Should We Worry About the Inter-Implant Gap in the Tibia? A Finite Element Analysis of Revision TKA and Distal Plating

Background and Objectives: The management of periprosthetic tibial fractures distal to revision Total Knee Arthroplasty (TKA) presents a biomechanical challenge, often requiring extramedullary locking plates when long stems preclude nailing. While in femoral fractures the gap between the stem and plate is a well-documented stress riser, requiring implant overlap to prevent an inter-implant fracture, this specific biomechanical scenario has not been studied in the tibia, and it remains unclear if the femoral dogma of mandatory overlap applies to the straight, centrically loaded tibial anatomy. This study utilized Finite Element Analysis (FEA) to evaluate stress distribution in the tibial inter-implant gap. Materials and Methods: A comparative FEA was performed using a validated standardized tibia model simulating a healed distal fracture. Two cemented revision TKA constructs (50 mm and 80 mm stems) were modeled. These were paired with medial locking plates of varying lengths (10, 12, and 14 holes) to create different inter-implant distances. Eight distinct configurations, including non-plated controls, were subjected to physiological axial compression and three-point bending. Outcome measures included von Mises stress and total displacement. Results: The analysis revealed no significant stress concentration in the bone within the inter-implant zone across all plated models, regardless of the gap size. Instead, the addition of plates universally reduced bone stress compared to controls, effectively transferring load to the fixation hardware. Peak stresses were consistently observed in the proximal locking screws rather than the bone gap. The longest plates (14 holes) offered superior construct rigidity and stress distribution. Conclusions: Under the conditions evaluated in this preclinical finite element model, the tibia does not exhibit a biomechanical requirement for implant overlap to prevent stress risers. Our findings suggest that extramedullary fixation with the longest available anatomical locking plate represents a biomechanically plausible strategy for these fractures, even if an inter-implant gap remains.