The injuries in question are called periprosthetic tibial fractures, breaks that occur in the bone surrounding a total knee replacement. They are rare. In a nationwide cohort study of primary knee replacements cited by the authors, only 0.2 percent of patients experienced a tibial fracture within ten years of surgery, compared with 1.7 percent for periprosthetic knee fractures overall. Yet rarity does not mean simplicity. A recent systematic review found that these fractures carry overall complication and reoperation rates of 38 and 28 percent respectively, figures that reflect the delicate balance surgeons must strike between stabilizing the bone and preserving the implant.

The decision about how to treat such a fracture hinges above all on one question: is the prosthesis still firmly anchored in the bone? If the tibial component has loosened, revision arthroplasty, replacing the whole construct, is usually the answer. But when the implant remains well fixed, salvaging it with internal fixation is far less invasive for the patient. To classify the injuries, the researchers used the Felix system, which separates fractures by location: type I involves the tibial plateau, type II occurs adjacent to the tibial component or stem, type III lies distal to the prosthesis, and type IV involves the tibial tubercle. Each type is subdivided, with subtype A indicating a well-fixed component, subtype B a loose one, and subtype C an intraoperative fracture.

The team focused on Felix type 2A and 3A fractures, in which the tibial component remains stable. Their reasoning was mechanical rather than categorical. In these fractures, the tibial tray, keel, stem, and cement mantle occupy the proximal medullary canal, drastically limiting the trajectories available for screws. Previous work on periprosthetic tibial fractures found that fixation failure was more frequent when the proximal fragment held fewer than eight cortices of screw purchase, suggesting that the quantity and distribution of proximal fixation matter more than the degree of comminution itself. By placing plates on both the medial and lateral sides of the tibia, the surgeons could spread the available screws around the prosthesis and reduce reliance on a single implant for coronal alignment and rotational control.

The study, published in Frontiers in Musculoskeletal Disorders, reviewed patients treated between June 2022 and December 2024 at the Luoyang Orthopedic-Traumatological Hospital of Henan Province. Of 25 patients screened, 12 were excluded because their fractures involved a loose component, a different Felix type, a unicompartmental prosthesis, or insufficient follow-up. The final cohort of 13 patients, six men and seven women, had a mean age of 80.4 years and a mean body mass index of 20.5. Seven had Felix type 2A fractures and six had type 3A. Five injuries resulted from high-energy trauma and eight from low-energy falls, while two fractures were open and required initial debridement before definitive plating. Eleven of the 13 had documented osteoporosis, underscoring how fragile the bone around these implants can be.

Before surgery, the team assessed component stability with anteroposterior and lateral radiographs, comparing them with previous postoperative images when available. A component was considered well fixed only if there was no progressive radiolucent line, migration, subsidence, or change in position. Computed tomography helped nine patients’ surgical planning by defining the relationship between the fracture and the tibial tray or stem, but stability was ultimately confirmed in the operating room, where the component was directly inspected and manually tested for gross motion at the bone-implant and bone-cement interfaces. All 13 fractures occurred around cemented tibial components, and screws were deliberately directed around the stem and cement mantle to maximize purchase in the remaining bone.

The technical execution was meticulous. Plate length and position were tailored to fracture location and prosthetic geometry, with longer plates used to span the diaphyseal fractures of type 3A injuries. Reduction quality, plate position, and alignment in both coronal and sagittal planes were verified with intraoperative fluoroscopy, and soft-tissue stripping was minimized. Notably, no bone graft or graft substitute was used in any patient. Postoperatively, patients began knee range-of-motion exercises within the first week, started partial weight-bearing at a mean of 5.3 weeks, and achieved full weight-bearing at a mean of 16.8 weeks.

The outcomes were strikingly uniform. Every one of the 13 fractures achieved radiographic union, first documented at a mean of 16.4 weeks, with no delayed unions, nonunions, or fixation failures. Reduction quality was graded as good in eight patients and acceptable in five, with no poor reductions. The mean postoperative mechanical proximal tibial angle was 87.2 degrees and the posterior tibial slope 2.3 degrees, with excellent agreement between the two independent radiographic reviewers. Most tellingly, the original tibial component was retained in all 13 patients, with no migration, subsidence, or loss of reduction during a mean follow-up of 20.5 months. Not a single reoperation or revision arthroplasty was recorded.

Functional recovery traced a steep trajectory. At the acute post-fracture assessment before surgery, mean knee range of motion was only 17.5 degrees, the Knee Society Score averaged 26.9, and the Hospital for Special Surgery score averaged 20.4. By six months, range of motion had climbed to 110.7 degrees and continued improving to 122.9 degrees at final follow-up, when the KSS reached 89.9 and the HSS score 86.7. All three measures differed significantly across the three assessment points, with adjusted pairwise comparisons all yielding P values below 0.001. The authors are careful, however, to note that the preoperative measurements reflected the acute injury state rather than the patients’ pre-fracture baseline, so these gains represent recovery from injury through fixation, healing, and rehabilitation, and cannot be attributed solely to the dual-plate construct itself.

The honest caveats are as instructive as the results. This was a small, single-center, retrospective case series with no comparison group, and during the study period no eligible patient received single-plate fixation, so the design cannot establish whether one plate would have sufficed or whether dual plating is superior. All components were cemented, limiting extrapolation to uncemented implants, and pre-fracture functional data were unavailable. Indirect evidence from periprosthetic distal femoral fractures, where dual plating has been studied more extensively, suggests a potential mechanical benefit at the price of roughly 27 additional minutes of operative time. The authors conclude that the decision to add a second plate should rest on specific fixation goals, sufficient screw purchase, balanced medial and lateral support, and control of multiplanar instability around a prosthesis that restricts screw corridors. Larger comparative studies will be needed to define the indications precisely, but for a fracture population whose historical reoperation rate approaches 28 percent, a series in which every patient healed and kept their original implant is a result worth watching closely.

Subject of Research: Surgical outcomes of dual locking-plate fixation for periprosthetic tibial fractures around a well-fixed tibial component after total knee arthroplasty

Article Title: Dual locking plate fixation for periprosthetic tibial fractures With a well-fixed tibial component after total knee arthroplasty: a retrospective case series

Article References: Wang, S., Zhao, J., Ma, J., Cao, G., Wang, S., & Tan, H. (2026). Dual locking plate fixation for periprosthetic tibial fractures With a well-fixed tibial component after total knee arthroplasty: a retrospective case series. Frontiers in Musculoskeletal Disorders, 4, Article 1885283. https://doi.org/10.3389/fmscd.2026.1885283

Image Credits: AI Generated

DOI: 10.3389/fmscd.2026.1885283

Keywords: periprosthetic tibial fracture, total knee arthroplasty, dual locking plates, Felix classification, fracture fixation, tibial component retention, osteoporosis, knee surgery, locking plate osteosynthesis, fracture union, revision arthroplasty, orthopedic trauma