ARIF and ORIF in tibial plateau fractures: current evidence and a practical framework for individualized surgical decision-making

Tibial plateau fractures remain challenging injuries because treatment must restore articular congruity, limb alignment, and knee stability while addressing associated intra-articular soft-tissue lesions. Open reduction and internal fixation (ORIF) remains the reference approach for many fracture patterns, whereas arthroscopically assisted reduction and internal fixation (ARIF) has gained increasing interest as a less invasive strategy. This narrative review summarizes current evidence regarding the indications, advantages, limitations, and clinical roles of ARIF and ORIF in tibial plateau fracture management, with emphasis on individualized surgical decision-making. A narrative literature review was conducted using PubMed, Embase, and Web of Science from database inception to May 2026. Literature was identified using predefined search terms related to tibial plateau fractures, ARIF, ORIF, fracture morphology, associated intra-articular injuries, and post-traumatic osteoarthritis. Systematic reviews, meta-analyses, comparative clinical studies, technical reports, and contemporary reviews were prioritized according to their methodological quality, clinical relevance, and contribution to surgical decision-making. ARIF provides direct intra-articular visualization, facilitates assessment of articular reduction, and allows simultaneous management of meniscal, chondral, and ligamentous injuries. It may be particularly useful in selected low-energy fractures, especially Schatzker type I–III patterns and cases with associated intra-articular lesions. In contrast, ORIF remains the reference treatment for complex bicondylar fractures, severe comminution, posteromedial instability, and injuries requiring extensive exposure and rigid fixation, often within a staged strategy when soft-tissue conditions are unfavorable. Schatzker type IV fractures represent a transitional indication in which treatment should be individualized according to fracture morphology, stability, associated injuries, and surgeon expertise. ARIF and ORIF should be regarded as complementary rather than competing strategies. Treatment selection should be indication-driven and based on fracture morphology, soft-tissue condition, patient factors, and surgical expertise.