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Are there four tibia plateau columns?

Article in International Orthopaedics August 2017

DOI: 10.1007/s00264-017-3602-3


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Harm Hoekstra
University of Leuven


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International Orthopaedics (SICOT)
DOI 10.1007/s00264-017-3602-3


Are there four tibia plateau columns?

Harm Hoekstra 1,2

Received: 29 July 2017 / Accepted: 2 August 2017

# SICOT aisbl 2017

Letter to the editor, duced by Luo et al. in 2010 [7], has proven very useful
We read with great interest the article in the last issue on and reliable for the pre-operative planning and treatment
the validation of the four-column classification of tibial of tibial plateau fractures. Subsequently, with the updated
plateau fractures [1]. However, we have some reserva- three-column concept they supported the surgical ap-
tions about the introduction of a fourth posterolateral proach and implant choice for the treatment of multiple
column of the proximal tibia. The authors demonstrate column fractures on the basis of the mechanism of injury
very high intra- and inter-observer agreement. This is in and fracture pattern [8]. In addition, we established and
line with others, who validated the three-column classi- validated the revised three-column classification ap-
fication approach, depicting the posteromedial and pos- proach, which proved to be of high reliability as well
terolateral column as a whole [24]. Addressing posterior [9]. According to the revised approach the posterior border
tibial plateau fractures is indeed increasingly recognized of the lateral column lies posterior instead of anterior of the
as an important prognostic factor. Neglected posterior fibula (Fig. 1a). Because of this, a blind-zone is created (i.e.
column fractures and subsequent sagittal malalignment posterolateral corner). Proximal tibia variable angle LCPs
predispose for significantly worse outcome scores [5]. make it possible to adequately fixate lateral column fractures
This underscores the need for new classification ap- that extend posteriorly into the posterolateral corner and pro-
proaches. Recently, Krause et al. [6] further strengthen vide articular support, whereas posterior column fractures
the evidence of frequent involvement of the posterior (with or without extension into the posterolateral corner) can
tibial plateau fractures and proposed a ten segment clas- sufficiently be treated using a posteromedial reversed L-
sification of tibial plateau fractures. Nevertheless, it does shaped approach. The latest LCP implant with an identical
not provide an appropriate tool for surgical guiding. In configuration, allows for both buttress and articular support
contrast, the three-column classification approach, intro- of the entire posterior column (Fig. 1b). Furthermore, treat-
ment of (isolated) posterolateral corner injury is aimed at
ligament repair or reconstruction using graft techniques.
Comment on reliability of a four-column classification for tibial plateau Hence, from the surgical point of view, posterolateral
tibial plateau fractures should not be considered as
* Harm Hoekstra
full-fledged fourth-column fractures. After all, Chang
harm.hoekstra@uzleuven.be et al. [11], as referred by the authors [1], previously
described in a small cases series the combined anterolat-
Department of Trauma Surgery, University Hospitals Leuven, eral and posteromedial L-shaped approach for the treat-
Herestraat 49, B-3000 Leuven, Belgium ment of complex bicondylar four-quadrant tibial plateau
Department of Development and Regeneration, KU Leuven - fractures, rather than establishing a four-column classifi-
University of Leuven, B-3000 Leuven, Belgium cation approach.
International Orthopaedics (SICOT)

Fig. 1 a revised three-column a b

concept with the posterolateral
blind-zone (dotted) [10]; b
posterior buttress and articular
support of the whole posterior
column Lateral Medial
column column


Compliance with ethical standards 5. van den Berg J, Reul M, Nunes Cardozo M, Starovoyt A, Geusens
E, Nijs S, Hoekstra H (2017) Functional outcome of intra-articular
Conflict of interest There is no conflict of interest. tibial plateau fractures: the impact of posterior column fractures. Int
Orthop. doi:10.1007/s00264-017-3566-3
6. Krause M, Preiss A, Mller G, Madert J, Fehske K, Neumann MV
et al (2016) Intra-articular tibial plateau fracture characteristics ac-
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