Outcomes of fixation for periprosthetic tibia fractures around and below total knee arthroplasty

Introduction The incidence of periprosthetic fractures after total knee arthroplasty (TKA) is rising due to an increasing number of TKAs performed annually and the growing elderly population. Like periprosthetic fractures of the distal femur, periprosthetic tibia fractures are primarily treated with operative fixation; however, there is limited scientific literature that has reported outcomes of periprosthetic tibia fractures treated with modern plating techniques. To our knowledge, this is the largest series of non-intraoperative periprosthetic tibia fractures treated with open reduction internal fixation (ORIF) ever reported. Methods Retrospective chart review of 4557 operatively treated tibia fractures with ORIF over a 16-year period at two Level 1 Trauma Centers. Results 38 patients with an average follow-up of 15.3 months (range 3–24) were identified. 11 (28.9%) fractures were in the proximal tibia (four with extension into the plateau (Felix 1A) and seven adjacent to the tibial stem (Felix 2A)), six (15.8%) in the midshaft/diaphysis (Felix 3A), and 21 (55.3%) in the distal 1/3rd (metaphysis, Felix 3A). 76.3% (29/38) of fractures united by 6 months following the index procedure, leaving 9 nonunions. The overall re-operation rate was 31.6% (12/38). There were no significant differences in rates of union (p = 1.00), reoperation (p = 0.66), superficial infection (p = 0.66), or deep infection (p = 0.31) in patients treated with single versus dual plating. Conclusion Periprosthetic tibia fractures are difficult to treat and have a high risk of nonunion and reoperation even with modern plating techniques. Most patients can be treated to union with operative fixation and do not require revision arthroplasty, if the components are stable initially. We recommend dual plating for fractures in the proximal third, and either single plating or nailing for fractures in the middle and distal thirds depending on bone quality, implant positioning, and fracture morphology.