Holding the line: predictors of coronal and sagittal loss of reduction after tibial plateau fracture fixation

INTRODUCTION: Tibial plateau fractures (TPFs) are challenging fractures that often suffer from secondary Loss of Reduction (LoR) after fracture fixation. In this study, we aimed to investigate the factors and characteristics associated with LoR after surgical fixation, using measurements of both coronal and sagittal displacement. METHODS: A retrospective analysis of 213 TPF patients (79.3% female, mean age 57.5 ± 14.4 years) surgically treated between 2017 and 2024 in a level 1 trauma center was performed. Patients were included if they had a minimum of 100-days radiological follow-up. Loss of reduction was defined as late postoperative depression ≥ 3 mm, condylar widening ≥ 5 mm, varus/valgus or tibial slope collapse > 5 degrees, breakage, loosening, or conversion to total knee arthroplasty (TKA). Radiographic images were assessed for preoperative, direct postoperative, and late postoperative (up to 1 year) displacement. Univariable and multivariable logistic regression analyses were employed to study factors associated with LoR.. RESULTS: At a mean follow-up of 325 days (SD ± 161) 77 patients (36.2%) suffered from LoR. The adjusted multivariable logistic regression model revealed that patient age (OR 1.03, p = 0.028), involvement of the posterior column (OR 2.87, p = 0.014), preoperative step-off (OR 1.08, p < 0.001), postoperative step-off (OR 1.61, p = 0.007), and postoperative widening (OR 1.31, p = 0.003) were independently associated with higher odds of LoR. CONCLUSION: Using strict radiological criteria, patient age, posterior column involvement, greater preoperative step-off, and residual step-off and condylar widening were associated with increased odds LoR. These findings underscore the importance of achieving optimal fracture reduction and fixation to minimize the risk of LoR, especially in older patients and complex posterior fracture patterns.