What complications can occur after a tibial plateau fracture?

Complications from Tibial Plateau Fracture

Tibial plateau fractures carry significant risks of both acute limb-threatening complications and chronic functional sequelae, with infection rates of 6-44% in open fractures, compartment syndrome requiring urgent fasciotomy, and at least 5% requiring conversion to total knee arthroplasty despite optimal treatment. 1, 2, 3

Acute Life- and Limb-Threatening Complications

Vascular Injury

• Arterial injury can occur due to proximity of major vessels to the fracture site and must be identified urgently 1
• Perform CT angiography (96.2% sensitivity, 99.2% specificity) if any of the following are present: externalised arterial bleeding, injury near main vascular axis, non-expanding hematoma, isolated neurological deficit, or ankle-brachial index <0.9 1

Acute Compartment Syndrome

• Must be recognized early to allow timely fasciotomy, as this complication specifically complicates tibial plateau fractures 4
• The presence of an open fasciotomy wound then complicates subsequent management of the articular fracture, requiring careful sequential treatment planning 4

Infection (Acute Phase)

• Open tibial plateau fractures carry infection rates of 6-44% compared to ~1% for closed fractures 1
• Administer antibiotic prophylaxis as soon as possible for maximum 48-72 hours (unless proven infection develops) 1
• Use cefazolin or clindamycin for all open fractures; add gram-negative coverage with piperacillin-tazobactam for Gustilo-Anderson Type III (and possibly Type II) fractures 1
• Do not add gentamicin or vancomycin to piperacillin-tazobactam, as this does not appear helpful 1
• Consider local antibiotic strategies as adjunct: vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails may all be beneficial 1

Systemic Complications from Surgical "Second Hit"

• Fat embolism syndrome and ARDS are particular risks with tibial shaft and plateau fractures 1
• In hemodynamically stable patients without severe visceral injury, perform early definitive osteosynthesis within 24 hours to reduce local and systemic complications 1
• In unstable patients with circulatory shock, respiratory failure, or severe visceral injuries, use damage control orthopedics with temporary external fixation, then delayed definitive fixation once stabilized 1

Postoperative Complications

Surgical Site Infection

• Postoperative NPWT can be considered for high-risk incisions following ORIF of tibial plateau fractures, though cost-benefit has not been fully evaluated 1
• If acute infection develops after fracture has healed, remove hardware and perform lavage, debridement, and antibiotic therapy 2
• If acute infection develops before fracture healing, retain hardware and perform lavage, debridement, and antibiotics (sometimes repeatedly) until fracture heals—fracture stability is crucial for both healing and infection resolution 2

Chronic Osteomyelitis

• Requires staged treatment: first stage involves aggressive debridement of devitalized tissue/bone, antibiotic spacer, and temporary external fixation until infection resolves 2
• Second stage involves definitive surgery with grafting or soft tissue coverage depending on bone defect 2

Knee Stiffness

• Mobilization under anesthesia (MUA) when duration is <3 months 2
• Arthroscopic release when duration is 3-6 months (can be combined with MUA) 2
• Open release for refractory cases or stiffness >6 months 2

Malunion

• Intra-articular or extra-articular osteotomy is the preferred option for young, active patients without significant joint damage 2
• When malunion is associated with extensive joint involvement or cartilage damage has progressed to osteoarthritis, total knee arthroplasty is indicated 2

Non-union

• Represents a significant complication requiring revision surgery with attention to fracture stability and biological environment 2, 5

Long-Term Sequelae

Post-Traumatic Osteoarthritis

• Most common long-term complication, particularly with high-energy fractures 6, 2, 3
• Risk factors include: bicondylar and comminuted fractures, meniscal removal, instability, malalignment, and articular incongruity 6
• At least 5% require conversion to total knee arthroplasty despite optimal initial treatment 3
• Progression often shows impaired quality of life and activities even when secondary arthroplasty is avoided 3

Associated Soft Tissue Injuries

• Articular depression >11 mm on CT predicts higher risk of lateral meniscus tear and ACL avulsion fracture 7, 8
• Order MRI after CT if articular depression >11 mm, clinical suspicion of meniscal/ligamentous injury, or surgical planning is being considered 7
• MRI has superb accuracy for evaluating bone marrow contusions, occult fractures, meniscal injuries, and ligamentous injuries 7

Functional Outcomes

• At least half of patients return to original level of physical activity when anatomy and stability are restored 6
• Medium-term functional outcomes are generally excellent with proper anatomic restoration 6
• However, high-energy fractures carry worse prognosis with frequent functional sequelae 3

Critical Pitfalls to Avoid

• Do not miss compartment syndrome—maintain high index of suspicion and low threshold for fasciotomy in tibial plateau fractures 4
• Do not delay vascular assessment—obtain CT angiography urgently when hard or soft signs of vascular injury are present 1
• Do not extend antibiotic prophylaxis beyond 72 hours in open fractures unless proven infection develops 1
• Do not perform early definitive fixation in hemodynamically unstable patients—use damage control orthopedics instead 1
• Do not remove hardware prematurely if acute infection develops before fracture healing—stability is essential for both healing and infection control 2