Three column fixation for complex PROXIMAL TIBIA FRACTURES

NEW CLASSIFICATION FOR PROXIMAL TIBIAL FRACTURES BY DR LUO

1. Three-Column Fixation for Complex Tibial Plateau Fractures Cong- Feng Luo , MD, PhD, Hui Sun, MD, Bo Zhang, MD, and Bing-Fang Zeng , MD J Orthop Trauma Volume 24, Number 11, November 2010 DR. LOKESH SHAROFF Orthopaedic Surgeon, Mumbai, India

2. JOT – JOURNAL OF ORTHOPAEDIC TRAUMA Objectives: 1 ) To introduce a computed tomography-based ‘‘ three column fixation ’’ concept; and 2 ) to evaluate clinical outcomes ( by using a column-specific fixation technique) for complex tibial plateau fractures ( Schatzker classification Types V and VI).

3. STUDY DESIGN PROSPECTIVE COHORT STUDY

4. PATIENTS From December 2004 to July 2006, 266 cases of tibial plateau fractures were operated. 32 cases diagnosed as ‘‘three-column fractures,’’ 3 patients - excluded because they could not be contacted during follow-up. So, 29 cases included for the study.

5. SURGICAL TEAM All patients were operated by 2 surgeons belonging to 1 surgical team.

6. EXTERNAL FIXATOR It was applied in patients, - who required pre –operative reduction, - high energy injury to the soft tissues.

7. INVESTIGATIONS - XRAYS, - CT- SCANS -- WERE PERFORMED AFTER EX-FIX as it gave more information.

8. THREE-COLUMN CONCEPT

9. 1 COLUMN -- 1 COLUMN – is 1 independent articular depression with break of the column is defined as a fracture of the relative column. -- Pure articular depression (S-type 3) was defined as a Zero Column Fracture. -- anterolateral fracture and a separate posterior–lateral articular depression with a break of the posterior wall, the fracture is defined as a ‘‘two-column (lateral and posterior column) fracture .’’ -- Antero-Medial + Postero -medial = 2 column

10. THREE COLUMN FRACTURE The ‘‘ three-column fracture’’ is defined as at least one independent articular fragment in each column.

11. POST OPERATIVE PROTOCOL -- AP & LATERAL XRAYS were done – immediate post- op , every 6 weeks till union and then 2 years after the index operation. -- TPA, FTA, MEDIAL AND LATERAL POSTERIOR SLOPE ANGLE – MEASURED MALREDUCTION – intra-articular step-off 2 mm, TPA > 95*OR < 80, PA > 15 OR <-5 SECONDARY LOSS OF REDUCTION- > 5* MALALIGNMENT OR 2MM ARTICULAR DEPRESSION SF-36 FORM – FILLED AT 2 YRS.

12. OPERATIVE TECHNIQUE -- Floating position- prone and lateral position - prone – posterior, postero medial and antero -medial columns 3.5 mm plates were used ( lcdcp , t-plate, cloverleaf plate)

13. POSTERIOR APPROACH

14. OPERATIVE TECHNIQUE

15. OPERATIVE TECHNIQUE -- ANTERO-LATERAL APPROCH – LATERAL COLUMN FIXATION – SUB-MENISCAL APPROACH -- L-PLATE or LISS PLATE applied

16. POST-OPERATIVE PROTOCOL --CPM – 3 DAYS --PARTIAL WEIGHT BEARING- BEGIN FROM 4 TH -6 TH WEEK -- FULL WEIGHT BEARING – AFTER BONY UNION

17. STASTICAL METHODS -- SPSS 11.0 -- CORRELATION – BY PEARSON CORRELATION COEFFICIENT

18. RESULTS -- 32 CASES -- 3 CASES LOST TO FOLLOW UP -- 23 MEN AND 6 WOMEN -- AVERAGE AGE – 46.8 -- 13 LEFT , 16 RIGHT ALL WERE CLOSED FRACTURES WITH NO DNVD -- TOTAL MEAN OPERATION TIME- 140 MINS -- MEAN BLOOD LOSS – 327 ML -- AVERAGE XRAY BONY TIME FOR UNION- 13.1 --AVERAGE FULL WT BEARING TIME – 16.7 WEEKS

19. RESULTS 1 case 2* varus and valgus deformity each, 2 cases had screw loosening 2 cases had wound drainage with negative bacterial culture Patient scores for the Short Form 36, Hospital for Special Surgery score, and lower-extremity measure at 24 months postoperatively were 89 (range, 80–98), 90 (range, 84–98) and 87 (range, 80–95), respectively. Average ROM of the affected knees was 2.7 to 123.4 . NO significant differences in either TPA or PA on the radiographs immediately postoperatively and 24 months postoperatively (P = 0.840 for TPA, 0.060 for medial posterior-slope-angle and 0.061 for lateral posterior-slope-angle)

20. CONCLUSION The ‘‘three-column concept’’ is a new and useful supplement to the present classification systems for tibial plateau fractures. ‘‘ Three-column fixation’’ seems to be an effective and a safe way for the treatment of multiplanar complex tibial plateau fractures.

21. THANK YOU