After elevation of a depressed tibial plateau fragment, a filler may be used when a residual support deficit remains beneath the reduced subchondral surface. Filler use is selective and remains part of the fixation construct rather than a replacement for it. The literature is much clearer on structural support than on any biological advantage in fracture healing. Across the comparative studies, reported between-group differences are concentrated in maintenance of reduction rather than in healing (Russell and Leighton, 2008; Hofmann et al., 2020; Cooper et al., 2022).
Summary
Comparative clinical evidence comes from a small number of substitute types, not for bone substitutes as a single group.
The clearest differences between groups concern maintenance of reduction, with some materials showing less subsidence or recurrent depression.
The most reported outcome is maintenance of the reduced articular surface, usually expressed as postoperative depression or subsidence.
Healing outcomes are usually similar to autograft where direct comparisons exist.
Direct comparisons between substitutes are scarce, while defect remodelling and long-term joint outcomes remain poorly characterised.
Calcium phosphate cement is the most extensively studied material in the published comparative tibial plateau literature. That describes the size of the published evidence base, not demonstrated superiority over other materials.
Why this matters
After elevation of a depressed tibial plateau fragment, the remaining metaphyseal void raises an immediate issue of structural support: how well will the reduced joint surface hold over time. Maintenance of reduction and fracture healing are related, but they are different endpoints. A filler may preserve the reduction without proving faster or better healing, and that distinction runs through the tibial plateau literature (Russell and Leighton, 2008; Hofmann et al., 2020).
The comparison with iliac crest autograft also involves donor-site morbidity. In a classic orthopaedic donor-site series, major complications occurred in 8.6% and minor complications in 20.6% of graft procedures (Younger and Chapman, 1989). Persistent donor-site pain also remained part of the background comparison in later synthesis work, so similar radiographic or healing outcomes do not by themselves indicate equivalent overall treatment burden (Cooper et al., 2022).
What the evidence shows
Comparative clinical evidence is limited to a small number of substitute types and fracture patterns. These studies include interporous hydroxyapatite, calcium phosphate cement, bioactive glass, porous titanium granules, biphasic hydroxyapatite/calcium sulfate cement, and a newer biologically active graft substitute. A topic-specific review identified studies of hydroxyapatite, calcium phosphate, calcium sulfate, bioactive glass, tricalcium phosphate, allograft, xenograft, and demineralised bone matrix, but the amount and quality of evidence varied considerably between these groups (Goff et al., 2013).
The comparative dataset remains small. One pooled analysis of randomised controlled trials identified six studies involving 353 fractures, with five studies and 338 fractures available for meta-analysis (Cooper et al., 2022). A later pooled analysis included seven randomised trials with 424 patients (Alshahrani et al., 2025). Much of the comparative evidence comes from depression and split-depression patterns rather than from the full spectrum of tibial plateau fracture morphologies (Hofmann et al., 2020; Jónsson and Mjöberg, 2015; Heikkilä et al., 2011).
The reported outcomes fall mainly into four domains: structural outcomes such as postoperative depression or subsidence; biological outcomes such as union and defect remodelling; clinical outcomes such as pain and function; and procedural or safety outcomes such as blood loss, operating time, complications, and donor-site morbidity (Cooper et al., 2022; Alshahrani et al., 2025).
Most comparative studies use iliac crest autograft as the comparator material. Direct comparisons between substitute products are very limited and do not support ranking across material families (Cooper et al., 2022; McNamara et al., 2015; Hanke et al., 2017).
The studies do not assess structural, biological, and long-term outcomes consistently. Outcome definitions vary, CT-based assessment of defect remodelling is uncommon, and long-term joint outcomes are reported using different endpoints and follow-up intervals (Hofmann et al., 2020; Heikkilä et al., 2011; Pernaa et al., 2011). The evidence is therefore stronger for maintenance of reduction and avoidance of graft harvest than for comparisons between substitutes or biological effects on healing.
What the evidence does not show
A Cochrane review judged the available evidence to be low in quality and noted that quality of life, pain, and return to pre-injury activity were generally not reported in the bone-substitute trials it reviewed (McNamara et al., 2015). Direct comparisons between substitute products remain very limited, CT-based assessment of remodelling is not performed systematically, and longer-term joint outcome remains poorly characterised across the published comparative studies (Hanke et al., 2017).
Calcium phosphate cement is the most extensively studied material in the comparative tibial plateau literature
Calcium phosphate cement is the most extensively studied material in the published comparative tibial plateau literature. Across the tested products and constructs, its most consistent reported advantage concerns maintenance of reduction rather than superior fracture healing (Russell and Leighton, 2008; Cooper et al., 2022).
A prospective randomised multicentre trial enrolled 120 acute closed unstable tibial plateau fractures in 119 adults and randomised them 2:1 to calcium phosphate cement or autologous iliac crest graft. Union rate and time to union were similar, but the autograft group had a significantly higher rate of articular subsidence during follow-up (Russell and Leighton, 2008).
A review of a smaller randomised radiostereometric study also reported greater articular stability and less subsidence until healing with calcium phosphate cement. The difference was attributed to immediate mechanical support beneath the reduced surface rather than to a biological effect on fracture healing (Larsson, 2010; Russell and Leighton, 2008).
Other clinical and experimental studies also reported better maintenance of reduction or greater mechanical support with calcium phosphate cement. A matched comparative series reported lower residual plateau depression at one year and shorter operative time with injectable calcium phosphate cement, while early prospective series reported generally good functional results but did not eliminate loss of reduction or complications (Simpson and Keating, 2004; Lobenhoffer et al., 2002; Horstmann et al., 2003). Biomechanical and preclinical studies help explain the structural signal by showing greater stiffness, better fatigue resistance, and less displacement or subsidence than cancellous graft, but those studies remain secondary to the clinical comparative data (Welch et al., 2003; McDonald et al., 2011; Trenholm et al., 2005).
Other materials have more limited evidence
Comparative studies have also evaluated porous titanium granules, biphasic hydroxyapatite/calcium sulfate cement, bioactive glass, interporous hydroxyapatite, and a biologically active parathyroid hormone-based graft substitute. Additional single-group studies report outcomes for several other materials. The evidence remains sparse and product-specific, and does not support direct ranking between material families (Bucholz et al., 1989; Heikkilä et al., 2011; Jónsson and Mjöberg, 2015; Hofmann et al., 2020; Kanakaris et al., 2026).
Healing outcomes are reported, but comparative studies do not show a consistent healing advantage of fillers over autograft
Healing-related outcomes were reported in several comparative studies, but structural and procedural outcomes showed larger reported differences between groups than healing outcomes did. Across calcium phosphate cement, biphasic hydroxyapatite/calcium sulfate cement, and bioactive glass, reported differences are more readily seen in subsidence, blood loss, or early postoperative burden than in union, time to union, or radiographic healing relative to autograft. Differences between groups were therefore more apparent in subsidence, blood loss, and early postoperative burden than in union or radiographic healing (Russell and Leighton, 2008; Hofmann et al., 2020; Heikkilä et al., 2011).
These comparisons are also limited by how healing and defect remodelling were measured.In the biphasic hydroxyapatite/calcium sulfate trial, bone healing was assessed on radiographs, postoperative CT was not obtained, and conventional radiographs were acknowledged to be imprecise for articular subsidence and defect remodelling. Even one of the best-designed studies in the field therefore leaves uncertainty about how filler behaviour, remodelling, and later function relate to one another (Hofmann et al., 2020).
Meta-analyses describe the overall evidence but not individual material performance
Meta-analyses combine a small number of heterogeneous studies, which limits their value for judging individual materials. The Cochrane review characterised the evidence on bone substitutes in tibial plateau fractures as limited and very low in quality (McNamara et al., 2015). Later meta-analyses reported lower blood loss and, in some analyses, shorter operating time, without a convincing pooled difference in longer-term clinical outcomes (Cooper et al., 2022; Alshahrani et al., 2025). These pooled findings describe overall patterns across the literature, but they do not show that calcium phosphate cement, porous titanium granules, bioactive glass, interporous hydroxyapatite, biphasic hydroxyapatite/calcium sulfate cement, and less-studied materials perform similarly.
Practical implications for clinical interpretation
Structural support and fracture healing should be interpreted as separate endpoints. The comparative signal appears more clearly in subsidence or recurrent depression than in healing (Russell and Leighton, 2008; Hofmann et al., 2020).
This literature does not support direct ranking between substitute materials. Most comparative studies compare substitutes with autograft, while the few direct product comparisons are too narrow to establish a ranking across material families (Cooper et al., 2022; McNamara et al., 2015; Hanke et al., 2017).
Calcium phosphate cement is the most extensively studied material in the published comparative tibial plateau literature. That describes the size of the published evidence base, not demonstrated superiority over other materials (Russell and Leighton, 2008; Cooper et al., 2022).
Autograft comparison includes donor-site burden, so similar radiographic outcomes do not by themselves indicate equivalent overall treatment burden (Younger and Chapman, 1989; Cooper et al., 2022).
Meta-analyses summarise a small and heterogeneous group of substitute-versus-autograft studies. They include little or no evidence for many materials, so material-specific conclusions still depend on the individual trials (Cooper et al., 2022; Alshahrani et al., 2025).
Closing note
Comparative studies in tibial plateau fractures provide more reliable evidence on maintenance of reduction than on biological healing. Some materials reduced subsidence in specific studies, but evidence for superior healing, defect remodelling, and long-term joint outcomes remains limited and inconsistent.
Briefing: bone void fillers in tibial plateau fractures
An overview of the clinical context and published evidence on bone void fillers in tibial plateau fractures.
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