Excellent long-term survivorship, radiologic and functional outcomes of operatively treated tibial plateau fractures

Purpose: Long-term reports of operative tibial plateau fractures are scarce. This study aimed to define long-term knee survivorship with total knee arthroplasty (TKA) as the primary endpoint, assess radiographic and functional outcomes, and the relationship between reduction and functional outcomes. Methods: Over 21 years, 170 patients were identified with operatively managed tibial plateau fractures treated by two orthopaedic trauma surgeons (109 unicondylar, 61 bicondylar). Survivorship analysis was performed to identify TKA conversion risk factors. Final follow-up radiographs were assessed for osteoarthritis severity, and clinical and functional outcomes were analyzed (KOS-ADLS, SF-12, and NRS-Pain). Results: In unicondylar fractures, survivorship free of TKA was 93.6% (95% CI 88.7%–98.5%) at 10- and 15-years. Survivorship free of TKA for bicondylar fractures was 88.5% (95% CI 80.5%-96.5%) at 10-years and 84.3% (95% CI 73.1%–95.5%) at 15-years. Bicondylar involvement and non-anatomic reduction were independent risk factors for TKA (HR 2.7, HR 3.7; respectively). Bicondylar fractures demonstrated severe osteoarthritis more frequently than unicondylar (p = 0.043). At average 10-year follow-up (2–24 years), mean KOS-ADLS was 68.7 ± 12.5. Unicondylar patients had increased mean KOS-ADLS compared to bicondylar (71.4, 63.1, respectively; p = 0.005). Mean SF-12 was similar between groups. Conclusion: Approximately 10% of operative tibial plateau fractures underwent TKA at 15-years; this rate approached 15% in bicondylar fractures. Bicondylar fractures had 2.7X higher TKA risk. In unicondylar fractures, non-anatomic reduction was associated with 3.7X higher TKA conversion risk. While both groups had similar SF-12 scores, bicondylar had significantly lower KOS-ADLS scores. Anatomic reduction is critical to prevent TKA conversion in unicondylar fractures.