This prospective cohort from a Level 1 trauma center introduces a CT-based 'three-column' concept for classifying and fixing complex tibial plateau fractures. It asks whether column-specific fixation using a novel 'floating position' and combined posterior plus anterolateral approach can safely address the posterior column — which standard bilateral dual plating cannot reach. The study reports clinical and radiographic outcomes in 29 patients at minimum 2-year follow-up.
Standard Schatzker and AO systems are built on AP radiographs and point surgeons toward medial and lateral fixation. The posterior column simply does not exist in those frameworks — which is why posterolateral articular fragments were routinely missed or inadequately fixed before CT-based planning became standard.
When you see a Schatzker V or VI fracture, get a CT before finalizing your plan. If the CT shows an independent articular fragment in the posterior column with a break of the posterior wall, you are dealing with a three-column fracture. Standard dual plating will not adequately reduce or hold that posterior fragment.
For true three-column fractures, plan a combined inverted L-shaped posterior approach plus anterolateral approach using the floating position. The posterior approach lets you directly visualize and buttress both posteromedial and posterolateral zones through a single incision and a fracture window. No second posterolateral incision needed.
Remember: posterolateral depression is impossible to reduce from the supine position. The floating position exists precisely because you need prone orientation for the posterior column, then can rotate to address the lateral column without re-draping.
This prospective cohort from a Level 1 trauma center introduces a CT-based 'three-column' concept for classifying and fixing complex tibial plateau fractures. It asks whether column-specific fixation using a novel 'floating position' and combined posterior plus anterolateral approach can safely address the posterior column — which standard bilateral dual plating cannot reach. The study reports clinical and radiographic outcomes in 29 patients at minimum 2-year follow-up.
Standard Schatzker and AO systems are built on AP radiographs and point surgeons toward medial and lateral fixation. The posterior column simply does not exist in those frameworks — which is why posterolateral articular fragments were routinely missed or inadequately fixed before CT-based planning became standard.
When you see a Schatzker V or VI fracture, get a CT before finalizing your plan. If the CT shows an independent articular fragment in the posterior column with a break of the posterior wall, you are dealing with a three-column fracture. Standard dual plating will not adequately reduce or hold that posterior fragment.
For true three-column fractures, plan a combined inverted L-shaped posterior approach plus anterolateral approach using the floating position. The posterior approach lets you directly visualize and buttress both posteromedial and posterolateral zones through a single incision and a fracture window. No second posterolateral incision needed.
Remember: posterolateral depression is impossible to reduce from the supine position. The floating position exists precisely because you need prone orientation for the posterior column, then can rotate to address the lateral column without re-draping.