Frailty Predicts Mortality While Fracture Complexity and Reduction Predict Failure After Surgery for Tibial Plateau Fractures in Elderly Patients: A Two-decade Cohort Study

Abstract Tibial plateau fractures in older patients are increasingly common and carry poor outcomes, yet the determinants of mortality and surgical failure are poorly defined, and frailty, central to hip fracture care, has not been examined in this group. We retrospectively reviewed all patients aged 65 years and older undergoing surgery for a tibial plateau fracture at a single center (2006–2025). Outcomes were all-cause reoperation, malunion, fracture-related infection (FRI), conversion to total knee arthroplasty (TKA), and death (treated as a competing event), analyzed with Fisher's exact test and Firth's penalized logistic regression adjusted for age, fracture complexity, and reduction. Among 47 patients (mean age 73 years; 83% female; open reduction internal fixation [ORIF] in 42, primary TKA in 5), malunion occurred in 57% of ORIF cases, all-cause reoperation in 29%, and FRI in 12%; 15% underwent conversion to TKA at a median of 9 months, accounting for 7 of 13 reoperations. Mortality over the study period was 21% (6% within 1 year). Frailty independently predicted mortality (adjusted odds ratio [aOR] 8.4, 95% confidence interval [CI]: 1.7–61.2) with a clear dose–response, but not reoperation. Fracture complexity (bicondylar/Schatzker 5–6) independently predicted malunion (aOR 7.1, CI: 1.8–37.9), while both complexity (aOR 5.0, CI: 1.2–24.8) and non-anatomical reduction (anatomical reduction protective: aOR 0.20, CI: 0.03–0.91) independently predicted reoperation. The five primary TKA patients, the only group permitted immediate weight-bearing, had fewer reoperations, no infection, no revisions or death, and earlier discharge to home. Mortality and surgical failure had distinct drivers: frailty for death, complexity and malreduction for failure. Reduction quality is the key modifiable surgical variable, and immediate-weight-bearing arthroplasty warrants prospective evaluation in select patients.