Abstract
Aims
Tibial plateau fractures comprise 1% of all fractures, with a gold standard management of open reduction and internal fixation. Post-traumatic osteoarthritis is a common complication following fixation that can result in the requirement of a total knee arthroplasty (TKA). This study was designed to review the rate of TKA following surgical fixation of tibial plateau fractures. Primary outcome was the incidence of periprosthetic joint infection (PJI) and secondary outcome was function in these patients.
Methods
This retrospective multicentre study identified all patients with tibial plateau fractures that underwent surgical fixation within our health board over a 12-year period. The patients who then went on to require a TKA were identified.
Results
Between May 2008 and May 2021, 854 patients had a tibial plateau fracture managed surgically. Of these, 26 patients (3.04%; 1.89% to 4.20%) went on to require a TKA. Three of the 26 patients (11.54%; -0.74% to 23.82%) developed a PJI. The average increase in Oxford Knee Score was 14.3 for patients who did not go on to develop a PJI, compared with an increase of only 4 points in those that did develop a PJI. All patients in our study who had a TKA following fracture fixation had reduced postoperative patient-reported outcome measures when correlated to those reported in National Joint Registry data nationally for patients following both primary and revision TKA.
Conclusion
The rate of TKA following tibial plateau fracture fixation reflected that in the literature. The rate of PJI in our patients who had a TKA following a tibial plateau fracture fixation was found to be significantly higher (p < 0.0001) when compared with primary TKA. In an attempt to reduce the rate of PJI, we advocate for a two-stage approach in these patients. Patients should be counselled that the results of TKA following fracture fixation are inferior to primary TKA.
Cite this article: Bone Jt Open 2025;6(12):1575–1580.
Keywords: Tibial plateau fracture, Total knee arthroplasty, Periprosthetic joint infection, Patient reported outcome measures, surgical fixation, total knee arthroplasty (TKA), periprosthetic joint infection (PJI), fracture fixation, primary total knee arthroplasty, patient-reported outcome measures (PROMs), open reduction and internal fixation (ORIF), tibial plateau fracture fixation, Oxford Knee Scores
Introduction
Tibial plateau fractures comprise 1% of all fractures,1 occurring in a bimodal incidence.2 They are graded by the Schatzker classification,3 with higher grade injuries reflecting a worse prognosis.3,4 This classification has withstood the test of time showing moderate reliability, with kappa coefficients for interobserver reliability at 0.68 and intraobserver reliability of 0.5,6
Grade II injuries predominate, and associated soft-tissue injuries are common, with 18% of grade VI injuries being associated with compartment syndrome.7,8 Gold standard management of such fractures is an open reduction and internal fixation (ORIF).4,9
Post-traumatic osteoarthritis is a common complication which follows a tibial plateau fracture fixation, occurring in up to 44% of patients.4,10 A higher Schatzker grade, loss of reduction, and malalignment increases the incidence of this further.11,12 Despite the significant risk of osteoarthritis, only 3% to 10% eventually undergo a total knee arthroplasty (TKA).13,14 It has been found that older patients with a more severe fracture are more likely to go on to require a TKA, and those with a direct articular injury.15
A TKA following a tibial plateau fracture ORIF is considered a more challenging operation compared with a primary TKA.16 Consequently, there is a higher rate of complications17 associated, including patellar tendon rupture, joint stiffness, and PJI. Despite this, the patient outcome and satisfaction is comparable with a primary TKA,18 even with a reoperation rate of over 20% in this patient group.17
Although Saleh et al16 commented on the organism and outcome of three patients in their study who developed infection following a TKA after tibial ORIF, predisposing factors were not fully determined.11 Furthermore, treatment for periprosthetic joint infection (PJI) has progressed significantly over the past few years with new research and guidelines continually being updated.19-21 This study was therefore designed to review the rate of TKA following surgical fixation of a tibial plateau fracture in our healthcare board.
The primary outcome of this study was the rate of TKA following tibial plateau fracture that underwent ORIF. The secondary outcomes concentrated on rate of PJI, responsible organism, treatment received, and patient-reported outcome measures (PROMs), specifically Oxford Knee Scores (OKS).22 Further predisposing patient factors associated with infection were also reviewed.
Methods
After obtaining local ethical approval, and as per Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, data were retrospectively analyzed from a single health board (NHS Greater Glasgow & Clyde, Glasgow, UK). Over a 12-year period, 854 patients sustained a tibial fracture that was managed surgically; 26 of these patients went on to require a TKA and these patients were further analyzed. No patients were excluded.
Diagnosis and demographic details
Age, sex, American Society of Anesthesiologists (ASA) grade,23 and comorbidities, along with timing to theatre for fixation following initial injury, mechanism of injury, other associated injuries, classification of fracture as per Schatzker, approach used for tibial fixation, length of operation, and grade of operating surgeon were all recorded for the initial tibial fixation procedure for the 26 patients from reviewing patient digital notes. All postoperative complications were recorded following initial fixation and the best mobility achieved by the patient.
OKS were recorded as PROMs. Complete preoperative and postoperative scores were variably recorded. In the event of absent preoperative OKS retrospective preoperative OKS were recorded while recording postoperative OKS.
With regards to the TKA surgery, we reviewed the reason for the TKA, if the metalwork was removed as a staged procedure prior to the TKA, the length of time between initial fixation and TKA, the length of time for the TKA operation, and the grade of surgeon. Finally, we looked at all postoperative complications following the TKA surgery- paying particular attention to infection and its sequelae.
With regards to infection, a diagnosis of a PJI was defined as per the Musculoskeletal Infection Society (MSIS) 2011 criteria,24 with the part modification at the International Consensus Meeting in 2013.25 Retrospectively, data was analyzed to ascertain if the infected joints met the new criteria set out by the European Bone and Joint Infection Society (EBJIS).21 The joints that developed infection all fell under the infection confirmed or infection likely category. We investigated the time between TKA surgery and infection developing and defined an acute infection as one that developed within one month after surgery and chronic if it occurred at any time thereafter.
If infection was suspected, radiographs and bloods including a white blood cell (WBC) count, ESR, and CRP were performed. Aspiration of the infected knee joints were performed when clinically indicated. In addition for the infected cases, intraoperative aspirates were taken and sent to the laboratory in blood culture bottles, and a specific set of tissue samples, as set out by a specific ‘PJI’ set on our electronic system.
Patient characteristics
A total of 854 patients had a tibial plateau fracture managed surgically between May 2008 and May 2021 in our health board. Of these, 26 patients went on to require a TKA following this (3.04%; 95% CI 1.89 to 4.20). The most common Schatzker classification grade was grade II, followed by grade VI. Patient demographic details are presented in Table I. Overall, 26 patients required a TKA due to the development of osteoarthritis. The mean time between initial fixation of tibial plateau fracture and TKA was 36 months, with the shortest time at seven months, and the longest 11 years and one month.
Table I.
Patient demographic details.
| Variable | Patients who did not develop PJI (n = 23), n (%) | Patient who developed a PJI (n = 3), n (%) | p-value* |
|---|---|---|---|
| Age, yrs | |||
| 31 to 40 | 2 (8.7) | 1 (33.3) | |
| 41 to 50 | 4 (17.4) | 1 (33.3) | |
| 51 to 60 | 9 (39.1) | 0 (0.0) | |
| 61 to 70 | 7 (30.4) | 1 (33.3) | |
| > 70 | 1 (4.4) | 0 (0.0) | |
| Mean age, yrs (SD) | 55.3 (10.3) | 49.7 (10.6) | 0.4053 |
| Comorbidities | |||
| 0 | 5 (21.7) | 0 (0.0) | |
| 1 to 2 | 10 (43.5) | 3 (100.0) | |
| > 2 | 8 (34.8) | 0 (0.0) | |
| Schatzker grade | |||
| I | 0 (0.0) | 0 (0.0) | |
| II | 10 (43.5) | 1 (33.3) | |
| III | 0 (0.0) | 0 (0.0) | |
| VI | 4 (17.4) | 0 (0.0) | |
| V | 3 (13.0) | 1 (33.3) | |
| VI | 6 (26.1) | 1 (33.3) | |
| Associated injuries | |||
| Associated number | 8 | 1 | |
| Soft-tissue injury | 3 | 0 | |
| Compartment syndrome | 1 | 0 | |
| No associated injury | 13 | 0 |
Unpaired t-test.
PJI, periprosthetic joint infection.
Surgery for infection, multidisciplinary team, and follow-up
The TKA operations were performed by a consultant in 23 cases. Three operations were performed by senior specialty registrars or senior clinical fellows. Follow-up following tibial plateau fracture fixation varied, with the shortest period between fracture fixation and TKA being nine months and the longest being over ten years. If the TKA was infected, further surgery when indicated was performed by a consultant knee surgeon with a specialist interest in revision knee arthroplasty. Follow-up was a minimum of 24 months for patients with infection.
Outcome measures
The purpose of this study was to identify the number of patients who went on to require a TKA following tibial plateau fracture fixation between May 2008 and May 2021, within our health board. Further we wanted to identify patients who developed postoperative complications following their TKA, in particular a PJI. As mentioned, PROMs were of specific interest as a secondary outcome measure.
Statistical analysis
Statistical analysis was performed using R Studio v. 1.3 (Posit Software, USA). Pearson chi-squared test was used to calculate the significance of developing a PJI following a TKA compared with tibial plateau fixation and subsequent TKA. The unpaired t-test (parametric data) and Fisher's exact test (non-parametric) were used to assess for significant differences between the 23 patients with a TKA with no PJI and the three who did develop a PJI. A significance value was set at p < 0.05. CIs were calculated as appropriate. Study power was calculated, with continuity correction applied.
Results
An anterolateral surgical approach was most commonly used, in isolation or combination with posteromedial incision for initial tibial fracture fixation.
All patients who went on to develop a PJI had removal of metalwork prior to TKA, compared with 65% of patients that did not develop a PJI, however due to the inadequate power of the study this was an insignificant finding. Further surgical information can be found in Table II.
Table II.
Surgery information.
| Variable | Patients who did not develop a PJI (n = 23), n (%) | Patient who developed a PJI (n = 3), n (%) | p-value |
|---|---|---|---|
| Surgeon grade | |||
| Consultant | 20 (87.0) | 3 (100.0) | |
| Senior registrar | 3 (13.0) | 0 (0.0) | 1.00* |
| Surgical approach | |||
| Anterolateral and posteromedial | 9 (39.1) | 1 (33.3) | |
| Anterolateral | 10 (43.5) | 1 (33.3) | |
| Posteromedial | 1 (4.35) | 0 (0.0) | |
| Lateral hockey stick | 1 (4.35) | 0 (0.0) | |
| Medial | 1 (4.35) | 0 (0.0) | |
| Percutaneous stab incisions | 1 (4.35) | 1 (33.3) | |
| Implant used | |||
| 1 plate | 19 (82.6) | 1 (33.3) | |
| 2 plates | 2 (8.7) | 1 (33.3) | |
| Screws | 2 (8.7) | 0 (0.0) | |
| Ilizarov | 0 (0.0) | 1 (33.3) | |
| Other postoperative complication following tibial plateau # fixation | |||
| Pain | 9 | 1 | |
| Nonunion | 0 | 1 | |
| Varus deformity | 5 | 0 | |
| Other | 2 | 0 | |
| Removal of hardware prior to TKA | |||
| Yes | 15 (65.2) | 3 (100.0) | |
| No | 8 (34.8) | 0 (0.0) | 0.5292* |
| Time between surgeries | |||
| < 12 mnths | 3 (13.0) | 1 (33.3) | |
| 12 mnths to 5 yrs | 16 (69.6) | 2 (66.7) | |
| > 5 yrs | 4 (17.4) | 0 (0.0) | |
| Mean time, mnths (SD) | 38.4 (34.3) | 14.7 (4) | 0.2512† |
| Length of TKA, hrs | |||
| < 2 | 13 (56.5) | 0 (0.0) | |
| > 2 | 8 (34.8) | 2 (66.7) | |
| Undocumented | 2 (8.7) | 1 (33.3) | |
| Reason for TKA | |||
| Osteoarthritis | 20 (90.0) | 3 (100.0) | |
| Other | 3 (10.0) | 0 (0.0) |
Fisher’s exact test.
Unpaired t-test.
PJI, periprosthetic joint infection; TKA, total knee arthroplasty.
The mean age of the patients was 54.6 years (32 to 77). Over 80% of patients had at least one comorbidity.
Three of the 26 patients (11.54%; -0.74% to 23.82%) developed a PJI. Three patients were managed surgically with a washout, debridement, and poly-exchange of the joint alongside intravenous antibiotics. All aspirates taken intraoperatively grew Staphylococcus aureus. Of these three patients, one had complete resolution of the infection, but two patients went on to develop further complications. One patient had chronic osteomyelitis, sinus formation, and exposure of metalwork and had an above-knee amputation in 2021. The other patient has chronic osteomyelitis and continues to require repeated antibiotic therapy, and is likely to require an above-knee amputation in the future. Patient outcomes with infection are summarized in Table III.
Table III.
Outcomes of patients who developed periprosthetic joint infections.
| Variable | Patient I | Patient II | Patient III |
|---|---|---|---|
| Organism | Staphylococcus aureus | Staphylococcus aureus | Staphylococcus aureus |
| Management | DAIR | DAIR | DAIR |
| Further complications | Extensive deep infection. Secondary washout required | Chronic osteomyelitis, sinus formation and exposure of metalwork | Chronic osteomyelitis and soft-tissue abscess |
| Outcome | Full resolution | Above-knee amputation of infected limb | Long-term antibiotic therapy. Likely to require above-knee amputation in the future |
DAIR, debridement, antibiotics, and implant retention .
The patients who developed a PJI had a higher Schatzker classification, with 66% having a grade V or VI, compared with 36% in those who did not develop a PJI. There was a much shorter time between the two surgeries, with a mean time between fracture fixation and TKA being 14.7 months (SD 4) in those that developed a PJI compared with 38.4 months (SD 34.3) in those that did not.
The rate of infection for TKA following surgical fixation of a tibial plateau fracture was found to be significantly higher (11.54% of patients) than the rate of infection following a primary TKA (0.84%) in our health board during the same time period (p < 0.0001, Pearson chi-squared test)). This is summarized in Figure 1.
Fig. 1.
Rate of periprosthetic joint infection following primary total knee arthroplasty (TKA) compared with TKA following tibial plateau fracture fixation.
PROMs are summarized in Table IV. The average increase in Oxford Knee Score was 14.3 for patients who did not go on to develop a PJI, compared with an increase in only 4 points in those that went on to develop a PJI.
Table IV.
Patient-reported outcome measures: preoperative, postoperative, and the change in Oxford Knee Scores from patients who underwent a total knee arthroplasty.
| Variable | Mean preoperative score | Mean postoperative score | Mean change in scores |
|---|---|---|---|
| Patients who did not develop PJI | 15.67 | 29.17 | + 13.5 |
| Patients who developed PJI | 14 | 18 | + 4 |
PJI, periprosthetic joint infection.
Discussion
The rate of TKA following tibial plateau fracture fixation in our health board reflected that in the literature. Similarly, we found the most common reason for TKA in our study was osteoarthritis (OA) which again is consistent with the literature.11 The rate of PJI in our patients who had a TKA following a tibial plateau fracture fixation was found to be high at 11.54%, significantly higher (p < 0.0001) than the rate of PJI following primary TKA in the same period.
The literature suggests that infection following ORIF of tibial plateau fractures is higher (with the incidence of surgical site infections being four to five times higher) when compared with ORIF of other fractures.26 It is well documented that tibial plateau fractures have an increased susceptibility to infection due to a number of factors, ranging from mechanism of injury, patient demographic details, fracture pattern, and soft-tissue injury. There is significant risk of soft-tissue injury with a tibial plateau fracture, particularly high-grade Schatzker injuries. In addition to this, surgical intervention to manage tibial plateau fractures often results in further soft-tissue disruption.17
The rate of infections in primary TKA has been found to be 0.5% to 1.9%;27 our health board is in keeping with this with a rate of 0.84%. The rate of an infection for a revision TKA in the literature is 8% to 10%.26Despite the patients in this study not having a previous TKA, they have had previous instrumentation of the joint. Furthermore, it has been found that a prior periarticular fracture is a major risk factor for the development of a PJI following future surgeries.28,29 Patients sustaining a tibial plateau fracture often have further compounding factors for developing a PJI: males, smokers, patients with systemic disease, and increased intraoperative time.1,30
In patients with suspected infection, all aspirates taken grew S. aureus, which is the most common organism found in patients with PJI.26,31-33 Genomic analysis of commensal isolates and PJI isolates of S. aureus found them to be genetically indistinguishable; therefore commensal S. aureus is capable of causing infection, likely reflecting why it is the most commonly found organism in PJI.30
The outcomes for patients who develop a PJI in this study appear more severe than overall outcomes for PJI. Above-knee amputation occurred in 33% of our patients, with a likelihood that this will increase further in the future. The rate of above-knee amputation following PJI with no prior fracture fixation/TKA is 0.1%.27 This study is limited by a small sample size; however steps should be taken to minimize the risk for development of PJI in this cohort.
As expected, those who went onto develop a PJI in our study had lower postoperative OKS compared with patients who did not develop a PJI. Of note, all patients in our study who had a TKA following fracture fixation had reduced postoperative PROMs when compared with those reported in data nationally for patients following both primary and revision TKA.34 Our patients who had a TKA and no PJI had a mean postoperative OKS of 29.17, an increase of 14.3, compared with patients nationally undergoing a primary TKA with a postoperative OKS increase of 17.3 from baseline.
PJI patients in our study had significantly worse outcomes, with a postoperative OKS of 18, an increase of 4, compared nationally with revision TKA (not all for infection) who have an improvement of 14.1 from baseline.
TKA after ORIF for tibial plateau fractures significantly increases the risk of PJI. We advocate for a two-stage approach in the management of these patients, especially in those individuals with a high risk of treatment failure. In our unit, the first stage consists of removal of metalwork and intraoperative tissue sampling including intra-articular joint aspiration to exclude infection. Once confirmation of no infection or evidence of resolution of infection following an appropriate antibiotic regime and when soft-tissues have settled, one can consider performing a TKA as the second stage. We would advocate that these patients are treated as culture-negative PJI, as recommended by the recent PJI guidelines;35 with multiple tissues samples being taken intraoperatively, and appropriate antibiotic cover given until results of these samples are known. Empirical therapy that covered for S. aureus would seem to be appropriate given the incidence of S. aureus infection in our study.
Finally, the reduced postoperative PROMs in all patients who underwent a TKA following fracture fixation highlights the difficulties in managing these patients, even when they do not go on to develop a PJI. Counselling should take place for individuals embarking on a TKA following tibial fixation to explain the reduced functional outcomes and increased risk of PJI reflected in this study. In some selected patients with increased risk factors, it may be better to undergo a primary or delayed primary TKA following a tibial plateau fracture, as this would likely result in a better functional outcome.
Take home message
- The rate of periprosthetic joint infection (PJI) in our patients who had a total knee arthroplasty (TKA) following a tibial plateau fracture fixation was found to be significantly higher when compared to primary TKA.
- In an attempt to reduce the rate of PJI, we advocate for a two-stage approach in these patients. Patients should be counselled that the results of TKA following fracture fixation are inferior to primary TKA.
Author contributions
M. Strafford: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing
M. Biddle: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing
B. Rooney: Project administration, Supervision, Writing – review & editing
Funding statement
No benefits in any form have been recieved or will be recieved from a commerical party related directly or indirectly to the subject of this article.
ICMJE COI statement
The authors have no conflicts of interest to disclose.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
Ethical review statement
This study was conducted in accordance with the Helsinki Declaration.
Open access funding
The open access fee was self-funded.
© 2025 Strafford et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.