Purpose: The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated. Methods: A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles’ reference lists and the ePublication lists of leading orthopedic and trauma journals. Results: A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found. Conclusion: At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.

The femoral neck fracture is one of the most common fractures in the elderly. A variety of methods and approaches are used to treat it. Total hip arthroplasty is a preferred approach in independent, mobile, elderly patients, given its more favorable long-term outcome. Our hypothesis is that the direct anterior approach in geriatric trauma patients has a lower dislocation-rate with the advantage of early recovery due to a muscle sparing approach and therefore early possible full weight-bearing. Patients were retrospectively sought who suffered a femoral neck fracture from 2008 to 2013. All patients were treated through a direct anterior approach and using the same brand of implants. Medical history, standardized physical exam, conventional pelvic plain and axial hip x-rays, Harris Hip Score, Merle D'Aubigné and Postel and SF-36 were assessed. Eighty-six patients were included in the study with a mean age of seventy-five years. The mortality rate was 16.7 %. Complications were encountered in nineteen patients (22.0 %) who needed operative revision and one postoperative complication (1.2 %) which could be handled conservatively. There were five intraoperative complications (5.8 %), two dislocations (2.3 %), one aseptic loosening in a non-cemented stem (1.2 %), six periprosthetic fractures in non-cemented stems (6.9 %), one displacement of a non-cemented cup (1.2 %), two early infections (2.3 %) and three hematomas (3.5 %) recorded. Although the direct anterior approach is associated with a rather long learning curve we have found it to preserve the soft-tissues with no injury to abductors. It therefore shows an early advantage in elderly patients in terms of early recovery and therefore early possible full weight-bearing. Fracture treatment with dual mobility cups might lead to lower dislocation rates, but are associated with higher costs. Due to higher complication rates in non-cemented versus cemented shafts, we have changed our practice towards favoring cemented femoral stems in patients with suspected or manifest osteoporosis.

(1) The malposition of the femoral tunnel in medial patellofemoral ligament (MPFL) reconstruction can lead to length changes in the MPFL graft, and an increase in medial peak pressure in the patellofemoral joint. It is the cause of 36% of all MPFL revisions. According to Schöttle et al., the creation of the drill canal should be performed in a strictly lateral radiograph. In this study, it was hypothesized that positioning the image receptor to the knee during intraoperative fluoroscopy would lead to a relevant mispositioning of the femoral tunnel, despite an always adjusted true-lateral view. (2) A total of 10 distal femurs were created from 10 knee CT scans using a 3D printer. First, true-lateral fluoroscopies were taken from lateral to medial at a 25 cm (LM25) distance from the image receptor, then from medial to lateral at a 5 cm (ML5) distance. Using the method from Schöttle, the femoral origin of the MPFL was determined when the femur was positioned distally, proximally, superiorly, and inferiorly to the image receptor. (3) The comparison of the selected MPFL insertion points according to Schöttle et al. revealed that the initial determination of the point in the ML5 view resulted in a distal and posterior shift of the point by 5.3 mm ± 1.2 mm when the point was checked in the LM25 view. In the opposite case, when the MPFL insertion was initially determined in the LM25 view and then redetermined in the ML5 view, there was a shift of 4.8 mm ± 2.2 mm anteriorly and proximally. The further positioning of the femur (distal, proximal, superior, and inferior) showed no relevant influence. (4) For fluoroscopic identification of the femoral MPFL, according to Schöttle et al., attention should be paid to the position of the fluoroscopy in addition to a true-lateral view.

Purpose: This study's main objective is to assess the feasibility of processing the MRI information with identified ACL‐footprints into 2D‐images similar to a conventional anteroposterior and lateral X‐Ray image of the knee. The secondary aim is to conduct specific measurements to assess the reliability and reproducibility. This study is a proof of concept of this technique.Methods: Five anonymised MRIs of a right knee were analysed. A orthopaedic knee surgeon performed the footprints identification. An ad‐hoc software allowed a volumetric 3D image projection on a 2D anteroposterior and lateral view. The previously defined anatomical femoral and tibial footprints were precisely identified on these views. Several parameters were measured (e.g. coronal and sagittal ratio of tibial footprint, sagittal ratio of femoral footprint, femoral intercondylar notch roof angle, proximal tibial slope and others). The intraclass correlation coefficient (ICCs), including 95% confidence intervals (CIs), has been calculated to assess intraobserver reproducibility and interobserver reliability.Results: Five MRI scans of a right knee have been assessed (three females, two males, mean age of 30.8 years old). Five 2D‐”CLASS” have been created. The measured parameters showed a “substantial” to “almost perfect” reproducibility and an “almost perfect” reliability.Conclusion: This study confirmed the possibility of generating “CLASS” with the localised centroid of the femoral and tibial ACL footprints from a 3D volumetric model. “CLASS” also showed that these footprints were easily identified on standard anteroposterior and lateral X‐Ray views of the same patient, thus allowing an individual identification of the anatomical femoral and tibial ACL's footprints.Level of evidence: Level IV diagnostic study

Background: Medial patellofemoral ligament (MPFL) reconstruction is a common treatment for patellar instability. Yet nearly 40% of revisions result from femoral tunnel misplacement. One reason may be the positioning of the C-arm relative to the knee. Purpose: To assess how the C-arm’s position affects femoral MPFL placement when the image receptor is positioned either contralateral or ipsilateral to the operated knee. Study Design: Controlled laboratory study. Methods: Ten human cadaveric knee specimens were dissected, and the femoral MPFL insertion site was identified and marked using a 10-mm eyelet. According to the possible clinical scenarios, true lateral radiographs in 2 different C-arm positions were taken. In the first scenario, the image receptor was on the ipsilateral side, being 5 cm away from the knee with the x-ray beam directed from medial to lateral (ML5). In the second scenario, the image receptor was on the contralateral side, being 25 cm away from the knee with the x-ray beam directed from lateral to medial (LM25). In each radiograph, the eyelet position was recorded and the distance (proximal-distal and anterior-posterior) from the optimal radiographic insertion point according to the literature was determined. Differences between the groups were calculated using the Wilcoxon signed-rank test, and a P value of <.05 was considered significant. Results: The anatomic femoral MPFL insertion in the ML5-position was located a mean of 2.7 ± 2.4 mm proximal and 4.5 ± 5.5 mm anterior to the Schöttle point. This resulted in an absolute distance of 7.2 ± 3.0 mm. In the LM25-position, it was located a mean of –0.7 ± 1.8 mm distal and 3.0 ± 5.3 mm anterior, which resulted in an absolute distance of 5.4 ± 3.2 mm. The ML5 was located more anterior (1.5 ± 2.1 mm) and proximal (3.4 ± 2.4 mm) compared with the LM25 position. Measurements following methods described in the literature significantly differed in both axes in the LM25 view when compared with the ML5 view measurements ( P = .005). Conclusion: Compared with the ipsilateral C-arm position (ML5), the contralateral C-arm position (LM25) showed a smaller range with a lower standard deviation in identifying the femoral MPFL approach across all measurement methods. Clinical Relevance: When applying the method according to Schöttle et al to locate the femoral MPFL insertion point, it should be noted that in the proximal-distal orientation, the femoral MPFL insertion point is situated proximal to the Blumensaat line in the contralateral view (LM25). In contrast, when using the ipsilateral view (ML5), the femoral MPFL footprint is positioned just distal to the proximal edge of the medial condyle.