Evidence-Based Preoperative Imaging and Outcomes After Open Reduction and Internal Fixation of Tibial Plateau Fractures

Purpose: Advanced imaging is commonly used in the evaluation of tibial plateau fractures (TPF), yet its association with postoperative outcomes and healthcare utilization remains unclear. We hypothesized that preoperative imaging strategy—radiographs alone, radiographs plus CT, or radiographs plus MRI—would be associated with differences in postoperative complications and resource use following open reduction and internal fixation (ORIF).

Methods/Materials: A retrospective cohort study was performed using the PearlDiver national administrative database (2010–2022) to identify adults undergoing ORIF of TPF. Patients were grouped by preoperative imaging strategy: radiographs only, radiographs plus CT, or radiographs plus MRI. Matched cohorts (1:1:1; n = 751 per group) were created controlling for age, sex, Charlson Comorbidity Index, obesity, tobacco use, and fracture diagnosis code.

The primary outcome was a composite 90-day postoperative complication, including surgical site infection, wound disruption, deep vein thrombosis, pulmonary embolism, acute kidney injury, or pneumonia. Secondary outcomes included ED admission within 90 days, total healthcare costs within 90 days, revision ORIF at 1 year, and conversion to total knee arthroplasty (TKA) at 2 years.

Results: 90-day composite complication rates did not significantly differ among imaging strategies. Wound disruption occurred more frequently in the radiograph-only cohort compared with the CT and MRI cohorts (2.66%, 1.46%, 1.07%; p = 0.047). ED visits within 90 days were also more common in the radiograph-only group (p = 0.038). Revision ORIF and TKA conversion trended higher in the radiograph-only cohort. Median 90-day costs were highest in the radiograph plus CT cohort.

Conclusions: Preoperative imaging strategy was associated with differences in wound disruption, ED admissions, and healthcare costs following ORIF of TPF. Higher adverse event rates in the radiograph-only cohort may reflect unrecognized fracture complexity or soft-tissue injury. Selective use of advanced imaging may improve risk stratification and preoperative planning while supporting evidence-based imaging practices in MSK radiology.