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Background and purpose: We aimed to assess joint failure rate, i.e., subsequent conversion to TKA after surgical treatment of a tibial plateau fracture (TPF). Secondary aims were to explore the association between joint failure and fracture type, and to determine the risk of failure associated with inadequate joint surface reduction.

Methods: We included all patients ≥ 18 years of age with a surgically treated TPF, treated at Uppsala University Hospital between 2002 and 2015. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Traumatology Association (AO/OTA) classification. Postoperative radiographs were evaluated to determine the quality of joint surface inadequate reduction, defined as an articular step-off ≥ 2 mm. The study cohort was linked with the Swedish Arthroplasty Register (SAR) for information on subsequent total knee arthroplasty (TKA).

Results: 439 patients (57% women) with a mean age of 55 years (SD 17) were included. According to the AO/OTA classification, the fracture distribution was B1: 4.8%, B2: 10%, B3: 47%, C1: 12%, C2: 6.4%, and C3: 19%. 23 patients (5.2%) were converted to a TKA within 2 years of initial surgery, and 34 patients (7.7%) had been converted by the end of follow-up (16 years). AO/OTA type B3 and C3 had a 6.8 (95% confidence interval [CI] 1.6–29) times greater risk of joint failure compared with B1–2 and C1–C2 at 2 years’ follow-up. Inadequate joint surface reduction led to an 8.4 (CI 3.6–20) times greater risk of conversion to TKA at 2 years’ follow-up.

Conclusion: Overall, 5.2% were converted to a TKA within 2 years. Fracture types AO/OTA B3 and C3 with a comminuted articular surface and inadequate joint surface reduction were strongly associated with joint failure.

Background: Tibial plateau fractures (TPFs) can be associated with development of significant joint degeneration, which can lead to functional impairment and pain severe enough to necessitate conversion to total knee arthroplasty (TKA). The factors influencing the progression to TKA after TPF, including preoperative fracture and patient characteristics, remain unclear. This study aimed to assess the national conversion rate to TKA following TPF depending on fracture type.

Patients and methods: The cohort consisted of all patients aged 18 years and older at time of injury with a TPF registered in the Swedish Fracture Register (SFR) between 2012 and 2023. The SFR holds information on baseline patient characteristics including fracture classification according to the AO/OTA system. Conversion to TKA was identified through linkage with the Swedish Arthroplasty Register (SAR). Kaplan-Meier survival analyses investigated conversion rate. Cox regression was performed to assess association between fracture type and TKA conversion adjusted for age, sex, and injury energy level. The follow-up period ranged from 0 to 12 years, with a mean of 4.2 years.

Results: A total of 12,012 patients with a mean age of 57 years were included; 63% were women. The observed conversion rate after 5 years was 2.8% in all patients and 4.1% in surgically treated patients. The conversion rate at 5 years was highest in the 65-74 years age group with 5.2%. Fractures with comminuted fracture patterns, particularly AO/OTA 41B3, 41C2, and 41C3, were associated with significantly increased risks of conversion, with adjusted hazard ratios (aHRs) of 2.1 (95% CI 1.3-3.3), 2.3 (1.2-4.5), and 3.2 (95% CI 2.0-4.5), respectively. High-energy trauma did not increase the risk of conversion, nor did sex. Increasing age was associated with an increased risk of conversion up to the age of 84, while age over 85 was not.

Conclusions: Fractures with complex fracture patterns, particularly AO/OTA 41B3, 41C2, and 41C3, were associated with an increased TKA conversion rate following TPF. The conversion rate increased with increasing age, but sex and high-energy injury mechanisms did not affect conversion rate. On a national level, 3% of patients were converted to TKA within 5 years of sustaining a TPF, and 4% of patients treated surgically. This may help surgeons when counseling patients with TPFs.

BackgroundAcute TKA has been proposed as an alternative to open reduction and internal fixation for complex tibial plateau fractures in patients who are older and who have compromised bone quality. The alternative is a delayed TKA after primary fracture management with an unfavorable outcome. However, the long-term outcomes and risk for reoperation after acute TKA compared with delayed TKA for fracture sequelae remain unclear.Questions/purposesWhen comparing acute TKA (< 3 months after injury) for tibial plateau fracture with delayed TKA for fracture sequelae, we asked: (1) Do the risks of reoperation or revision for any cause differ? (2) Do the risks of reoperation or revision for infection differ? (3) Do the risks of reoperation or revision for loosening differ?MethodsData for all TKAs performed between 2014 and 2023 with the indication of acute tibial plateau fracture (n = 152) or fracture sequelae (n = 950) were extracted from the Swedish Arthroplasty Register. Patients who underwent TKA for acute tibial plateau fractures were older (73 versus 66 years), more often women (78% [118 of 152] versus 57% [539 of 950]), had lower BMI (26.7 versus 27.9 kg/m2), and received constrained or hinged implants more frequently (59% [89 of 152] versus 33% [311 of 950]). Reoperations were identified in the Swedish Arthroplasty Register through subsequent procedures on the index knee and classified as reoperations (where the implant remained in situ) or revisions (with exchange, addition, or removal of components). When bilateral procedures occurred within the study period, only the first TKA was retained to ensure independence of observations. Loss to follow-up because of emigration or incomplete revision reporting was expected to be minimal, as the Swedish Arthroplasty Register captures approximately 98% of primary TKAs and 94% of revisions nationally. We estimated the cumulative event probability of secondary procedures using the Kaplan-Meier method and used logistic regression models to estimate adjusted ORs for (1) any reoperation or revision, (2) infection-related procedures, and (3) loosening-related procedures, adjusting for age, gender, and BMI. Because implant type reflects the underlying clinical situation and cannot be reliably adjusted for, it was reported descriptively.ResultsDuring follow-up, 7% (78 of 1102) of patients underwent a reoperation and 5% (60 of 1102) of patients underwent a revision. At 5 years, the cumulative event probability of any revision was 8% (95% confidence interval [CI] 2% to 14%) for acute TKA and 5% (95% CI 4% to 7%) for delayed TKA (p = 0.41). For reoperations, the cumulative event probability at 5 years was 9% (95% CI 3% to 15%) for acute TKA and 7% (95% CI 5% to 9%) in the delayed TKA group (p = 0.26). After adjusting for age, gender, and BMI, there was no difference between groups in odds for any reoperation (OR 0.76 [95% CI 0.38 to 1.5]; p = 0.43) or any revision (OR 0.68 [95% CI 0.31 to 1.5]; p = 0.32). Infections accounted for 9% (1 of 11) of reoperations for acute TKAs and 40% (27 of 67) of delayed TKAs. At 5 years, the cumulative event probability of reoperation or revision due to infection was 2% (95% CI 0% to 5%) for acute TKA and 3% (95% CI 2% to 4%) for delayed TKA (p = 0.06). There was no difference in the adjusted odds of infection-related reoperation (OR 3.7 [95% CI 0.48 to 28]; p = 0.21) or infection-related revision (OR 3.0 [95% CI 0.40 to 23]; p = 0.28). Loosening accounted for 27% (3 of 11) of revisions after acute TKAs and 9% (6 of 67) after delayed TKAs. At 5 years, the cumulative event probability of loosening-related revision was 2.9% (95% CI 0% to 7.1%) for acute TKAs and 0.6% (95% CI 0.1% to 1.2%) for delayed TKAs (p = 0.50). The adjusted odds of loosening-related revision were lower for delayed TKAs (OR 0.21 [95% CI 0.05 to 0.97]; p = 0.045).ConclusionThe timing and pattern of revision differ between the two investigated groups, with delayed TKAs undergoing unplanned reoperation or revision earlier and with a higher proportion of infection-related revisions, whereas acute TKAs underwent reoperation or revision later and with a higher proportion of revisions for mechanical loosening. In the absence of large prospective trials, future observational work should include evaluation of pre- and postoperative radiographs and patient-reported outcomes, to determine which patients may benefit from acute TKA for tibial plateau fracture.