Total knee arthroplasty with metaphyseal sleeves for acute tibial plateau fractures

Abstract

Aims

Total knee arthroplasty (TKA) allows immediate weightbearing and avoids challenges associated with secondary arthroplasty following conservative management or failed fixation of tibial plateau fractures (TPFs). Metaphyseal sleeves may overcome the limitations of conventional implants by addressing issues of deficient bone stock and inadequate proximal fixation in the fracture zone.

Methods

We conducted a retrospective case series of patients undergoing TKA with metaphyseal sleeves for acute TPFs at a single tertiary centre between January 2019 and June 2025. Demographic details, injury characteristics, clinical outcomes, and complications were extracted from electronic records.

Results

A total of 16 patients were included (mean age 73.8 years (SD 6.0), 93.8% female). Of these patients (87.5% (n = 14/16) were osteoporotic, and 37.5% (n = 6/16) had pre-existing osteoarthritis. The median follow-up was 12 months (IQR 3 to 72). Immediate weightbearing was achieved in all. Radiographs in all patients showed metaphyseal sleeve integration and no subsidence by three months. One patient was followed up at six years showing no adverse radiological signs. Mean knee range of motion improved from 90.7° at sixweeks to 108.1° at final follow-up. Complications occurred in 25.0% of patients (n = 4/16), most commonly wound-related (n = 2/16). Two patients (12.5%) required further surgical intervention.

Conclusion

TKA with metaphyseal sleeves has a role in selected elderly patients with TPF not amenable to reconstruction. It addresses fixation failure in TPF and enables early mobilization with acceptable outcomes.

Cite this article: Bone Jt Open 2026;7(4):557–565.

Introduction

Tibial plateau fractures (TPFs) are increasingly common in the elderly.¹ They pose surgical challenges due to osteoporotic bone, pre-existing degenerative joint disease, and medical comorbidities.² Open reduction and internal fixation (ORIF) is the mainstay surgical treatment;³ however, it is frequently challenged by adverse outcomes including joint stiffness,⁴ surgical site infections,⁵ and the development of post-traumatic arthritis requiring secondary total knee arthroplasty (TKA).² These risks are amplified in the elderly osteoporotic cohort. It has been reported that up to 79% of patients aged over 60 years experienced malunions compared with 7% reported in those aged below 60 years,⁶ and long periods of restricted weightbearing predisposes frail patients to deconditioning and functional decline.^7,8 Secondary TKA after failed fixation is a recognized salvage strategy; however, challenges include retained hardware, compromised soft-tissue, patella baja, bone loss, occult infection from the initial surgery, and may require augments and increased implant constraint.⁹

For selected elderly patients with severe comminution and poor bone quality, primary TKA has emerged as an alternative,^10,11 and offers early mobilization and avoidance of fixation failure. Consensus is lacking regarding implant choice and surgical technique. A major barrier to conventional primary TKA in this setting is deficient bone stock and lack of proximal fixation in the fracture zone. Previously, diaphyseal components were used to address tibial defects but when used in isolation, can create a diaphyseal stress riser resulting in tibial component tip pain.¹²

Metaphyseal sleeves were introduced for revision TKA with bone loss by achieving metaphyseal fixation.¹³ It provides rotational stability, distributes load, and avoids diaphyseal stress risers. Their porous coating supports osseointegration and durable biological fixation and they have demonstrated excellent survivorship and radiological outcomes in the medium to long term.¹⁴ Two recent case series describe preliminary mid-term clinical and radiological outcomes to address bone loss following a TPF.^15,16 They demonstrated excellent clinical and radiological outcomes up to five years.^15,16 Nonetheless, the role of metaphyseal sleeves in acute tibial plateau fractures remains relatively undefined.

The aim of this study was to evaluate the use of metaphyseal tibial sleeves in primary TKA for the management of acute tibial plateau fractures in elderly patients in an orthopaedic tertiary centre over a 6.5-year period.

Methods

Study cohort

Patients were identified retrospectively from an electronic database. Patients were included who sustained a TPF between January 2019 and June 2025, and who were managed with a TKA using a tibial metaphyseal sleeve.

Patient demographic and injury characteristics

Electronic patient records were reviewed to determine the patients’ age at the time of injury, sex, BMI, American Society of Anesthesiologists (ASA) grade,¹⁷ and Clinical Frailty Scale (CFS).¹⁸ Mechanism of injury was characterised as low energy (fall from standing height), and moderate energy (low speed motor vehicle accident (MVA) and pushbike collision). Injury patterns were defined using the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification.¹⁹ Pre-existing osteoarthritis(OA) was graded using Kellgren-Lawrence (KL). This was based on prior imaging where patients had known documented OA. It was also noted whether the patient had osteoporosis. This was either a known diagnosis or diagnosis made by the orthogeriatric team in their acute admission at the time of injury.

The study included 16 participants with a mean age of 73.8 (SD 6.0) years (Table I). The majority were female (n = 15/16). The mean BMI was 31.0 kg/m² (SD 9.1) (n = 10).

Table I.

Patient demographic characteristics.

Variable	Data (n = 16)*
Demographic characteristics
Mean age, yrs (SD)	73.8 (6.0)
Female sex, n (%)	15 (93.8)
Mean BMI, kg/m2 (SD)†	31 (9.1)
ASA grade, n (%) †
II	9 (60.0)
III	5 (33.3)
IV	1 (6.7)
Frailty score, n (%) †
2	7 (46.7)
3	3 (20.0)
4	3 (20.0)
5	2 (13.3)
Baseline cognition, n (%) †
AMT 4	15 (100)
Living situation, n (%)
Home	16 (100)
Baseline mobility, n (%)
Independent	15 (93.8)
Frame	1 (6.2)
Bone quality
Normal	2 (12.5)
Osteoporotic	14 (87.5)
KL grade, pre-existing osteoarthritis, n
0	0
1	2
2	2
3	2
4	0
Skin condition, n (%) †
Good	12 (80.0)
Compromised	3 (20.0)

^*Percentages based on available data.

^†Categories where data were missing.

AMT, Abbreviated Mental Test; ASA, American Society of Anesthesiologists; KL, Kellgren-Lawrence.

Surgical technique

All surgeries were performed by five fellowship trained trauma/revision arthroplasty surgeons. The DePuy Synthes metaphyseal sleeves were used for all TKA (DePuy Synthes, USA). Surgical approach (medial and lateral parapatella) and implant constraint (posterior-stabilized (PS), constrained condylar, and hinged designs) were used at the discretion of the surgeon. Cemented tibial baseplates and uncemented metaphyseal sleeves were used in all cases. Components were cemented if there was concern for fracture propagation distally or very poor diaphyseal bone quality. The patella was resurfaced in all patients. Adjuncts to the arthroplasty in the form of screws, plates, and grafts were determined by the surgeon at the time of surgery

Clinical outcomes and complications

Electronic patient records were used to assess postoperative complications including wound complications, infection, venous thrombotic events (VTE), and fractures. Electronic records were used to assess clinical outcomes such as range of motion (ROM), pain, and return to baseline mobility. Radiological integration and subsidence were assessed by a senior orthopaedic surgeon (PY) by comparing day the one postoperative radiograph with follow-up radiographs.

Statistical analysis

Retrospectively collected data was managed with Excel (Microsoft, USA). Continuous variables were presented as the mean (SD) or by the median (IQR) for skewed continuous data, with normality assessed through the Shapiro-Wilk test. Categorical variables were presented as counts and percentages. Statistical significance was set at p < 0.05.

Ethics approval

This retrospective study was registered with and approved by the local institutional audit and governance department, the Quality Improvement Governance Sub-committee (Quality Activity 61763). Projects approved through the GEKO system are classified as Quality Improvement activities and, as such, do not require Human Research Ethics Committee (HREC) review or approval.

Results

Most patients were ASA grade II (n = 9/16), with fewer in grade III (n = 5/16) and IV (n = 1/16). Frailty score was most commonly 2 (n = 7/15) and all patients lived at home. Most patients (n = 15/16) were independently mobile pre-injury and were cognitively intact. Osteoporosis was present in 14/16. Pre-existing arthritis was present in 37.5% (n = 6/16) of patients, distributed equally across KL grade 1 to 3 (Table I).

Injury and surgery

Most TPF resulted from low-energy mechanisms, typically a fall from standing height. Two patients (12.5%) were moderate energy mechanisms (hit by low-speed car and fall from e-bike) (Table II). The majority of TPF had significant intra-articular depression, with ten patients having Schatzker 2 TPFs (Table III).²⁰ Using the AO classification, the most common fracture pattern was B3.1 (n = 11/16), followed by C3.3 (n = 4/16), and B2.1 (n = 1/16). Skin was noted as compromised preoperatively in 20.0% (n = 3/15) of patients. This included one case with poor friable skin from steroid use, one case with significant contusion and swelling, and one case with marked swelling and abrasion.

Table II.

Outcomes and complications following a primary total knee arthroplasty for a tibial plateau fracture.

Variable	n = 16 (%)
Length of stay (LOS)
Mean ICU LOS, days	0
Mean acute postoperative LOS, days (SD)	3.6 (1.3)
Rehabilitation required, n (%)	11 (73.3)
Mean rehabilitation LOS, days (SD)*	11.1 (5.5)
Functional outcomes
Mean ROM at 6 weeks, °(SD)	90.7 (19.3)
ROM at final follow-up, ° (SD)	108.1 (16.2)
Pain free at 6 weeks, n (%)*	5/13 (38.5)
Pain free at 12 months, n (%)*	6/9 (66.7)
Pain free at final follow-up	12/16 (75)
Return to baseline mobility at final follow-up,n (%) *	9/13 (69.2)
Complications, n (%)
Any postoperative complication	4 (25.0)
Wound complications	2 (12.5)
Prosthetic joint infection	1 (6.3)
Deep vein thrombosis/pulmonary embolism	1 (6.3)
Periprosthetic fracture	0 (0.0)
Screw migration	1 (6.3)
Surgical re-intervention	2 (12.5)
Wound dehiscence and infection	1/2 (50)
Screw migration	1/2 (50)

^*Categories where data was missing.

ICU, intensive care unit; ROM, range of motion.

Table III.

Summary of patient characteristics, surgery, and surgical outcomes.

Age	Sex	BMI	Comorbidities	ASA	CFS	AO	Schatzker	MOI	Skin	Component cementing	Augmentation	Constraint	Follow-up, mths	Final ROM	Return to baseline mobility	Complications	Radiograph
71	F	17.7	IHD, T2DM, PVD, Smoker, OP	3	2	B2.1	2	Fall	Normal	Uncemented	None	PS	12	130	N/A	Wound complication	I, ∅S
78	F	30.1	OSA, COPD, Myasthenia gravis on biologics	4	5	B3.1	2	Fall	Friable 2˚ steroid use	Cemented	Buttress plate, graft (lateral)	CCK	8	80	Y	Wound complication; PJI; Revision surgery	I, ∅S
76	F	33.1	ILD, HTN	2	2	B3.1	2	Fall	Normal	Uncemented	Screw (lateral)	PS	57	110	N	Revision surgery	I, ∅S
76	F	36.7	Aflutter, NAFLD, GORD, Haemochromatosis	3	3	B3.1	2	Fall	Normal	Cemented	Screw (lateral)	PS	33	95	N/A	None	I, ∅S, TBL
73	F	NA	HTN, COPD, OP, OA	2	4	B3.1	2	Fall	Normal	Uncemented	Buttress plate (lateral)	PS	19	95	N	None	I, ∅S
73	M	NA	OSA	2	2	B3.1	2	Low speed car vs knee	Normal	Uncemented	Buttress plate(lateral)	PS	12	120	Y	None	I, ∅S, TBL
72	F	33.7	HTN, hyperlipidaemia	2	4	B3.1	5	Fall	Normal	Uncemented	None	CCK	12	120	N/A	None	I, ∅S
86	F	22.1	Nil	2	3	B3.1	2	Fall	Normal	Cemented	None	CCK	24	90	Y	DVT	I, ∅S
73	F	30.8	HTN, Hyperlipidaemia, Breast cancer	2	2	B3.1	2	Fall	Normal	Uncemented	None	PS	18	100	N/A	None	I, ∅S
58	F	34.4	DVT, IHD, GORD, Obesity, PAD, OA	3	4	B3.1	2	Bike vs wall	Normal	Uncemented	None	PS	5	120	Y	None	I, ∅S
74	F	21.8	Nil	2	2	B3.1	2	Fall	Normal	Uncemented	None	PS	3	N/A	N/A	N/A	I, ∅S
71	F	49.6	Stroke, HTN, Hyperlipidaemia, Obesity	3	5	C3.3	6	Fall	Normal	Cemented	None	HK	72	N/A	N/A	N/A	I, ∅S
75	F	NA	HTN, T2DM, Osteoporosis, AVM repair	N/A	N/A	B3.1	5	N/A	Normal	Cemented	None	PS	12	120	Y	None	I, ∅S
81	F	NA	T2DM, GTN, Osteoporosis, Reflux	3	2	C3.3	6	Fall	Bruised	Uncemented	None	RH	12	‘good’	Y	None	I, ∅S
75	F	NA	HTN, hyperlipidaemia	2	3	C3.3	6	Fall	Abrasion	Cemented	Buttress plate (medial)	RH	12	110	Y	None	I, ∅S
67	F	NA	F5L, hyperlipidaemia	2	2	C3.3	5	Fall	Normal	Uncemented	None	RH	12	120	Y	None	I, ∅S

AO, Arbeitsgemeinschaft für Osteosynthesefragen; ASA, American Society of Anesthesiologists grade; CCK, constrained condylar knee; CFS, Clinical Frailty Scale; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; I, integrated; N/A, not available; OA, osteoarthritis; PS, baseplate; RH, rotating hinged; ROM, range of motion; S, subsidence ; T2DM, type 2 diabetes mellitus.

Surgical intervention was timely, with 50% (n = 8/16) of patients undergoing arthroplasty within three days, 67% (n = 11/16) within seven days, and all by 14 days post-injury. Delays to surgery were the result of waiting for adequate soft-tissue, and for an appropriately trained surgeon to become available. Six patients had additional intraoperative augmentative strategies which included isolated cortical screws, buttress plating, and bone grafting (Table III). Five patients had Schatzker 2 TPFs subsequently received augmentation laterally (Figure 1). One patient was a Schatzker 6 TPF and received a medial buttress plate.

Fig. 1.

Schatzker 2 tibial plateau fractures and their day one postoperative radiographs, following total knee arthroplasty with tibial metaphyseal sleeve. a) 72-year-old female, rotating hinge prosthesis with an uncemented component; b) 76-year-old-female, posterior-stabilized prosthesis with an uncemented component augmented with two lateral screws; c) 72-year-old female, posterior stabilized prosthesis with lateral buttress plate.

Implant selection reflected the stability of the knee following the injury. Posterior-stabilized prostheses were most frequently used (n = 9/16), followed by constrained condylar (n = 3/16) and hinged designs (n = 4/16). This demonstrates a tailored surgical approach, balancing stability and biological challenges inherent in these injuries. Cemented tibial baseplates and uncemented metaphyseal sleeves were used in all patients; 37.5% (n = 6/16) of patients had cemented components.

Length of stay

No patients required intensive care unit (ICU) admission. The mean acute postoperative length of stay was 4.0 days (SD 1.3) (Table III). Rehabilitation was required in 75.0% (n = 12/16) of patients, with a mean rehabilitation stay of 10.8 days (SD 5.9).

Functional outcomes

All patients commenced full weightbearing immediately postoperatively. The median follow-up time for all 16 patients was 12 months (IQR 12 to 20.2), with two patients followed for less than six months. The mean range of motion (ROM) improved from 90.7° (SD 19.3°) at six weeks to 108.1° (SD 16.2°) at final follow-up. At six weeks, 38.5% (n = 5/13) of patients were pain free, increasing to 66.7% (n = 6/9) at 12 months and 75.0% (n = 12/16) at final follow-up. At final review, 69.2% (n = 9/13) of patients had returned to their baseline level of mobility.

Radiological outcomes

The median radiological follow-up was 12 months (IQR 10.5 to 24). All radiographs demonstrated integration of the metaphyseal sleeve with no subsidence by three months (Table III). Two radiographs showed a radiolucent line at the tibial baseplate which had no features of loosening of the tibial component. This was observed at 12 months and three years. One patient had an radiograph at six years, and this showed no adverse radiological features (Figure 2).

Fig. 2.

Day one postoperative and final follow-up radiographs. a) Rotating hinge prosthesis at the six-year follow-up showing integration and no subsidence; b) posterior stabilized prosthesis at 12 months follow-up showing a radiolucent line at the tibial baseplate illustrated by the arrow.

Complications

A total of four patients (25.0%) experienced at least one postoperative complication (Table II). Wound-related complications occurred in two patients (6.3%). One patient had a wound dehiscence that resulted in a periprosthetic joint infection (PJI) requiring a washout, soft-tissue coverage, and prolonged antibiotics. This patient was obese, on immunosuppressants, and preoperatively was noted to have friable skin due to long-term steroid use. The infection was managed with a washout, soft-tissue coverage, and life-long antibiotics. By six months, the patient had returned to baseline mobility and remains well on antibiotics. The second wound complication was persistent wound ooze that resulted in a re-admission within 30 days and negative pressure dressing. This was self-limiting. One patient experienced pain and stiffness secondary to migration of a screw and underwent a reoperation to remove the screw and manipulation under anaesthesia at 19 months. This resolved the pain and there were no issues found with the prosthesis. One patient developed a lower leg deep vein thrombosis (DVT) despite immediate weightbearing and chemical prophylaxis. They were commenced on treatment with no further sequelae. No cases of periprosthetic fracture were recorded, and the one-year mortality was zero.

Discussion

This retrospective review represents one of the first description of the use of tibial metaphyseal sleeves in TKA for acute TPF and demonstrates encouraging early- to mid-term clinical and radiological outcomes. The cohort defined in this study were elderly, osteoporotic patients who sustained non-reconstructable TPFs. Patients were cognitively intact, able to engage with rehabilitation, and benefitted from immediate weightbearing. Pre-existing arthritis may also be a positive indication for an acute TKA.

In our cohort, the combination of metaphyseal sleeves with tibial components has shown osseointegration by three months with no adverse radiological features up to six years. Two cases demonstrated radiolucent lines at the tibial baseplate with no features of loosening of the tibial component. This was evident at 12 months and did not progress on serial imaging. We believe this to occur due to the shift in load to the metaphyseal sleeve resulting in offloading of the ridged tibial baseplate, and has previously been reported in metaphyseal sleeves.¹⁶

In our study, zonal fixation was achieved by using a cemented baseplate for epiphyseal zone fixation, porous titanium-coated sleeves to achieve cementless osseointegration in the metaphyseal zone and long components (either press-fit or cemented) for diaphyseal zone fixation.²¹ Adjuncts to the arthroplasty in the form of screws, plates, and grafts were determined by the surgeon at the time of surgery. Metaphyseal sleeve survivorship is predicated on achieving a reliable circumferential press-fit against a stable metaphyseal rim to ensure osseointegration.^22,23 In our cohort, fracture patterns frequently resulted in disruption of the metaphyseal cortical shell or severe depression with an unsupported rim. In these instances, adjunct buttress plating or screws were used to restore metaphyseal containment and allow the construct to resist expansile hoop stresses during sleeve impaction, thereby facilitating the circumferential contact required for long-term stability. Adjunct fixation was predominantly lateral to address the lateral defect observed in Schatzker 2 TPFs. Over the course of the study period, the frequency of adjunct fixation decreased, reflecting a learning curve as the surgical team gained confidence in the inherent stability of the sleeve in the trauma setting. Subsequently, there was a shift towards a medial parapatellar approach as access laterally for augmentation was not required.

Four patients experienced complications in our cohort with the most significant being a PJI secondary to wound dehiscence and soft-tissue breakdown. In elective TKAs, this is a rare complication reported in the literature^24,25 and minimized by delaying surgery until adequate swelling and skin quality.²⁶ In the trauma setting, delaying surgery is not practical. We would therefore recommend that acute TKA should be delayed or not offered in patients with compromised skin. It is important to compare these complications with the complication profile associated with ORIFs and secondary TKAs in the osteoporotic elderly. An ORIF in this group has reported radiological failure rates as high as 79%,⁶ and higher wound complications up to 23.7%.²⁷ The elderly are also more likely to receive a subsequent TKA following an ORIF at ten years.² A recent matched cohort study demonstrated that TKAs after prior tibial plateau ORIF behave more like revision TKAs than primaries.²⁸ Conversion TKA after failed TPF ORIF is not only technically challenging in the context of retained metalware, scar tissue, malunion, and bone loss, but carries significantly higher risk of both PJI-related and aseptic revision compared with primary TKA for OA.²⁹ This highlights the value in avoiding a two-stage strategy for TPF where possible.

In addition to avoiding a second operation and its associated challenges, acute TKA confers two potential benefits: immediate weightbearing and the ability to address ligamentous deficiency. All patients commenced immediate weightbearing day 1 postoperatively, reducing risks of deconditioning and medical complications.³⁰ Implant selection can also be tailored to create sagittal and coronal stability based on osseous and ligamentous deficiencies. TPFs often involve comminution with significant bone loss and can have associated collateral and cruciate ligament injuries.³¹ In our cohort, we addressed this issue by tailoring the level of constraint using posterior stabilized, constrained condylar, and rotating hinge implants. This decision was made at the discretion of the surgeon and may be a reason why a fellowship-trained revision arthroplasty surgeon is desirable to perform this operation.

Our study is subject to several limitations inherent to its retrospective design, including a small sample size and loss to follow-up. Additionally, the reliance on a single implant system and the lack of long-term data preclude definitive conclusions regarding comparative benefits in infection control, implant survivorship, and functional outcomes. Our study is therefore best viewed as a proof of concept for the use of metaphyseal sleeves for TKA in TPF. Lack of patient-reported outcome measures makes it challenging to objectively comment on functional outcomes. While randomized controlled trials remain the gold standard, their feasibility here is limited. We advocate for pragmatic alternatives such as prospective registries or multicentre comparative studies to attain high-quality observational data over longer follow-up periods.

In conclusion, TKA with tibial metaphyseal sleeve fixation has a role in selected elderly patients with difficult to reconstruct, osteoporotic TPF. This surgical strategy addresses the loss of bone stock in TPF and enables early mobilization with acceptable outcomes.

Take home message

- Total knee arthroplasty with metaphyseal sleeves has a role in selected elderly patients with tibial plateau fracture (TPF) not amenable to reconstruction non-reconstructable, osteoporotic TPF.

- It addresses fixation failure in TPF and enables early mobilization with acceptable outcomes.

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.