Factors influencing patient-reported outcomes in operatively managed tibial plateau fractures

TL;DR

This study explores how factors like age, injury type, and treatment affect recovery outcomes in patients with surgically treated tibial plateau fractures.

Contribution

The study identifies specific demographic and injury-related factors that influence patient-reported outcomes after tibial plateau fracture surgery.

Findings

Younger patients, especially females under 50, reported worse pain and global physical health outcomes.

High-energy injury mechanisms were linked to poorer physical and psychological recovery outcomes.

Adjustments showed significant associations between injury type and multiple domains of patient-reported outcomes.

Abstract

Tibial plateau fractures are complex injuries with high complication rates, yet their broader impact on patient-reported function and quality of life remains underexplored. This study assessed the impact of demographics, fracture patterns, and treatment characteristics on patient-reported outcomes measurement information system (PROMIS) scores in patients who underwent surgical fixation of tibial plateau fractures.

A retrospective cohort study was conducted at a Level I trauma center (2022–2024) including adults with operatively treated tibial plateau fractures who completed 6-month PROMIS surveys. Exclusions were age < 18 years, non-operative or percutaneous fixation, and inadequate medical record documentation. Primary outcomes were 6-month scores for PROMIS physical function (PF), pain interference (PI), global physical health (GPH), global mental health (GMH), anxiety/depression, brief resilience scale (BRS), and percent of normal function. Outcomes were compared by sex, age, mechanism of injury, fracture pattern, Schatzker type, and external fixation.

Of 413 patients, 106 met inclusion criteria. Mean age was 50.4 years and 51.9% were male. Patients < 50 reported higher PI (62.7 vs. 59.3, p = 0.017) and lower GPH (38.8 vs. 42.4, p = 0.023). Among females, those < 50 had higher PI (64.0 vs. 58.5, p = 0.009), lower GPH (37.5 vs. 43.1, p = 0.011), and lower anxiety (60.2 vs. 64.1, p = 0.046). After adjustment, high-energy injuries were associated with worse GPH (p = 0.014), GMH (p = 0.011), depression (p = 0.009), anxiety (p = 0.015), percent of normal (p = 0.002), and BRS (p = 0.004).

Early recovery after surgically treated tibial plateau fractures varies by patient and injury characteristics: younger patients, particularly females under 50, reported worse pain and global physical health, while high-energy mechanisms were independently associated with poorer physical and psychological outcomes across multiple domains.

The online version contains supplementary material available at 10.1007/s00590-026-04687-0.

Full text

Introduction

Fractures of the tibial plateau can be devastating injuries that account for up to 8% of fractures in the elderly and 1% of all fractures [1–4]. They are associated with relatively high complication rates including 2–20% for nonunion, 3–26% for infection, and 21–44% for post-traumatic osteoarthritis [5–7]. Although previous literature has highlighted adverse clinical outcomes, the extent to which these injuries impact patient function and quality of life remains less well understood.

The patient-reported outcomes measurement information system (PROMIS), developed by the National Institutes of Health, is designed to assess a patient’s perception of their health and quality of life [8–10]. It has been adopted in clinical practice to track outcomes after interventions across domains such as pain interference, physical function, global health, depression, and anxiety [9, 10]. As its use expands in orthopaedics, PROMIS offers a standardized framework to compare injury patterns, operative approaches, and patient characteristics in relation to functional outcomes, helping to identify factors associated with recovery [11].

Although prior studies have used PROMIS scores to evaluate outcomes in tibial plateau fractures, most have focused on fixation techniques for bicondylar patterns or specific injury characteristics, including tubercle involvement or concurrent meniscal repair [12–16]. Moreover, these studies have largely focused on physical function and pain interference PROMIS domains [12, 14, 15].

With the growing use of PROMIS scores in orthopedic trauma, evaluating the influence of non-modifiable risk factors on both physical function and mental health has become increasingly important [17]. This study aimed to assess the impact of patient demographics, fracture patterns, and treatment characteristics on 6-month PROMIS scores in patients who underwent surgical fixation of tibial plateau fractures. It was hypothesized that younger age, female sex, or high-energy mechanisms of injury may be associated with lower PROMIS, percent of normal, or BRS scores.

Methods

Study design, setting, and participants

Following institutional review board approval, a retrospective review was conducted to identify patients with tibial plateau fractures (AO/OTA 41) at a Level I trauma center from July 2022 to May 2024. Patients were identified using Current Procedural Terminology codes 27535 and 27536.

Patients who sustained tibial plateau fractures and underwent open reduction internal fixation (ORIF) were included. Patients were excluded if they were under 18 years of age, had insufficient medical record documentation, were managed non-operatively or with closed reduction percutaneous fixation, or did not complete 6-month PROMIS surveys.

PROMIS is a standardized question bank developed by the National Institute of Health to measure patient-reported outcomes (PROs), including physical, mental, and social health across many medical conditions and disease states, including disease and pathology of the musculoskeletal system [10]. PROMIS scores are reported on a T-score metric standardized to the U.S. general population (mean = 50, standard deviation = 10). For physical function (PF), global physical health (GPH), and global mental health (GMH), higher scores indicate better health, whereas for pain interference (PI), anxiety, and depression, higher scores indicate worse symptoms.

The Brief Resilience Scale (BRS) is a validated six-item questionnaire scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) designed to assess an individual’s ability to recover from stress, and percent of normal function is a single-item global assessment in which patients estimate their current level of function as a percentage of their pre-injury status (scaled 0–100%) [18, 19]. PROMIS, percent of normal function, and BRS surveys were administered electronically and sent directly to patients. All surveys utilized in this study are available in the Supplemental Digital Content.

The primary outcomes were 6-month patient-reported outcome scores for PF, PI, GMH, GPH, anxiety, depression, BRS and percent of normal function. Six months was selected as the primary survey timepoint because it yielded the highest response rate and offered a practical reflection of early functional recovery. Follow-up beyond 6 months was limited due to well-documented frequent loss to follow-up among orthopaedic trauma patients [20, 21].

Demographic variables including sex, age, race, and body mass index (BMI) were collected. Comorbidities were also noted, including diabetes mellitus (DM), hypertension (HTN), tobacco use, alcohol use, and American Society of Anesthesiologists (ASA) score. Injury-related variables included laterality, mechanism of injury, open versus closed injury, and Schatzker classification. Additional injury characteristics collected included polytrauma status, presence of an ipsilateral lower extremity injury, and use of an external fixation. Polytrauma was defined as an Injury Severity Score (ISS) greater than 15 [22, 23]. All variables were collected via retrospective review of the electronic medical record.

PROMIS, BRS, and percent of normal scores were compared by sex, age group, injury mechanism (high- vs. low-energy), fracture type (unicondylar vs. bicondylar), Schatzker classification, and use of external fixation. High-energy mechanisms of injury were defined as those including motor vehicle collisions (MVC), motorcycle collisions (MCC), falls from height (FFH), gunshot wounds (GSW), pedestrian-versus-automobile accidents (peds vs. auto), and crush injuries. Low-energy mechanisms were defined as falls from standing (FFS) and other miscellaneous, low-impact injuries.

Statistical analyses

Descriptive statistics were generated to characterize the study population. Categorical variables were presented as numbers and percentages and were compared using chi-square or Fisher’s exact test. Continuous variables were reported with means and standard deviation and were compared using independent t-tests. To further evaluate the relationship between mechanism of injury and patient-reported outcomes, multivariable linear regression models were performed, adjusting for age, sex, and injury burden, measured by ISS. Two-sided p values of ≤ 0.05 were considered statistically significant. All statistical analyses were performed with IBM SPSS (Version 29.0.2.0).

Results

Of 413 patients with tibial plateau fractures treated at this institution during the study period, 106 completed 6-month patient-reported outcome surveys and were included in the analysis. The mean age of this cohort was 50.4 years (range 19–81 years), and the majority (51.9%) were male. Most patients identified as white (70.8%), with a mean BMI of 30.7 kg/m^2^ (range 17.2–54.92 kg/m^2^). Hypertension was documented in 48 patients (45.3%), diabetes mellitus in 21 (19.8%), tobacco use in 31 (29.2%), and alcohol use in 57 (53.8%). Most patients were classified as ASA III (63.2%) (Table 1).Table 1. Demographic and clinical characteristics among 106 patients with tibial plateau fracturesVariablen (%) or mean (SD)Age50.4 (14.4)Sex Male55 (51.9) Female51 (48.1)Follow up (days)261.5 (136.0)Race White75 (70.8) Black26 (24.5) Other5 (4.7)Body mass index (kg/m^2^)30.8 (7.8)Diabetes21 (19.8)Hypertension48 (45.3)Tobacco use31 (29.2)Alcohol use57 (53.8)ASA score 13 (2.8) 231 (29.2) 367 (63.2) 45 (4.7)SD standard deviation, ASA American Society of Anesthesiologists, kg/m^2^ kilograms per meters squared

The most common mechanism of injury in this cohort was motor vehicle collision (41.5%). Open fractures were present in 25.5% of patients. The majority sustained Schatzker type VI fractures (63.2%). Almost half (45.3%) were polytrauma patients, and 66.0% had associated ipsilateral lower extremity injuries. External fixation was used in 52.8% of cases (Table 2).Table 2. Injury characteristics among 106 patients with tibial plateau fracturesVariableCount (%)Laterality Right49 (46.2) Left57 (53.8)Mechanism of injury MVC44 (41.5) MCC12 (11.3) FFS14 (13.2) FFH17 (16.0) GSW3 (2.8) Peds versus auto8 (7.8) Crush injury5 (4.7) Other3 (2.8)Open injury27 (25.5)Polytrauma48 (45.3)Schatzker classification I5 (4.7) II24 (22.6) III5 (4.7) IV5 (4.7) V0 (0) VI67 (63.2)Ipsilateral lower extremity injury70 (66.0)External fixation56 (52.8)MVC motor vehicle collision, MCC motorcycle collision, FFS fall from standing, FFH fall from height, GSW gunshot wound, Peds versus auto pedestrian versus automobile

Six-month patient-reported outcomes stratified by sex, age group, fracture pattern, and external fixation are summarized in Table 3. There were no significant differences in PROMIS scores, percent of normal, or BRS between males and females. Similarly, most survey outcomes did not differ significantly by age group (< 50 vs. ≥ 50 years), although younger patients reported significantly higher PI (62.7 vs. 59.3, p = 0.017) and lower GPH (38.8 vs. 42.4, p = 0.023) (Table 3). Stratification by fracture pattern (unicondylar vs. bicondylar) and external fixation status revealed no statistically significant differences; however, patients treated with external fixation trended toward lower PF scores (35.7 vs. 38.1, p = 0.079) and higher percent of normal function (56.7 vs. 48.0, p = 0.076) (Table 3).Table 3. Six-month patient-reported outcome scores stratified by sex, age, fracture pattern, and external fixation status in patients with tibial plateau fracturesDomainMaleFemalep valueAge < 50Age ≥ 50p valueUnicondylarBicondylarp valueNo ex-fixex-fixp valuePF37.8 (7.6)35.8 (6.2)0.14136.2 (6.8)37.4 (7.2)0.38437.9 (7.6)36.3 (6.7)0.27838.1 (6.8)35.7 (7.1)0.079PI60.9 (6.9)61.0 (7.6)0.92962.7 (7.0)****59.3 (7.0)****0.01760.1 (7.5)61.4 (7.1)0.39559.8 (7.4)61.9 (7.0)0.146GPH40.8 (8.3)40.6 (8.2)0.91338.8 (7.7)****42.4 (8.3)****0.02340.0 (7.5)41.1 (8.6)0.52640.6 (8.1)40.7 (8.4)0.990GMH43.9 (8.0)46.0 (8.7)0.20343.5 (7.5)46.2 (9.0)0.09144.8 (8.7)45.0 (8.3)0.89445.1 (8.9)44.6 (8.0)0.765Depression54.1 (11.9)54.8 (10.4)0.76056.3 (11.3)52.8 (10.8)0.11454.3 (11.0)54.6 (11.3)0.89554.2 (11.3)54.6 (11.1)0.839Anxiety54.3 (11.4)56.7 (10.4)0.29057.0 (11.5)54.2 (10.3)0.22456.8 (10.0)54.8 (11.4)0.38156.8 (10.4)54.1 (11.3)0.234Percent of normal53.6 (22.3)51.4 (26.9)0.66752.6 (24.5)52.6 (24.6)0.99449.9 (21.7)53.9 (25.7)0.44848.0 (24.6)56.7 (23.7)0.076BRS3.5 (0.8)3.5 (0.7)0.8403.5 (0.7)3.4 (0.9)0.7043.55 (0.84)3.46 (0.75)0.5913.43 (0.9)3.54 (0.7)0.494PF physical function, PI pain interference, GPH global physical health, GMH global mental health, BRS brief resilience scale, ex-fix external fixation, Age < 50 less than 50 years of age, ≥ 50 greater than or equal to 50 years of ageBolded values indicate statistical significance (p < 0.05)

When stratified by both sex and age, younger females reported higher PI (64.0 vs. 58.5, p = 0.009), lower GPH (37.5 vs. 43.1, p = 0.011), and lower anxiety (60.2 vs. 64.1, p = 0.046) than females ≥ 50 (Table 4). No statistically significant differences were found in PROMIS scores, percent of normal, or BRS between younger and older males (Table 4).Table 4. Six-month patient-reported outcome scores by age group and sex in tibial plateau fracture patientsDomainFemaleMale< 50 years, mean (SD)≥ 50 years, mean (SD)p value< 50 years, mean (SD)≥ 50 years, mean (SD)p valuePF35.5 (4.8)36.0 (7.2)0.78136.8 (8.2)38.8 (7.1)0.327PI64.0 (5.9)****58.5 (8.1)****0.00961.6 (7.9)60.2 (5.8)0.471GPH37.5 (6.1)****43.1 (8.9)****0.01139.9 (8.8)41.7 (7.9)0.420GMH43.6 (6.7)47.9 (9.8)0.06943.1 (8.2)44.5 (8.0)0.587Depression57.7 (8.1)52.3 (11.6)0.07155.1 (13.5)53.1 (10.1)0.561Anxiety60.2 (9.3)****64.1 (10.6)****0.04654.3 (12.6)54.4 (10.3)0.972Percent of normal53.9 (26.1)49.1 (27.9)0.55751.5 (23.4)55.6 (21.5)0.506BRS3.68 (0.7)3.35 (0.8)0.1253.38 (0.7)3.56 (1.0)0.441PF physical function, PI pain interference, GPH global physical health, GMH global mental health, BRS brief resilience scale

Table 5 presents 6-month outcomes by Schatzker classification. Patients with Schatzker IV fractures reported significantly higher PI (67.7) compared to those with Schatzker I (63.1), II (57.4), III (65.5), and VI (61.1) fractures (p = 0.015) (Table 5). No significant differences were seen in other PROMIS scores, BRS, or percent of normal (Table 5).Table 5. Six-month patient-reported outcome scores by Schatzker classification in patients with tibial plateau fracturesDomainImean (SD)IImean (SD)IIImean (SD)IVmean (SD)VImean (SD)p valuePF34.9 (8.3)39.5 (7.7)37.0 (2.7)34.1 (6.6)36.3 (6.9)0.299PI63.1 (6.9)****57.4 (7.5)****65.5 (2.2)****67.7 (4.0)****61.1 (7.1)****0.015GPH37.3 (6.4)41.9 (7.5)37.4 (5.8)35.3 (6.7)41.2 (8.7)0.336GMH47.4 (4.5)45.8 (9.1)42.6 (7.2)39.8 (8.7)45.0 (8.5)0.577Depression51.7 (16.4)53.8 (10.4)60.1(4.0)58.6 (9.9)54.2 (11.4)0.720Anxiety57.2 (15.9)56.5 (9.5)59.7 (4.9)60.5 (9.7)54.3 (11.4)0.620Percent of normal44.8 (29.9)52.0 (22.5)39.2 (18.1)38.2 (27.6)55.7 (24.6)0.319BRS3.03 (1.1)3.53 (0.8)3.73 (0.4)3.93 (0.7)3.46 (0.7)0.415PF physical function, PI pain interference, GPH global physical health, GMH global mental health, BRS brief resilience scale

When stratified by injury mechanism (Table 6), patients with high-energy injuries demonstrated significantly worse unadjusted GPH (39.4 vs. 43.5, p = 0.016), GMH (43.5 vs. 48.0, p = 0.010), and higher depression scores (55.9 vs. 51.2, p = 0.049). These differences remained statistically significant after adjusting for age, sex, and ISS: adjusted GPH (p = 0.014), GMH (p = 0.011), depression (p = 0.009). Additionally, following adjustment, patients with high-energy injuries demonstrated significantly higher anxiety scores (56.6 vs. 53.3, p = 0.015), lower percent of normal function (52.4 vs. 55.0, p = 0.002), and lower BRS scores (3.48 vs. 3.60, p = 0.004) (Table 6).Table 6. Six-month patient-reported outcome scores by mechanism of injury in patients with tibial plateau fracturesDomainLow energy, Unadj. mean (SD)High energy, Unadj. mean (SD)Unadj. p valueLow energy, Adj. mean* (95% CI)High energy, Adj. mean* (95% CI)Adj. p valuePF37.9 (5.8)36.39 (7.5)0.30836.8 (33.4–40.2)36.4 (34.5–38.3)0.850PI58.9 (6.7)61.88 (7.3)0.05260.6 (57.1–64.2)61.7 (59.7–63.7)0.611GPH43.5 (8.5)****39.4 (7.8)0.01642.5 (38.6–46.3)****40.0 (37.9–42.2)****0.014GMH48.0 (8.8)****43.5 (7.9)0.01046.4 (42.5–50.4)****44.2 (42.0–46.4)****0.011Depression51.2 (11.1)****55.9 (10.9)0.04952.8 (47.3–58.4)****55.5 (52.4–58.6)****0.009Anxiety52.6 (11.1)56.8 (10.6)0.07653.3 (47.9–58.6)****56.6 (53.5–59.7)****0.015Percent of normal50.3 (24.9)53.5 (24.3)0.55955.0 (42.5–67.6)****52.4 (45.8–59.0)****0.002BRS3.42 (0.8)3.52 (0.7)0.567**3.60 (3.2–4.0)**3.48 (3.3–3.7)**0.004PF physical function, PI pain interference, GPH global physical health, GMH global mental health, BRS brief resilience scale, unadj. unadjusted, adj. adjustedAdjusted values derived from multivariable linear regression models adjusting for age, sex, and ISSBolded values indicate statistical significance (p < 0.05)

Discussion

This study evaluated 6-month patient-reported outcomes following surgical fixation of tibial plateau fractures using PROMIS domains, percent of normal, and BRS scores. Younger patients, particularly females under 50, reported worse global physical health and greater pain interference compared to older counterparts. High-energy mechanisms of injury were associated with significantly lower global physical and mental health, and higher depression, even after adjusting for age, sex, and injury severity. These findings suggest that both patient- and injury-specific factors may influence recovery following tibial plateau fractures.

In this cohort, patients under 50 who underwent surgical fixation of tibial plateau fractures demonstrated worse global physical health and higher pain interference scores when compared to patients aged 50 and older. This trend was especially pronounced in younger females, who demonstrated higher PI and lower GPH relative to females aged 50 and older. This contrasts from Keating, who observed poorer functional outcomes in patients over 60 following surgical fixation of tibial plateau fractures [24]. Other studies, however, found no statistically significant differences in outcomes when stratified by age [25–27]. These mixed findings suggest a need for further investigation into the relationship between age and patient-reported outcomes following tibial plateau fractures.

Although external fixation may be used as part of staged management for more severe injuries, use of external fixation in this cohort was not associated with statistically significant differences in 6-month PROMIS domains, percent of normal function, or BRS scores compared with no external fixation management in this cohort.

When examining fracture characteristics, no significant differences in PROMIS scores, BRS, or percent of normal were observed when stratified by unicondylar versus bicondylar injuries. However, patients with Schatzker IV fractures reported significantly higher PI compared to other Schatzker types. Despite Schatzker VI fractures representing the most severe bony injury pattern with bicondylar involvement and metaphyseal-diaphyseal dissociation, these patients did not report the poorest outcomes as might be expected, possibly owing to worse soft tissue or articular injuries associated with Schatzker IV fractures as they are often viewed as knee dislocation equivalents [25, 26, 28–30]. These findings contrast Rademakers et al., who found that surgically treated unicondylar fractures had significantly better functional outcomes compared to bicondylar fractures, with Schatzker type VI fractures having the poorest outcome [26]. Barei et al. also found that severity of tibial plateau injury was significantly related to functional outcomes [29].

To contextualize these findings, the Minimal Clinically Important Difference (MCID) for PROMIS Physical Function after operatively treated tibial plateau fractures, estimated at 3.93 points, was considered [7]. In this cohort, most between-group PF differences were below this threshold (e.g., sex: 2.0 points; age < 50 vs. ≥ 50: − 1.2; unicondylar versus bicondylar: 1.6; external fixation: − 2.4; high- vs. low-energy, adjusted: − 0.4), suggesting limited clinical separation across these groups in physical function at 6 months. Although the absolute difference in PROMIS PF between Schatzker II and IV fractures exceeded the MCID (5.4 points), overall differences in physical function across Schatzker classifications did not reach statistical significance. While MCID values are typically derived for within-patient change, and therefore may not translate perfectly to between-group cross-sectional comparisons, MCID offers a clinically relevant benchmark for interpreting whether observed differences are likely to matter to patients in early recovery [7, 8].

In this cohort, most between-group differences in PROMIS domains were below MCID thresholds at 6 months. Prior PROMIS literature examining chronic medical conditions has demonstrated larger deviation from baseline PROMIS scores than those observed across orthopaedic injury subgroups in the present study [31–34], providing context for the effect sizes observed in this study.

In this study, patients sustaining high-energy injuries demonstrated significantly poorer global physical and mental health scores and higher depression scores compared to those with low-energy mechanisms. These differences remained statistically significant after adjustment for age, sex, and ISS. Furthermore, adjusted analyses revealed that patients sustaining high-energy mechanisms of injury demonstrated higher anxiety scores, lower percent of normal function, and lower BRS scores. Prior studies have demonstrated that high-energy mechanisms are associated with worse functional outcomes and increased complication rates across different fracture types compared to that of low-energy mechanisms [25, 35–37]. Additionally, the high prevalence of mental health conditions, including depression, anxiety, and post-traumatic stress symptoms in orthopedic trauma patients has been previously reported [38–42]. Together, these findings suggest that recovery following tibial plateau fractures is highly complex and encompasses both physical and psychological components.

Limitations

This study has limitations that should be considered when interpreting these findings, including those inherent to its retrospective design. This study was conducted at a single institution, which may limit generalizability to other settings with different patient populations, clinical protocols, or tibial plateau management practices. While statistically significant differences in PROMIS scores, percent of normal, and BRS were observed, the clinical relevance of these findings is less clear. This is due, in part, to the limited availability of established MCID thresholds for specific PROMIS domains, particularly within orthopaedic trauma populations. Furthermore, surveys were administered electronically, and only 6-month scores were evaluated in this study, which may not fully capture the longitudinal trajectory of functional recovery or outcomes. Because this analysis relied on complete survey data, patients who did not complete PROMIS assessments were excluded, which may limit the generalizability of our findings and could have influenced the observed results in this study.

Conclusion

Patient-reported recovery following tibial plateau fractures varied across patient- and injury-specific characteristics. Younger patients, particularly females under 50, demonstrated greater pain interference and lower global physical health, while high-energy mechanisms of injury were independently associated with worse physical and psychological outcomes across multiple domains, even after adjustment for age, sex, and injury severity. These findings support an approach to postoperative care that addresses both functional recovery and mental well-being.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1