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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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International Orthopaedics (SICOT)
DOI 10.1007/s00264-017-3602-3
LETTER TO THE EDITOR
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,
We read with great interest the article in the last issue on
the validation of the four-column classification of tibial
plateau fractures [1]. However, we have some reserva-
tions about the introduction of a fourth posterolateral
column of the proximal tibia. The authors demonstrate
very high intra- and inter-observer agreement. This is in
line with others, who validated the three-column classi-
fication approach, depicting the posteromedial and pos-
terolateral column as a whole [24]. Addressing posterior
tibial plateau fractures is indeed increasingly recognized
as an important prognostic factor. Neglected posterior
column fractures and subsequent sagittal malalignment
predispose for significantly worse outcome scores [5].
This underscores the need for new classification ap-
proaches. Recently, Krause et al. [6] further strengthen
the evidence of frequent involvement of the posterior
tibial plateau fractures and proposed a ten segment clas-
sification of tibial plateau fractures. Nevertheless, it does
not provide an appropriate tool for surgical guiding. In
contrast, the three-column classification approach, intro-
Comment on reliability of a four-column classification for tibial plateau
fractures
* Harm Hoekstra
harm.hoekstra@uzleuven.be
1
Department of Trauma Surgery, University Hospitals Leuven,
Herestraat 49, B-3000 Leuven, Belgium
2
Department of Development and Regeneration, KU Leuven -
University of Leuven, B-3000 Leuven, Belgium
duced by Luo et al. in 2010 [7], has proven very useful
and reliable for the pre-operative planning and treatment
of tibial plateau fractures. Subsequently, with the updated
three-column concept they supported the surgical ap-
proach and implant choice for the treatment of multiple
column fractures on the basis of the mechanism of injury
and fracture pattern [8]. In addition, we established and
validated the revised three-column classification ap-
proach, which proved to be of high reliability as well
[9]. According to the revised approach the posterior border
of the lateral column lies posterior instead of anterior of the
fibula (Fig. 1a). Because of this, a blind-zone is created (i.e.
posterolateral corner). Proximal tibia variable angle LCPs
make it possible to adequately fixate lateral column fractures
that extend posteriorly into the posterolateral corner and pro-
vide articular support, whereas posterior column fractures
(with or without extension into the posterolateral corner) can
sufficiently be treated using a posteromedial reversed L-
shaped approach. The latest LCP implant with an identical
configuration, allows for both buttress and articular support
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.
Hence, from the surgical point of view, posterolateral
tibial plateau fractures should not be considered as
full-fledged fourth-column fractures. After all, Chang
et al. [11], as referred by the authors [1], previously
described in a small cases series the combined anterolat-
eral and posteromedial L-shaped approach for the treat-
ment of complex bicondylar four-quadrant tibial plateau
fractures, rather than establishing a four-column classifi-
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

Posterior
column

Compliance with ethical standards
Conflict of interest There is no conflict of interest.
References
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