• Results of open reduction and internal fixation for complex articular fractures around the knee are poor, particularly in elderly osteoporotic patients.

• Open reduction and internal fixation may lead to an extended hospital stay and non-weight-bearing period.

• This may lead to occurrence of complications related to decubitus such as thrombo-embolic events, pneumonia and disorientation.

• Primary arthroplasty can be a valuable option in a case-based and patient-specific approach. It may reduce the number of procedures and allow early full weight-bearing, avoiding the above-mentioned complications.

• There are four main indications:

  • 1) Elderly (osteoporotic) patients with pre-existing (symptomatic) end-stage osteoarthritis.

  • 2) Elderly (osteoporotic) patients with severe articular and metaphyseal destruction.

  • 3) Pathological fractures of the distal femur and/or tibia.

  • 4) Young patients with complete destruction of the distal femur and/or tibia.

• The principles of knee (revision) arthroplasty should be applied; choice of implant and level of constraint should be considered depending on the type of fracture and involvement of stabilizing ligaments. The aim of treatment is to obtain a stable and functional joint.

• Long-term data remain scarce in the literature due to limited indications.

Cite this article: EFORT Open Rev 2020;5:713-723. DOI: 10.1302/2058-5241.5.190059