Overview
The tibial plateau is the flat top of the shinbone that the femur rests on. When it fractures, the joint surface is split, pushed down or both, and the knee no longer has a level platform to bear weight on. Open reduction and internal fixation (ORIF) lifts the depressed surface back to its original height, fills the void beneath it with bone graft, and holds the reconstruction with a plate and screws so the joint heals level. The purpose is a stable, aligned knee that moves fully and is protected against the arthritis that follows a joint surface left uneven.
Dr. O'Donnell fixes these fractures as a short-stay procedure, with patients going home the same day or after one night, and starts knee motion within the first days.
Who It's For
Surgery is recommended when the joint surface is displaced enough to change how the knee bears load: a step or depression of more than a few millimeters on CT, a split fragment that has moved, widening of the plateau, or a knee that tilts when stressed. In older patients with softer bone, a simple fall can depress the outer plateau. A tibial plateau fracture often comes with a meniscus tear or ligament injury that is treated during the same operation.
Fractures that are not displaced heal well in a hinged brace without surgery, with the same period of protected weight bearing and early motion. Surgery is delayed, sometimes by one to two weeks, when the soft tissues are badly swollen or blistered, because operating through compromised skin raises the risk of wound problems.
A depression measured on CT is not by itself the reason to operate. Dr. O'Donnell fixes a tibial plateau fracture when the displacement on imaging, the stability of the knee on exam and the patient's demands together favor it, and an undisplaced fracture is braced with the same protected weight bearing. The tibial plateau fracture page explains how the fracture is measured and classified.
What the Procedure Involves
A CT scan maps every fragment before surgery. The operation is done under general anesthesia with a nerve block for pain control afterward. Through an incision on the side of the knee that is broken, Dr. O'Donnell exposes the fracture, lifts the meniscus to look directly at the joint surface, and elevates the depressed cartilage and bone back to its original level with a bone tamp working from below. The cavity beneath the raised surface is packed with bone graft or a calcium-phosphate substitute so it cannot sink again. A contoured plate is laid along the tibia and fixed with screws, including screws placed just under the joint surface, like rafters, to hold it up. X-ray or arthroscopy confirms the surface is level, a torn meniscus is repaired, and the capsule is closed. Fractures involving both sides of the plateau take two incisions and two plates. The operation takes about two hours.
Risks & How They Are Minimized
Stiffness is the most common problem after a tibial plateau fracture and the reason the protocol pushes knee motion from the first week. Post-traumatic arthritis is the long-term risk and is driven by how level the joint surface is left, which is why the reduction is checked directly and by imaging during the operation. Loss of reduction, the raised surface settling back down, is guarded against by bone graft beneath it, rafter screws and strict non-weight-bearing for 6 to 8 weeks. Infection and wound breakdown are more common than with arthroscopic surgery because the skin around the knee is thin and the injury swells; timing surgery for when swelling has settled, a pre-incision antibiotic and careful soft-tissue handling reduce the risk. Deep-vein thrombosis is a real concern with a non-weight-bearing leg and is prevented with a blood thinner, ankle pumps and early motion. Injury to the peroneal nerve is a risk of the injury itself and is checked at every visit. Hardware irritation over the plate can be addressed by removing it after the fracture has healed.
Recovery & Rehabilitation
Two things happen at once: the joint surface is protected from load until it has healed, and the knee is moved from the beginning so that it does not stiffen.
| Phase | Timing | What happens |
|---|---|---|
| Protected motion | Weeks 0–6 | Non- or touch-down weight bearing on crutches; hinged brace; no loaded flexion. Passive and active-assisted knee motion with an early goal of 0–90°, quad sets and straight-leg raises, patellar mobilizations, full passive extension. Advance with full extension, flexion to 90° and a good quad set. |
| Weight bearing & motion | Weeks 6–12 | Weight bearing advanced per X-ray healing, often beginning at 6 to 8 weeks and full by about 12; crutches weaned. Full range of motion, closed-chain strengthening in protected ranges, stationary bike, balance work. Advance with pain-free full weight bearing, full motion and radiographic healing. |
| Strengthening | Months 3–4 | Progressive resistive strengthening, single-leg strength and balance, low-impact conditioning. Advance at 80% strength of the opposite side with a normal gait. |
| Return to activity | Months 4–6 | Advanced strengthening, impact and sport-specific progression as cleared. Full loading requires symmetric strength and function and surgeon clearance. |
Desk work is possible within 1 to 2 weeks with the leg elevated. Driving waits until full weight bearing is allowed and the brace is off, about 10 to 12 weeks for a right leg. Cycling from about 3 months, running and impact at 4 to 6 months once cleared.
Protocol summary
Precautions: non-weight-bearing or touch-down weight bearing with crutches for about 6 to 8 weeks until radiographic healing; hinged knee brace as directed; early knee motion encouraged while loaded flexion is avoided; no lifting or pivoting until cleared.
Criteria: the first phase ends with full extension, flexion of about 90° and a good quad set; weight bearing is advanced on X-ray evidence of healing, and the second phase ends with pain-free full weight bearing, full motion and radiographic union; strengthening advances at 80% strength; full loading requires symmetric strength and surgeon clearance.
Physical Therapy Protocol
Tibial Plateau Fracture — Open Reduction & Internal PDF ↗Frequently Asked Questions
How long are you non-weight-bearing after tibial plateau surgery?
About 6 to 8 weeks on crutches with no or touch-down weight on the leg, until X-rays show the fracture healing. Weight bearing is then advanced gradually and is usually full by about 12 weeks. Loading the surface earlier can let the elevated fragment sink.
Can I bend my knee after tibial plateau fracture surgery?
Yes, and you should, starting in the first days. Early motion with a goal of 0 to 90° is the priority of the first phase because stiffness is the most common problem after this fracture. The hinged brace allows bending while protecting against sideways stress, and bending is done without weight on the leg.
How long does a tibial plateau fracture take to heal?
The bone is usually healed enough for full weight bearing by about 12 weeks, and strength and a normal gait return over months 3 to 4. Return to impact and sport is typically 4 to 6 months, and the knee continues to improve for a year.
Will I get arthritis after a tibial plateau fracture?
The risk depends on how level the joint surface heals, whether the meniscus was preserved, and the cartilage damage done at the moment of injury. Restoring the surface accurately and protecting it while it heals is the purpose of the operation and reduces that risk substantially, though it cannot undo cartilage crushed by the injury itself.
When can I drive after tibial plateau ORIF?
For a right leg, once full weight bearing is allowed, the brace is off and you can brake hard without hesitation, usually 10 to 12 weeks. For a left leg with an automatic transmission, once you are off narcotic pain medication and can get in and out of the car safely, often within a few weeks.
Will the plate need to be removed?
Usually not. The plate and screws are designed to stay permanently, and most patients never notice them. Removal is considered after the fracture has fully healed, generally a year or more out, if the plate irritates the skin or tendons over the outer knee, which is more likely in slim patients.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.