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

Abstract

Introduction: 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. Methods: 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 threecolumn concept. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Results: Median follow-up was 43.1 months (IQR 29.0-63.3) with a response rate of 80,2%. Outcomescores 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 were found to significantly influence outcome. Conclusions: 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 threecolumn concept might be important in order to consummate the three-column concept as guiding tool.

Bone metabolism is a key factor for clinical outcome of tibial plateau fractures

“…Common comorbidities, such as type II diabetes or arterial hypertension, have not been associated with clinical outcomes [ 6 , 7 , 10 ]. However, reports analyzing the risk factors of bone metabolism in a cohort of TPF are rare.…”

“…Numerous studies that have analyzed the outcome of TPF have identified several risk factors for poor clinical and radiological outcome, such as fracture complexity, leg axis malreduction [ 9 ], involvement of the posterior column [ 7 ], residual articular depression of more than 2 mm [ 9 , 13 ], or postoperative malreduction due to an impaired intraoperative fragment visualization [ 26 , 49 ], while the impact of associated soft-tissue injuries is still under debate [ 50 , 51 ]. In the individual failure analysis of the present study, two of six cases may be explained solely by a potential IBM.…”

“…Nonetheless, persistent pain, impaired range of motion (ROM), and/or instability are repeatedly described. While short-and mid-term outcomes have been associated with a low return-to-sports rate and a low patient-related outcome compared to healthy individuals (Knee Injury and Osteoarthritis Outcome Score), a good-toexcellent knee function in the long term has been reported (Rasmussen and Hospital for Special Surgery Knee Scoring System) [6][7][8][9][10]. Several studies have identified potential fracture-specific and surgery-related risk factors for impaired patient outcomes [6][7][8][9][10][11].…”

“…While short-and mid-term outcomes have been associated with a low return-to-sports rate and a low patient-related outcome compared to healthy individuals (Knee Injury and Osteoarthritis Outcome Score), a good-toexcellent knee function in the long term has been reported (Rasmussen and Hospital for Special Surgery Knee Scoring System) [6][7][8][9][10]. Several studies have identified potential fracture-specific and surgery-related risk factors for impaired patient outcomes [6][7][8][9][10][11]. As a result, there is general consensus that anatomical reconstruction within a 2-3-mm articular step-off, a straight leg axis, and stable bony and ligamentous fixation should be considered [9,[11][12][13][14].…”

“…While some studies have also analyzed the influence of patient-specific risk factors, medication, or comorbidities, their association with bone metabolism and its impact on patient outcomes has not been in the focus [6,7,10,[15][16][17]. Instead, impaired bone metabolism (IBM) and its association with patient-specific risk factors such as vitamin D deficiency, thyroid dysfunction, chronic kidney disease (CKD) or liver failure, systemic immunodeficiency after organ transplantation or with HIV, or osteoporosis itself have most commonly been studied in relation to fracture risk of vertebral and hip fractures.…”