Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over-A Systematic Review and Meta-Analysis

Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

Methods

This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded.

Results

Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA.

Conclusion

Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing knee arthritis were independent risk factors for both post-traumatic OA and TKA. These features should be investigated as potential indications for acute TKA in older adults with TPFs.

Acute Total Knee Arthroplasty for Unicondylar Tibial Plateau Fracture Using Metaphyseal Cones

Tibial plateau fractures (TPFs) in older adults are increasing in incidence and now account for 8% of all fractures in patients over 60 years of age. Although primary fixation remains standard, the risk of fixation failure, loss of reduction, and the development of posttraumatic osteoarthritis are all markedly increased in this age group with higher rates of conversion to total knee arthroplasty (TKA) of 12%. When joint depression is severe with significant subchondral bone loss, up to half ultimately require TKA. TPFs with unicondylar depression can be managed primarily using tibial cones in acute TKA. In this study, we report the surgical technique for performing acute TKA using tibial cones for the primary management of TPFs in older adults and illustrate this technique with case examples.