Updated Three-Column Concept in surgical treatment for tibial plateau fractures - A prospective cohort study of 287 patients.

PURPOSE: This study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures.

PATIENTS AND METHODS: From 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed.

RESULTS: 287 treated fractures were followed up for a mean period of 44.5 months (range: 22-96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10-28) and 14.8 weeks (range: 10-26) respectively. The average functional Knee Society Score was 93.0 (range: 80-95). The average range of motion of the affected knees was 1.5-121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated.

CONCLUSION: An updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. Limited results demonstrate successful application of biologically friendly fixation constructs while avoiding fixation failure and associated complications of both simple and complex tibial plateau fractures.

LEVEL OF EVIDENCE: Level II, prospective cohort study.