Expected Progression of Osteoarthritis After Tibial Plateau Fracture
Osteoarthritis develops in approximately 44-46% of patients following tibial plateau fractures, with progression typically occurring within the first 7 years post-injury and continuing to worsen over decades. 1, 2
Timeline and Natural History
Early progression (0-7 years): Joint space narrowing typically begins within the first 7 years after injury, usually affecting the same compartment as the fractured plateau. 2 At short-term follow-up (median 3 years), radiographic osteoarthritis may be present but has limited prognostic value for individual patients, as good early results can deteriorate substantially over time. 3
Long-term progression (>10 years): At extended follow-up (median 22 years), significant deterioration of symptoms, signs, and radiological osteoarthritis is the norm, though approximately one-third of patients may have minimal or no osteoarthritis even at long-term follow-up. 3 In athletic populations, the grade of osteoarthritis is most severe in the lateral compartment corresponding to fracture location. 4
Risk Factors That Accelerate Progression
Meniscal injury is the single most critical modifiable factor: Meniscectomy during fracture surgery results in secondary degeneration in 74% of cases, compared to only 37% when the meniscus is intact or repaired. 2 This parallels the high-certainty evidence from knee trauma showing that meniscectomy dramatically increases osteoarthritis odds. 5
Age significantly impacts outcomes: Advanced age >50 years increases osteoarthritis odds by 9.1 times (OR 9.1,95% CI 3.7-22.1). 1 Female gender also increases risk (OR 3.40,95% CI 1.36-8.46). 1
Articular depression and malalignment are critical: Articular depression increases osteoarthritis odds by 35.25 times (OR 35.25,95% CI 11.49-108.1), while degree of malalignment increases odds by 25.72 times (OR 25.72,95% CI 9.30-71.12). 1 Normal or slight valgus alignment with intact menisci provides the best protection against secondary degeneration. 2
Associated injuries compound the risk: Ligamentous injuries and postoperative infection increase the incidence of secondary degeneration. 2 This aligns with guideline evidence showing that multistructure injuries (fractures with meniscal or chondral injuries) carry substantially higher osteoarthritis risk than isolated injuries. 5, 6
Functional Deterioration
Activity levels decline progressively: In athletic populations, both Tegner Activity Scale and Lysholm Score decrease significantly during long-term follow-up, with median Tegner scores dropping from 6 to 5 and Lysholm scores from 100 to 95 over approximately 10 years. 4
Pain increases over time: Higher pain scores (VAS >4) are strongly associated with osteoarthritis development (OR 73.28,95% CI 15.7-341.5). 1 Conversely, excellent functional outcomes are protective against osteoarthritis (OR 4.8). 1
Clinical Endpoint: Total Knee Arthroplasty
Conversion to TKA is common: Among patients who develop secondary arthritis, 60% ultimately require total knee replacement. 1 In elderly patients with pre-existing osteoarthritis and poor bone quality, primary TKA at the time of fracture may be considered to allow immediate weight-bearing, though this carries significant complication risks and should be reserved for selected patients. 7
Key Clinical Pitfalls
Do not rely on early radiographic appearance: The severity of articular irregularities correlates poorly with the degenerative process, and short-term follow-up results have little prognostic value for individual patients. 3, 2
Preserve meniscal tissue aggressively: The difference between meniscectomy (74% osteoarthritis rate) versus meniscal preservation/repair (37% rate) represents the most impactful modifiable factor under surgical control. 2
Achieve anatomic alignment: Even with intact menisci, medial or lateral tilt of the tibial plateau is followed by osteoarthritis in most cases. 2