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Tibial plateau fractures (TPFs) encompass a broad spectrum of injuries, ranging from simple, undisplaced splits to complex intra-articular fracture patterns. These fractures are frequently associated with long-term sequelae, most notably post-traumatic osteoarthritis (PTOA) and eventual conversion to total knee arthroplasty (TKA). As the incidence of fragility fractures is projected to rise within expanding ageing populations, the burden of TPF-related knee degeneration is expected to increase substantially. Despite advances in internal fixation techniques, uncertainty persists regarding long-term clinical outcomes, the risk factors driving joint deterioration, and the potential role of primary arthroplasty for selected patients.

The overarching aim of this thesis was to investigate the long-term consequences of TPF, with focus on epidemiology, the progression to TKA, and the role of patient- and fracture-related characteristics in risk stratification for joint conversion. This objective was addressed through a series of longitudinal cohort studies, leveraging both single-centre clinical data and comprehensive national register-based datasets. First, national incidence patterns and mortality rates following TPF were evaluated using the National Patient Register (NPR). A single-centre cohort study linked to the Swedish Arthroplasty Register (SAR) was used to identify factors associated with subsequent TKA conversion. Subsequently, national data from the SFR were linked to the SAR to examine the association between fracture severity and TKA conversion within a large, population-based cohort. Finally, SAR data were analysed to evaluate clinical outcomes following acute TKA as a primary treatment for TPF, with these results compared against outcomes of delayed TKA performed for PTOA.

Findings from this thesis indicate that although most TPFs managed with ORIF have low TKA conversion rates, a distinct subset of patients faces an elevated risk of conversion. This high-risk group is characterised by severe fracture patterns, advanced age, and inadequate postoperative reduction. Moreover, TKA following TPF often resembles revision surgery rather than primary arthroplasty in terms of surgical complexity, implant selection, and clinical outcomes. Consequently, acute arthroplasty in carefully selected high-risk individuals may serve as a viable primary intervention with favourable results.

In conclusion, this thesis offers new insights into the trajectory from fracture to arthroplasty following TPF. The findings underscore the critical importance of achieving high-quality anatomical reduction, early stratification of patients at elevated risk of failure, and individualised decision-making regarding joint preservation versus primary arthroplasty. Collectively, these findings advance clinical understanding and provide a foundation for future research aimed at refining treatment strategies and improving long-term outcomes.