Outcomes of Nonunion Surgery After Tibial Plateau Fractures: A Case Series of 28 Patients

OBJECTIVES: To evaluate outcomes of tibial plateau fracture nonunion surgery, including rates of final radiographic healing, additional surgery, and conversion to total knee arthroplasty (TKA). DESIGN: Retrospective case series. SETTING: Two Level I academic trauma centers. PATIENTS: Adult patients who underwent nonunion surgery after open reduction internal fixation of tibial plateau fractures (OTA/AO 41B-C) between 2000 and 2024 were included. OUTCOME MEASURES AND COMPARISONS: The primary outcome was final radiographic healing. Secondary outcomes included additional surgery and conversion to TKA. RESULTS: Twenty-eight patients were included (median age 55 years (IQR: 38-61), 57% male). The median follow-up from the date of the nonunion surgery was 19 months (IQR:13-33). Twenty-one (75%) fractures were classified as Schatzker VI. Nonunion surgery involved revision open reduction internal fixation in 23 (82%) cases, bone grafting alone (with or without hardware removal) in 3 (11%) cases, screw augmentation in 1 (3.6%) patient, and 1 patient (3.6%) underwent multistage treatment, ending with definitive treatment using an Ilizarov frame for 6 months. Overall, 54% of patients received bone grafting to address bone defects. Radiographic healing was achieved in 24 patients (86%). All 4 (14%) patients with a persistent nonunion had Schatzker VI fractures. Of these, 3 (75%) ultimately underwent conversion to TKA, whereas 1 had no further surgery until the last follow-up 12.4 months after the initial procedure. Overall, 13 (46%) patients required additional surgery, of which 5 (18%) underwent TKA at a median of 3.1 years (IQR: 1.68-6.74). CONCLUSION: In the current study of patients who underwent tibial plateau fracture nonunion surgery, 86% of patients ultimately achieved radiographic healing, with 71% healed after the index nonunion surgery. Close to half of the patients required additional surgery, with 14% who underwent further procedures to achieve healing, and 18% ultimately required conversion to TKA. These findings can help surgeons counsel patients and guide expectations after surgery for tibial plateau fracture nonunion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.