The surgical management of tibial plateau fractures can be technically demanding. In younger patients, the mainstay is fixation with cartilage preservation. In older patients with osteoporotic bone, this method has higher rates of fixation failure; in addition, it requires prolonged bed rest or protected weight bearing, which are major challenges in this group. In contrast, total knee arthroplasty performed acutely for primary treatment of tibial plateau fractures has potential advantages for elderly patients, such as immediate stability, early mobilization, and positive functional outcomes with decreased rates of reoperation. Additionally, arthroplasty can be technically challenging in younger patients with previous tibial plateau fractures in whom debilitating posttraumatic arthritis develops. In these patients, old wounds, retained metalwork, bony deficiency, and instability can lead to poorer outcomes and higher complication rates than in routine knee arthroplasty. In both cases, we recommend surgery be performed by experienced arthroplasty surgeons with ample access to a range of implants with varying constraints and the option of stems and augments.