Tibial plateau fractures are common fractures which constitute approximately 1% of all fractures [1]. The tibial plateau is a critical weight-bearing surface in the body's largest and most complex joint in terms of movement. Fractures typically result from a combination of axial loading force and coronal plane (varus/valgus) stress, which causes articular shear, depression, and misalignment of the mechanical axis [2]. The knee's degree of flexion at the moment of impact determines the fracture pattern [3]. These fractures are often accompanied by a range of soft tissue and bone injuries, which can lead to long-term disabilities. They significantly impact the stability, biomechanics, and range of motion of the knee joint [4]. The mechanism of injury and the amount of force needed to cause these fractures vary with age. In younger individuals, tibial plateau fractures are typically the result of high-energy trauma, such as falls from significant heights or motor vehicle accidents. In contrast, older individuals usually occur due to low-energy trauma, such as low-level falls or tripping [5,6]. These fractures are frequently accompanied by a high incidence of complications, such as soft tissue damage, nerve injuries, vascular complications, infections, delayed or nonunion, and osteoarthritis (OA), making them particularly difficult to treat. Furthermore, due to their intra-articular characteristics, ensuring accurate anatomical reduction and proper limb alignment is essential for optimal treatment outcomes [7]. The Schatzker classification system, which categorizes these fractures into six distinct types, remains a critical framework for guiding clinical decision-making; however, the management of these fractures has historically been a subject of considerable debate [8]. The treatment options for tibial plateau fractures encompass a broad spectrum, ranging from conservative approaches like casting and bracing to more advanced methods such as skeletal traction, early mobilization, and open reduction with internal fixation [5]. Ali et al. reported a 31% failure rate in fixation among elderly patients with tibial plateau fractures [9]. Similarly, Stevens et al. observed that only 57% of cases under 40 years of age showed favorable functional outcomes following surgical management [10]. While open reduction and internal fixation are common, they are associated with significant complications [11]. To address the limitations of both non-operative and operative methods, a minimally invasive approach involving closed reduction through ligamentotaxis and limited internal fixation was developed and adopted [12]. Thus, various surgical techniques are available for treating tibial plateau fractures, ranging from percutaneous screw fixation to unicondylar and bicondylar plating, as well as MIPO (minimally invasive percutaneous osteosynthesis) and external fixation [13,14]. Though studies have demonstrated the efficacy of these methods with satisfactory outcomes, there remains no consensus on which technique is superior in terms of results and functional recovery. Therefore, the objective of this study was to evaluate the functional outcomes of patients who underwent surgical management for tibial plateau fractures in a tertiary care hospital.

Tibial plateau fractures are common fractures which constitute approximately 1% of all fractures [1]. The tibial plateau is a critical weight-bearing surface in the body's largest and most complex joint in terms of movement. Fractures typically result from a combination of axial loading force and coronal plane (varus/valgus) stress, which causes articular shear, depression, and misalignment of the mechanical axis [2]. The knee's degree of flexion at the moment of impact determines the fracture pattern [3]. These fractures are often accompanied by a range of soft tissue and bone injuries, which can lead to long-term disabilities. They significantly impact the stability, biomechanics, and range of motion of the knee joint [4]. The mechanism of injury and the amount of force needed to cause these fractures vary with age. In younger individuals, tibial plateau fractures are typically the result of high-energy trauma, such as falls from significant heights or motor vehicle accidents. In contrast, older individuals usually occur due to low-energy trauma, such as low-level falls or tripping [5,6]. These fractures are frequently accompanied by a high incidence of complications, such as soft tissue damage, nerve injuries, vascular complications, infections, delayed or nonunion, and osteoarthritis (OA), making them particularly difficult to treat. Furthermore, due to their intra-articular characteristics, ensuring accurate anatomical reduction and proper limb alignment is essential for optimal treatment outcomes [7]. The Schatzker classification system, which categorizes these fractures into six distinct types, remains a critical framework for guiding clinical decision-making; however, the management of these fractures has historically been a subject of considerable debate [8]. The treatment options for tibial plateau fractures encompass a broad spectrum, ranging from conservative approaches like casting and bracing to more advanced methods such as skeletal traction, early mobilization, and open reduction with internal fixation [5]. Ali et al. reported a 31% failure rate in fixation among elderly patients with tibial plateau fractures [9]. Similarly, Stevens et al. observed that only 57% of cases under 40 years of age showed favorable functional outcomes following surgical management [10]. While open reduction and internal fixation are common, they are associated with significant complications [11]. To address the limitations of both non-operative and operative methods, a minimally invasive approach involving closed reduction through ligamentotaxis and limited internal fixation was developed and adopted [12]. Thus, various surgical techniques are available for treating tibial plateau fractures, ranging from percutaneous screw fixation to unicondylar and bicondylar plating, as well as MIPO (minimally invasive percutaneous osteosynthesis) and external fixation [13,14]. Though studies have demonstrated the efficacy of these methods with satisfactory outcomes, there remains no consensus on which technique is superior in terms of results and functional recovery. Therefore, the objective of this study was to evaluate the functional outcomes of patients who underwent surgical management for tibial plateau fractures in a tertiary care hospital.

A total of 62 patients with tibial plateau fractures were included in this study, with a mean age of 45.28 years (SD ±12.51). The age distribution revealed that 19.35% (n=12) of the participants were aged between 20-30 years, while the largest group, comprising 35.48% (n=22), fell within the 31-40 years age range. Additionally, 25.81% (n=16) of the participants were aged 41-50 years, 12.90% (n=8) were between 51-60 years, and 6.45% (n=4) were over 60 years (Table 1). The gender distribution indicated a predominance of male participants, accounting for 69.35% (n=43), compared to 30.65% (n=19) who were female. The mechanisms of injury were diverse. Road traffic accidents were the leading cause of tibial plateau fractures, accounting for 32.26% of the cases. Low-energy trauma and high-energy trauma were responsible for 20.97% and 17.74% of the fractures, respectively. Additionally, 12.90% of the patients sustained their fractures from falls from height, while simple falls constituted 11.29%. Interestingly, sports-related injuries were the least frequent, representing only 4.84% of cases (Table 2). The distribution of injuries by side revealed that 54.84% (n=34) of the fractures were on the left side, whereas 45.16% (n=28) were on the right side (Table 3). In terms of classification, the majority of patients presented with Schatzker Type I fractures, constituting 50.00% (n=31) of the cases. Types II and III accounted for 19.35% (n=12) and 14.52% (n=9) respectively. Types IV, V, and VI were less common, with frequencies of 8.06% (n=5), 4.84% (n=3), and 3.23% (n=2) respectively (Table 4). The assessment of time to union indicated that more than half of the patients (54.84%, n=34) achieved union within 12 weeks. However, 14.52% (n=9) took between 12 to 14 weeks, and 27.42% (n=17) required more than 14 weeks for union. Notably, 3.23% (n=2) experienced non-union (Table 5). Patient satisfaction was evaluated based on their perceived outcomes. A total of 41.94% (n=26) rated their experience as excellent, while 33.87% (n=21) described it as good. Conversely, 8.06% (n=5) rated their outcome as fair, and 16.13% (n=10) reported poor satisfaction with the surgical management of their tibial plateau fractures (Table 6).

Table 1: Age and Gender distribution of participants (N=62)

Table 2: Distribution of patients categorized by the mechanism of injury

Table 3: Distribution of patients categorized by the side of injury

Table 4: Distribution of patients as per Schatzker classification

Table 5: Distribution of patients on basis of time to union.

Table 6: Patient’s outcome as per patient’s satisfaction

Tibial plateau fractures represent one of the most common intra-articular fractures, typically resulting from high-energy trauma such as road traffic accidents, falls from height, or physical violence. These fractures are often accompanied by other osseous or soft tissue injuries, adding to their complexity. Fractures involving weight-bearing joints, particularly in the lower extremities, are of significant clinical concern as they frequently lead to substantial morbidity and impairment in quality of life. Consequently, the management of tibial plateau fractures with intra-articular extension remains a formidable challenge for orthopaedic surgeons [15,16]. Extensive research has been conducted to determine the optimal treatment strategies for tibial plateau fractures, with many studies comparing outcomes between surgical and conservative management [17]. Generally, surgical interventions for tibial plateau fractures yield favorable functional outcomes [18]. In this context, the present study aimed to evaluate the functional outcomes of surgical management for tibial plateau fractures at a tertiary care hospital, encompassing a diverse cohort of 62 patients. In our study, the mean age of the participants was 45.28 years, with a standard deviation of 12.51 years. The age group most affected was 31-40 years (35.48%), followed by 41-50 years (25.81%). These findings are in line with previous studies, such as the one by Blokker et al. (1984), which reported a mean age of 44.5 years in patients with tibial plateau fractures [19]. Similarly, a study by Rasmussen (1973) also found that tibial plateau fractures were more common in individuals aged between 30 and 50 years [20]. The predominance of middle-aged patients may be attributed to their higher participation in physical activities, which exposes them to trauma risks. Regarding gender, males accounted for 69.35% of cases, while females comprised 30.65%, reflecting a male-to-female ratio of approximately 2:1. This male predominance has been consistently reported in various studies. For example, a study by Lansinger et al. (1986) reported a male preponderance in tibial plateau fractures, attributing it to higher male participation in labor-intensive jobs and high-energy activities [21]. The gender distribution in our study aligns well with these previous findings, reinforcing the notion that males are more frequently exposed to mechanisms of injury that lead to such fractures [22,23]. The most common mechanism of injury in our study was road traffic accidents (32.26%), followed by low-energy trauma (20.97%) and high-energy trauma (17.74%). This pattern is consistent with studies like those by Mallik et al. (1997), which reported that motor vehicle accidents were a leading cause of tibial plateau fractures due to high-impact trauma [24]. This finding also aligns with the results of a previous study conducted by Chiax et al., where 71% of injuries in their cohort were attributed to road traffic accidents (RTA) [25]. The significant proportion of injuries resulting from low-energy trauma in our study could be explained by the increasing incidence of fractures in elderly individuals who suffer from osteoporotic bones, as previously noted by Burdin et al. (2010) [26]. The distribution of patients according to the Schatzker classification in our study showed that Type I fractures were the most common (50%), followed by Type II (19.35%) and Type III (14.52%). The higher prevalence of Schatzker Type I fractures was also reported in a study by Koval et al. (1992), which found that these fractures occur most frequently due to direct trauma to the knee, resulting in split fractures [27]. The prevalence of other types of fractures, such as Type IV (8.06%), V (4.84%), and VI (3.23%), was relatively low, which is consistent with prior findings by Tscherne et al. (1993), who noted that complex fractures (Types V and VI) are less common but associated with worse outcomes [28]. In this present study, 54.84% of fractures achieved union in less than 12 weeks, while 14.52% united between 12 and 14 weeks. A significant proportion (27.42%) required more than 14 weeks for union, and 3.23% developed non-union. These outcomes are comparable to those of previous studies, such as the one by Watson et al. (1981), which reported a mean time to union of 12 weeks [28]. However, cases with delayed union or non-union have been linked to factors such as the severity of the fracture and the patient's comorbidities, as highlighted by Higgins et al. (2009) [29]. The functional outcomes in our study showed that 41.94% of patients had excellent results, 33.87% had good outcomes, 8.06% reported fair outcomes, and 16.13% had poor outcomes. These findings align closely with the results of Rasmussen (1973), who reported that approximately 80% of patients attained either excellent or good outcomes [20]. Additionally, Ebraheim et al. documented that in their cohort of 117 tibial plateau fractures, 68% of patients had excellent results, 13% achieved good outcomes, 11% reported fair results, and 8% had poor outcomes [30]. A more recent study reported that despite the inherent complexities of the fractures, their fixation techniques yielded an impressive 83.3% acceptable outcomes, including 33.3% classified as excellent and 50% as good, with fair results in 13.3% and poor results in 3.3% of cases [31].

The study concluded that surgical management of tibial plateau fractures in a tertiary care hospital resulted in generally favorable functional outcomes. The majority of patients achieved fracture union within 12 weeks, with a significant portion reporting excellent or good satisfaction levels. Road traffic accidents were the predominant cause, and Schatzker Type I fractures were most common. Despite the complexity and potential complications associated with these fractures, surgical interventions, including minimally invasive techniques, demonstrated effective results. However, a small percentage experienced non-union and poor outcomes, highlighting the need for tailored approaches to optimize recovery and minimize complications.

Funding: No funding sources

Conflict of interest: None declared

1. Gill, T.J., Moezzi, D.M., Oates, K.M., & Sterett, W.I. "Arthroscopic Reduction and Internal Fixation of Tibial Plateau Fractures in Skiing." Clinical Orthopaedics and Related Research (1976-2007), vol. 383, 2001, pp. 243-9, https://doi.org/10.1097/00003086-200102000-00031.
2. Schmitt, Kai-Uwe, et al. Trauma biomechanics. Berlin: Springer, 2010
3. Watson, J.T., Schatzker, J., Browner, B.D., Jupiter, J.B., Levine, A.M., & Trafton, P.G. Skeletal Trauma: Basic Science, Management, and Reconstruction. Elsevier, 2002.
4. Barr, J.S. "The Treatment of Fracture of the External Tibial Condyle: (Bumper Fracture)." Journal of the American Medical Association, vol. 115, no. 20, 1940, pp. 1683-7, https://doi.org/10.1001/jama.1940.02810460009003.
5. Apley, A.G. "Fractures of the Tibial Plateau." Orthopedic Clinics of North America, vol. 10, no. 1, 1979, pp. 61-74.
6. DeCoster, T.A., Nepola, J.V., & El-Khoury, G.Y. "Cast Brace Treatment of Proximal Tibia Fractures: A Ten-Year Follow-up Study." Clinical Orthopaedics and Related Research (1976-2007), vol. 231, 1988, pp. 196-204, https://doi.org/10.1097/00003086-198806000-00028.
7. Honkonen, S.E. "Degenerative Arthritis After Tibial Plateau Fractures." Journal of Orthopaedic Trauma, vol. 9, no. 4, 1995, pp. 273-7, https://doi.org/10.1097/00005131-199508000-00002.
8. Schatzker, J., McBroom, R., & Bruce, D. "The Tibial Plateau Fracture: The Toronto Experience 1968-1975." Clinical Orthopaedics and Related Research (1976-2007), vol. 138, 1979, pp. 94-104, https://doi.org/10.1097/00003086-197901000-00014.
9. Ali, A.M., El-Shafie, M., & Willett, K.M. "Failure of Fixation of Tibial Plateau Fractures." Journal of Orthopaedic Trauma, vol. 16, no. 5, 2002, pp. 323-9, https://doi.org/10.1097/00005131-200205000-00005.
10. Stevens, D.G., et al. "The Long-Term Functional Outcome of Operatively Treated Tibial Plateau Fractures." Journal of Orthopaedic Trauma, vol. 15, no. 5, 2001, pp. 312-20, https://doi.org/10.1097/00005131-200106000-00006.
11. J., Y. "Complications of Internal Fixation of Tibial Plateau Fractures." Orthopaedic Review, vol. 23, 1994, pp. 149-54.
12. Duwelius, P.J., Rangitsch, M.R., Colville, M.R., & Woll, S.T. "Treatment of Tibial Plateau Fractures by Limited Internal Fixation." Clinical Orthopaedics and Related Research, vol. 339, 1997, pp. 47-57, https://doi.org/10.1097/00003086-199706000-00006.
13. Keogh, P., et al. "Percutaneous Screw Fixation of Tibial Plateau Fractures." Injury, vol. 23, no. 6, 1992, pp. 387-9, https://doi.org/10.1016/0020-1383(92)90296-T.
14. Marsh, J.L., Smith, S.T., & Do, T.T. "External Fixation and Limited Internal Fixation for Complex Fractures of the Tibial Plateau." JBJS, vol. 77, no. 5, 1995, pp. 661-73, https://doi.org/10.2106/00004623-199505000-00006.
15. Chapman, M.W. Chapman's Orthopaedic Surgery, Lippincott Williams & Wilkins, 2001.
16. Phisitkul, Phinit, et al. "Complications of locking plate fixation in complex proximal tibia injuries." Journal of orthopaedic trauma 21.2 (2007): 83-91
17. Jensen, D.B., et al. "Tibial Plateau Fractures: A Comparison of Conservative and Surgical Treatment." The Journal of Bone & Joint Surgery British Volume, vol. 72, no. 1, 1990, pp. 49-52, https://doi.org/10.1302/0301-620X.72B1.2298794.
18. Su, E.P., et al. "Operative Treatment of Tibial Plateau Fractures in Patients Older than 55 Years." Clinical Orthopaedics and Related Research, vol. 421, 2004, pp. 240-8, https://doi.org/10.1097/01.blo.0000129896.31614.5e.
19. Blokker, C.P., Rorabeck, C.H., & Bourne, R.B. "Tibial Plateau Fractures: An Analysis of the Results of Treatment in 60 Patients." Clinical Orthopaedics and Related Research (1976-2007), vol. 182, 1984, pp. 193-9, https://doi.org/10.1097/00003086-198401000-00028.
20. Rasmussen, P.S. "Tibial Condylar Fractures: Impairment of Knee Joint Stability as an Indication for Surgical Treatment." JBJS, vol. 55, no. 7, 1973, pp. 1331-50, https://doi.org/10.2106/00004623-197355070-00016.
21. Lansinger, O., et al. "Tibial Condylar Fractures: A Twenty-Year Follow-Up." JBJS, vol. 68, no. 1, 1986, pp. 13-9, https://doi.org/10.2106/00004623-198668010-00003.
22. Hasenhuttl, K. "The Treatment of Unstable Fractures of the Tibia and Fibula with Flexible Medullary Wires: A Review of Two Hundred and Thirty-Five Fractures." JBJS, vol. 63, no. 6, 1981, pp. 921-31, https://doi.org/10.2106/00004623-198163060-00008.
23. Ibeanusi, S.E., & Ekere, A.U. "Epidemiology of Open Tibial Fractures in a Teaching Hospital." Port Harcourt Medical Journal, vol. 3, no. 1, 2007, pp. 156-60, https://doi.org/10.4314/phmedj.v3i1.38789.
24. Mallik, A.R., Covall, D.J., & Whitelaw, G.P. "Internal Versus External Fixation of Bicondylar Tibial Plateau Fractures." Orthopaedic Review, vol. 21, no. 12, 1992, pp. 1433-6.
25. Pelser, P. C. "Controversies in the management of tibial plateau fractures." SA Orthopaedic Journal 9.3 (2010): 75-82
26. De Mourgues, G., & Chaix, D. "Treatment of Tibial Plateau Fracture." Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur, vol. 55, no. 6, 1969, pp. 575-6.
27. Koval, K.J., et al. "Split Fractures of the Lateral Tibial Plateau: Evaluation of Three Fixation Methods." Journal of Orthopaedic Trauma, vol. 10, no. 5, 1996, pp. 304-8, https://doi.org/10.1097/00005131-199607000-00003.
28. Tscherne, H.A., & Lobenhoffer, P. "Tibial Plateau Fractures: Management and Expected Results." Clinical Orthopaedics and Related Research, vol. 292, 1993, pp. 87-100, https://doi.org/10.1097/00003086-199307000-00012.
29. Watson, J.T., & Coufal, C. "Treatment of Complex Lateral Plateau Fractures Using Ilizarov Techniques." Clinical Orthopaedics and Related Research, vol. 353, 1998, pp. 97-106, https://doi.org/10.1097/00003086-199808000-00012.
30. Ebraheim, N.A., Sabry, F.F., & Haman, S.P. "Open Reduction and Internal Fixation of 117 Tibial Plateau Fractures." Orthopedics, vol. 27, no. 12, 2004, pp. 1281-7, https://doi.org/10.3928/0147-7447-20041201-12.
31. Mathur, Hitin, et al. "Operative results of closed tibial plateau fractures." Indian J Orthop 39.2 (2005): 108-112.