The tibial plateau, an important element of the knee joint, plays a vital role in both movement and weight distribution. Proximal tibial fractures account for 1.2% of all fractures. These fractures are more prevalent among individuals in their third to fifth decades of life and are increasing in frequency due to high-speed traffic accidents, falls from significant heights, sports injuries, and other contributing factors [1,2].

Tibial plateau fractures cause changes in the movement of the knee, the stability of the joint, and lead to misalignment of the joint [3].

The treatment outcomes and long-term impairment are influenced by the intricate biomechanics of the joint, the stability of the ligaments, and the congruency of the joint surfaces [4,5]. Schatzker's type IV, V, and VI fractures result from severe trauma and account for 20-40% of all fractures of this nature. These fractures are often accompanied by local soft tissue damage, compartment syndrome, and ligament instability [6].There is a significant controversy on the optimal approach to treating tibial plateau fractures with high energy impact. Open reduction and stable internal fixation enable early mobilisation of the knee by preserving articular congruency and restoring mechanical alignment [7,5,8]. Schatzker's classification is a straightforward and concise technique that focuses solely on the anterior-posterior view X-ray to determine the columns of the proximal tibia. Luo et colleagues devised a 3-column idea utilizing Axial CT scans to enhance the detection of postero-medial fragments that are often overlooked on conventional X-rays [9]. This categorization aids in the development of a surgical strategy by determining the optimal patient positioning, surgical approach, and incision placement [2].

This ambispective observational study was conducted on patients undergoing columnar fixation of proximal tibia fractures at the Department of Orthopaedics, Sri Aurobindo Medical College and PG Institute, Indore, from August 2021 to February 2024. The study included patients aged 18 years and above who were treated with columnar fixation for tibial plateau fractures classified under the Three Column Fracture classification. Patients with neurovascular injury, those with associated ipsilateral limb fractures, those with previous deformities, and those who were not willing to provide consent were excluded from the study. 30 patients who attended the OPD and emergency department at the Sri Aurobindo Institute of Medical Science were enrolled in the study. Preoperative preparations included routine OT profile checks and pre-anaesthetic evaluations for all cases. Parenteral routine antibiotics were administered 1 hour prior to surgery. All patients meeting the inclusion criteria underwent open reduction and internal fixation. Follow-up assessments were conducted at 6 weeks, 3 months, and 6 months postoperatively. The functional outcomes were evaluated using the New Oxford Knee Score.

The socio-demographic profile of the study participants, as presented in the table, includes 30 individuals, with a majority being male (73.3%) and the remaining female (26.7%). The average age of participants is approximately 46 years, with the age distribution showing 40% of participants being 40 years or younger, 26.7% aged between 41 and 50, and 33.3% over 50 years. Most participants were engaged in occupations such as daily wage labor (50.0%) or homemaking (23.3%), with a smaller proportion being farmers (20.0%) and students (6.7%). The majority of cases were closed (76.7%), with only 23.3% being open. Additionally, the majority of participants did not experience complications (80.0%), and most cases involved two columns (50.0%), followed by one column (30.0%) and three columns (20.0%).

Table-2 Comparisons of Oxford Knee Score at 6weeks, 3months and 6 months

The Oxford Knee Score (OKS) results indicate a significant improvement in knee function over time among the study participants. At 6 weeks post-intervention, the mean OKS was 30.83 with a standard deviation of 3.28. This score increased to 36.33 at 3 months and further to 41.67 at 6 months, with standard deviations of 3.07 and 2.68, respectively. The Friedman test, is highly significant indicating that the improvements in the Oxford Knee Score over the three time points were statistically significant.

Table-3 Comparison of complication according to gender among study subjects

The table presents the distribution of complications by gender among the study participants. Out of the 30 participants, 22 were male and 8 were female. Complications were observed in 5 males (22.7%) and 1 female (12.5%) (Knee stiffness being more common), while the majority of participants did not experience complications, with 17 males (77.3%) and 7 females (87.5%) reporting no complications. The Fisher’s exact test was used indicating that there is no statistically significant association between gender and the likelihood of experiencing complications in this study.

Table-4 Comparison of complication according to Age among study subjects

The table presents the distribution of complications across different age groups among the study participants. Out of the 30 participants, 12 were aged 40 years or younger, 8 were between 41 and 50 years old, and 10 were over 50 years old. Complications were observed in 2 participants (16.7%) aged 40 or younger, 2 participants (25.0%) aged between 41 and 50, and 2 participants (20.0%) aged over 50. The majority of participants in each age group did not experience complications, with 83.3% in the ≤40 age group, 75.0% in the 41-50 age group, and 80.0% in the >50 age group reporting no complications.

Tibial plateau fractures are a frequently encountered type of intra-articular fractures that typically arise from incidents such as road traffic accidents, falls from elevated surfaces, or acts of violence. For a long time, there has been a lot of debate over how to treat proximal tibial fractures, including when surgery is necessary and what type of surgery should be used. Insufficient treatment of intra-articular fractures can lead to joint instability, deformity, and limited range of motion[10,11]. For many years, the preferred therapy has been open reduction and rigid internal fixation, following the guidelines of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF). This therapeutic approach has produced excellent outcomes in both the short and long term in numerous studies.

The study predominantly included male participants (73.3%), which may reflect a higher incidence of proximal tibia fractures among men. This could be due to occupational hazards or higher participation in activities that pose a risk for such injuries[12]. The mean age of participants was 46.17 years, with a fairly even distribution across age groups, suggesting that these fractures can occur across a wide age range.

The majority of cases (76.7%) were closed fractures, which is generally associated with better outcomes compared to open fractures. The study utilized the three-column classification system, with half of the cases involving two columns, indicating complex fracture patterns that require careful surgical planning[13].The Oxford Knee Score (OKS) showed significant improvement over time, with mean scores increasing from 30.83 at 6 weeks to 41.67 at 6 months post-surgery. This progressive improvement indicates that columnar fixation for proximal tibia fractures leads to good functional outcomes[12]. The statistically significant increase in OKS suggests that patients experience substantial recovery in knee function and reduced pain over the first 6 months post-operatively. The overall complication rate was relatively low at 20%, which is encouraging for this type of complex fracture. There was no significant association between gender or age and the likelihood of complications, suggesting that the surgical technique may be equally effective across different patient demographics[12].While there were slight variations in complication rates between genders and age groups, these differences were not statistically significant. This indicates that columnar fixation may be a suitable treatment option regardless of the patient's age or gender[14].Although not directly measured in this study, the improvement in OKS over 6 months suggests potential for good long-term functional outcomes and quality of life, which aligns with findings from other studies on tibial plateau fracture fixation[14].

The use of columnar fixation, particularly in two-column and three-column fractures, demonstrates the application of advanced surgical techniques for complex tibial plateau fractures. This approach allows for stable fixation and anatomical reduction, which are crucial for good functional outcomes[13,15].

The study demonstrates that columnar fixation for proximal tibia fractures results in significant functional improvement over the first 6 months post-surgery, with a relatively low complication rate. The technique appears to be effective across different age groups and for both genders, supporting its use in a diverse patient population with complex tibial plateau fractures.

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