedic practice. Posterior column fracture is an uncommon type of tibial plateau fracture. The supine position for the surgical approach is familiar to most surgeons; however, it is difficult to achieve good reduction and fixation in posterior column fracture. HypothesesThe prone position and direct posterior approach can achieve proper reduction and fixation for posterior column tibial plateau fracture, yielding good functional outcome. Materials and methodsBetween January 2010 and January 2012, 184 tibial plateau fractures were diagnosed and operated on in our institution. Sixteen posterior column tibial plateau fractures (10 male and 6 female patients, with a mean age of 41.5±14.3 years) were diagnosed by preoperative plain films and CT scans. Ten patients presented with fracture dislocation of the knee joint. A direct posterior approach in prone position was used to reduce the tibial condyle and fix it with an anti-glide buttress plate. Radiographic evaluation included reduction quality and bone union. Functional evaluation included Lysholm score and Tegner activity score. ResultsAll fractures healed within 6 months, without secondary displacement. Ten knees had postoperative anatomic reduction (0mm step-off) and 6 had acceptable reduction (<2mm step-off). At 34.4±9.6 months, median extension was 3° (5–10°) and flexion 135° (100–145°). The mean Lysholm score was 95 (75–100) and the mean Tegner activity score was 6 (5–8). All patients were satisfied with the operation. No cases of post-traumatic osteoarthritis of the knee occurred during follow-up. ConclusionsThe prone position and direct posterior approach has great advantages in terms of reduction and stable fixation, yielding good results. Type of studyRetrospective, case series. Level of evidenceIV.

Prone and direct posterior approach for management of posterior column tibial plateau fractures

IntroductionThe three-column fixation concept is becoming popular in orthopedic practice. Posterior column fracture is an uncommon type of tibial plateau fracture. The supine position for the surgical approach is familiar to most surgeons; however, it is difficult to achieve good reduction and fixation in posterior column fracture. HypothesesThe prone position and direct posterior approach can achieve proper reduction and fixation for posterior column tibial plateau fracture, yielding good functional outcome. Materials and methodsBetween January 2010 and January 2012, 184 tibial plateau fractures were diagnosed and operated on in our institution. Sixteen posterior column tibial plateau fractures (10 male and 6 female patients, with a mean age of 41.5±14.3years) were diagnosed by preoperative plain films and CT scans. Ten patients presented with fracture-dislocation of the knee joint. A direct posterior approach in prone position was used to reduce the tibial condyle and fix it with an anti-glide buttress plate. Radiographic evaluation included reduction quality and bone union. Functional evaluation included Lysholm score and Tegner activity score. ResultsAll fractures healed within 6months, without secondary displacement. Ten knees had postoperative anatomic reduction (0mm step-off) and 6 had acceptable reduction (<2mm step-off). At 34.4±9.6months, median extension was 3 (5–10) and flexion 135 (100–145). The mean Lysholm score was 95 (75–100) and the mean Tegner activity score was 6 (5–8). All patients were satisfied with the operation. No cases of post-traumatic osteoarthritis of the knee occurred during follow-up. ConclusionsThe prone position and direct posterior approach has great advantages in terms of reduction and stable fixation, yielding good results. Type of studyRetrospective, case series. Level of evidence: Level IV.

Treatment of posterior column fracture in tibial plateau injury

Objective To describe the operative procedures.fracture patterns and clinical outcomes of treatment of posterior column tibial plateau fractures.Methods From February 2005 to August 2006,36 patients with posterior column tibial plateau fracture were operated on.Twenty patients were treated with open reduction and buttress plate fixation via a posterior approach.They were 13 males and 7 females,with a mean age of 38.5(ranging from 29 to 52)years.The other 16 patients were operated on via anterior plus posterior approaches.They were 11 males and 5 females,with a mean age of 37.3(ranging from 27 to 49) yeam. Results All were followed up for an average of 14.5(ranging from 12 to 15)months.All frac- tures got united with an average radiographic bone union time of 15.7(ranging from 11 to 16)weeks and an average full weight-bearing time of 17.6(range from 13 to 21)weeks.The mean HSS(The Hospital for special surgery)score of all these patients at 12 months postoperatively were 83.4(ranging from 68 to 92). There were 1 case of inferior medial genicular vessel injury during the operation,1 wound dehiscence and 1 partial incision necrosis postoperatively which were all eventually healed with conservative treatments.Three cases of numbness within the posterior lower part of the calf occurred postoperatively.No screw toggle,slide, dislodging or fixation failure was found during follow-up.There were no significant differences both between TPA and PA on radiographies and between immediately after operation and 12 months psstoperatively. Conclusion Open reduction and internal fixation with buttress plates via a posterior or anterior plus posterior approaches is appropriate for treatment of posterior column tibial plateau fractures. Key words: Tibial; Fracture; Fracture fixation.internal; Posterior column; Posterior approach