Intraoperative Tibial Periprosthetic Fractures During Total Knee Arthroplasty: Incidence, Risk Factors, and Early Outcomes

Abstract Intraoperative tibial periprosthetic fractures during total knee arthroplasty (TKA) are uncommon, but clinically relevant complications with distinct mechanisms compared with postoperative fractures. This review summarizes the incidence, intraoperative risk factors and mechanisms, recognition, and early outcomes to provide a practical, procedure-based framework. In primary TKA, intraoperative tibial fractures occur in approximately 0.1 to 0.5% of cases, with higher rates reported in keeled tibial components and revision procedures, where incidence may approach 1.5%. These fractures occur at predictable high-force steps, most commonly during keel preparation and final component impaction, with 90 to 100% occurring at these stages across multiple series. The medial tibial plateau is particularly susceptible, and excessive insertion forces, implant size and geometry, and depth of tibial resection contribute to fracture risk. Recognition relies on intraoperative awareness of timing, tactile feedback, and subtle visual and mechanical cues. Audible cracking, sudden loss of resistance, abnormal component seating, and unexpected instability should prompt suspicion. Some fractures remain occult and are identified only on postoperative imaging, emphasizing the importance of vigilance during high-risk steps. Early outcomes are generally favorable when fractures are recognized and addressed at the time of surgery, with high rates of union and implant survivorship. Large series report survivorship free from tibial component revision exceeding 95% at up to a mean 6-year follow-up, although outcomes vary by fracture pattern. Intraoperative tibial periprosthetic fractures are predictable, mechanically driven complications that occur during specific steps of TKA. Understanding their timing, mechanisms, and presentation is essential to improve recognition and optimize outcomes.