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A retrospective study of 128 patients with fractures of the tibial plateau treated at the Johns Hopkins Medical Institutions over a 20-year period was undertaken to compare the results of operative treatment with the results of the nonoperative treatment. Outcome was evaluated with respect to healing, length of hospital stay, time to weight bearing and full activity, and functional result. The fractures were grouped into the four types of the Association for the Study of the Problems of Internal Fixation (AO/ASIF) system, with nondisplaced fractures considered separately. Overall, patients with displaced fractures treated operatively had a shorter average hospital stay (22 days vs 26 days), a higher percentage of satisfactory functional results (78% vs 63%), and a shorter period of immobilization (5 weeks vs 10 weeks), but took longer to return to prefracture activity level (23 weeks vs 18 weeks). The patients treated operatively had more complications with regard to infections (9 vs 2), fewer complications with regard to thromboembolism (2 vs 13), and approximately equal numbers of nonunion or malunion. Our study supports operative therapy for patients with displaced Type III or Type IV fractures and closed treatment for patients with Type I, Type II, and nondisplaced fractures.