The Three-Column Concept of the Tibial Plateau
The three-column concept divides the tibial plateau into lateral, medial, and posterior columns to guide surgical approach selection and fixation strategy for complex tibial plateau fractures, particularly those involving posterior column injuries that traditional classification systems fail to adequately address. 1, 2
Anatomical Division
The tibial plateau is conceptually divided into three distinct columns 1, 3:
- Lateral column: The lateral tibial plateau region
- Medial column: The medial tibial plateau region
- Posterior column: The posterior aspect of the tibial plateau, which is often inadequately visualized and treated with traditional anterior approaches
Clinical Application and Classification
CT imaging with three-dimensional reconstruction is essential for applying the three-column concept, as it identifies fracture patterns that plain radiographs and traditional classification systems miss. 3 The Schatzker classification failed to classify 14 cases in one series that were all successfully classified using the three-column approach 3.
The classification process involves 2, 3:
- Identifying which column(s) are injured and locating associated articular depression or comminution
- Determining the injury mechanism including varus/valgus and flexion/extension forces
- Using this information to determine surgical approach(es) and the location and function of applied fixation
Surgical Strategy
For complex tibial plateau fractures involving all three columns (Schatzker Types V and VI), a combined posterior and anterior-lateral approach in the floating position allows direct visualization and fixation of all fracture components. 1
The posterior approach provides 1, 4:
- Enhanced exposure of the posterior column
- Ease of access for buttress plate application
- Ability to place posterior-to-anterior screws for optimal fixation
Clinical Outcomes
Studies using the three-column fixation approach demonstrate 1, 2:
- Mean radiographic union time of 13.1-13.5 weeks
- Mean full weight-bearing time of 14.8-16.7 weeks
- Hospital for Special Surgery scores averaging 90-93
- Average knee range of motion of 1.5-2.7° to 121.5-123.4°
- Low rates of fixation failure and secondary articular depression
Important Caveats and Limitations
The three-column concept has significant limitations and should not be applied dogmatically. 5 A study of 111 consecutive posterior column fractures found that:
- Only 22.5% of patients were actually treated according to the three-column concept 5
- Treatment according to the three-column concept did not significantly influence functional outcomes 5
- Posterior column fractures had equal outcomes regardless of whether they received specific posterior column fixation 5
- The concept may be insufficient without incorporating trauma mechanism-based fracture morphology 5
Interobserver Reliability
The three-column classification demonstrates superior reliability compared to traditional systems 3:
- Mean κ value of 0.766 for interobserver reliability (substantial agreement) versus 0.567 for Schatzker classification (moderate agreement)
- Mean κ value of 0.810 for intraobserver reliability (substantial agreement)
- All fractures could be classified using the three-column system, whereas some could not be classified by Schatzker 3
Practical Implementation
When CT shows a subtle tibial plateau abnormality, proceed with CT imaging as it demonstrates 100% sensitivity for detecting tibial plateau fractures compared to 83% for radiographs alone. 6 Articular depression >11 mm on CT predicts higher risk of lateral meniscus tear and ACL avulsion fracture, which may necessitate MRI for complete surgical planning 6, 7.