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Abstract Purpose Meniscal injuries are common in the young and active population. There is increasing utilization of surgical interventions like meniscal allograft transplantation (MAT) to restore the protective function of menisci following injury leading to meniscal deficiency. Extensive research and publications exist on the management of meniscal injury and the sequalae of meniscal deficiency. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. This study aims to fill this gap by providing a current examination of the literature on MAT. Methods A comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta‐analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of the included studies was assessed using the AMSTAR‐2 tool. Results A total of 41 studies were included in the review, with most published within the last decade. The majority of studies (56.1%) received a ‘Critically Low’ confidence rating, 26.8% were rated as ‘Low’, and only 14.6% were rated as ‘High’ confidence. From the included studies, 51.2% reported on PROMs, with the Lysholm score being the most common. Transplant failure and reoperation rate were reported in 34.1% and 19.5% of studies respectively. Studies on MAT reported favourable short‐term outcomes in terms of patient‐reported outcome measures (PROMs) but were limited by the lack of randomized control trials and consistent comparison groups. Conclusions This umbrella review highlights an increase in interest in MAT but underscores the need for higher‐quality reviews with standardized reporting and rigorous methodologies. Future research should focus on long‐term outcomes, optimal surgical techniques, patient selection criteria and risk factors for transplant failure. There is also a need for more studies focusing on MAT in pediatric populations. Overall, this review provides a comprehensive assessment of the current state of research in MAT and identifies areas for improvement in future studies. Level of Evidence Level IV.

Purpose: To report objective measures utilized to assess readiness to return to sport after shoulder instability procedures. Methods: Our systematic review included studies if they assessed active individuals after a shoulder instability procedure with at least 1 patient-reported outcome or physical performance measure. We excluded studies of atraumatic instability, studies only reporting imaging, or studies of biomechanics. Risk of bias was assessed with the Methodological Items for Non-Randomized Studies tool, and studies were further scored with the Return to Sport Value Assessment. Results: Thirty-seven articles selected for inclusion scored a median of 18.5 (comparative) and 10.0 (noncomparative) on the Methodological Items for Non-Randomized Studies and a mean of 2.5 on the Return to Sport Value Assessment. Twelve patient-reported outcomes were utilized across 19 studies to assess pain, function, and psychological readiness, with the Western Ontario Shoulder Index and the Shoulder Instability Return to Sport Index reported most frequently. Eighteen studies reported strength, most commonly internal and external rotation, and 18 studies reported range of motion. Physical performance tests, 6 discrete tests and 1 composite score, were less frequently reported (8 studies), with the Closed Kinetic Chain Upper Extremity Stability Test, Y-Balance Test of the Upper Quarter, and Unilateral Seated Shot-Put Test reported in more than 1 study. Deficits in patient-reported outcomes and limb symmetry persisted at the time of return to sport. Conclusions: Most patients undergoing shoulder stabilization procedures regained fundamental strength and range of motion. However, some studies noted difficulties in achieving sufficient performance metrics for athletic activities 6 months postsurgery. Due to lack of standardized measures, recommendations for specific test components and benchmark data for clinical decision-making are not available. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Introduction: Articular cartilage injuries of the knee are a complex and challenging clinical pathology. Objectives: The purpose of this study was to establish consensus statements via a Delphi process on rehabilitation and return to play (RTP) following knee cartilage injuries. Methods: A consensus process on knee cartilage injuries utilizing a modified Delphi technique was conducted. Seventy-nine surgeons across 17 countries participated in these consensus statements. Eleven questions were generated on rehabilitation and RTP, with 3 rounds of questionnaires and final voting occurring. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was defined as 100% agreement with a proposed statement. Results: Of the 11 total questions and consensus statements on rehabilitation and RTP developed from 3 rounds of voting, 0 achieved unanimous consensus, 2 achieved strong consensus, 4 achieved consensus, and 5 did not achieve consensus. Conclusions: The statements achieving consensus were related to the benefits of early motion and that concomitant procedures may alter the rehabilitation process. RTP following cartilage-related procedures typically follows a rehabilitation guideline largely dependent on the type of cartilage procedure. The statements that did not reach a consensus were related to specific timing to meet goals.

Abstract Purpose Meniscal injuries are common in knee surgery and often require preservation techniques to prevent secondary osteoarthritis. Despite advancements in repair techniques, some patients undergo partial meniscectomy, which can lead to postmeniscectomy syndrome. To address these challenges, meniscal substitution techniques like scaffolds have been developed. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. Methods A comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta‐analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of included studies was assessed using the AMSTAR‐2 tool. Results A total of 17 studies met the inclusion criteria and were included in the review. Most studies focused on the use of collagen‐based scaffolds, with fewer studies evaluating synthetic scaffolds. The majority of studies (52.9%) were rated as having ‘Critically Low’ overall confidence, with only one study (5.9%) rated as ‘High’ confidence and most studies exhibiting methodological limitations, such as small sample sizes and lack of long‐term follow‐up. Despite these limitations, the majority of studies reported positive short‐term outcomes, including pain relief and functional improvement, following scaffold implantation. However, some studies noted a relatively high failure rate. Radiographically, outcomes also varied, with some studies reporting morphological deterioration of the implant seen on MRI, while others noted possible chondroprotective effects. Conclusions Meniscal scaffold‐based approaches show promise in the management of meniscal deficiency; however, the current evidence is limited by methodological shortcomings. One notable gap in the literature is the lack of clear guidelines for patient selection and surgical technique. Future research should focus on conducting well‐designed randomized controlled trials with long‐term follow‐up to further elucidate the benefits and indications of these techniques in clinical practice. Additionally, efforts should be made to develop consensus guidelines to standardize the use of meniscal scaffolds and improve patient outcomes. Despite limited availability, synthesizing the literature on meniscal scaffold‐based approaches is crucial for understanding research, guiding clinical decisions and informing future directions. Level of Evidence Level IV.

Background: Anterior cruciate ligament (ACL) repair has historically had poor outcomes and fell out of favor in the 1980s with the majority of surgeons opting to do an ACL reconstruction instead due to the high failure rate. The Bridge-Enhanced ACL Restoration or BEAR technique utilizes a de-cellularized, bovine-derived, type I collagen implant to aid in the ACL repair. The device is implanted to augment the healing of the ACL. Indications: The BEAR technique is indicated to augment ACL repair in cases of complete rupture where there is a residual tibial stump of sufficient length and good tissue quality. Results: In our experience to date, patients undergoing an ACL repair with BEAR recover range of motion quickly and have less quadriceps atrophy and less postoperative swelling than those undergoing ACL reconstruction requiring autograft harvest. We will continue to follow up our patient cohort to assess for re-rupture rate as they return to sport. Conclusion: The BEAR technique is a promising development that enables ACL repair as an alternative option to reconstruction. This article describes our approach including tips and tricks to successfully perform this procedure. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking’s impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking’s effect on meniscus treatment is mixed, necessitating further investigation.

Background: Jones fracture, or proximal fifth metatarsal fracture, is a common injury in National Football League (NFL)-caliber athletes. Combine draft performance can greatly impact the long-term success of these athletes, and substantial emphasis has been placed on early return to play (RTP) and the minimization of post-operative complications after Jones fracture in these athletes. To date, no study has specifically described the treatment and outcomes of this injury specifically in NFL-caliber players, considering factors relevant to this unique population. Thus, the purpose of this review is to delve into Jones fracture in NFL-caliber athletes, evaluating the diagnostic, treatment, and RTP considerations. Methods: We searched Medline (PubMed), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCOhost) for the concept of Jones fractures in the NFL. Using the PRISMA guidelines, a team of three reviewers conducted abstract screenings, full-text screenings, and the extraction of studies describing Jones fractures specifically in the NFL. Results: Of the 1911 studies identified, 6 primary retrospective studies met the inclusion and exclusion criteria. The heterogeneity of the outcome reporting precluded a meta-analysis; thus, a qualitative review of manuscripts describing Jones fracture was carried out. Classification, diagnosis, and treatment considerations, RTP statistics and outcomes, and complications were discussed. Amongst the primary studies, there were 285 Jones fractures, all athletes were able to RTP, and the average time to RTP ranged from 6 weeks to 27 weeks. For complications, with operative treatment, the refracture rate ranged from 4 to 12%, and incomplete healing ranged from 7 to 50%. RTP was 15 weeks for refractures. There were no patient-reported outcomes. Conclusions: The vast majority of Zone 2/3 Jones fractures are treated with IM screw fixation with or without adjunctive orthobiologics, such as bone marrow aspirate concentrate, in NFL-caliber athletes. The six major series investigating outcomes after the operative treatment of Jones fractures in NFL players reveal very positive findings overall with regard to RTP, reoperation, and career continuation.

Abstract Background After anterior cruciate ligament (ACL) reconstruction, patient-reported outcomes are improved 10 years post-surgery; however, cytokine concentrations remain elevated years after surgery with over 80% of those with combined ACL and meniscus injuries having posttraumatic osteoarthritis (PTOA) within 10–15 years. The purpose of this multicenter, randomized, placebo-controlled trial is to assess whether a 6-month course of oral montelukast after ACL reconstruction reduces systemic markers of inflammation and biochemical and imaging biomarkers of cartilage degradation. Methods We will enroll 30 individuals undergoing primary ACL reconstruction to participate in this IRB-approved multicenter clinical trial. This trial will target those at greatest risk of a more rapid PTOA onset (age range 25–50 with concomitant meniscus injury). Patients will be randomly assigned to a group instructed to take 10 mg of montelukast daily for 6 months following ACL reconstruction or placebo. Patients will be assessed prior to surgery and 1, 6, and 12 months following surgery. To determine if montelukast alters systemic inflammation following surgery, we will compare systemic concentrations of prostaglandin E2, monocyte chemoattractant protein-1, and pro-inflammatory cytokines between groups. We will also compare degradative changes on magnetic resonance imaging (MRI) collected 1 and 12 months following surgery between groups with reductions in early biomarkers of cartilage degradation assessed with urinary biomarkers of type II collagen breakdown and bony remodeling. Discussion There is a complex interplay between the pro-inflammatory intra-articular environment, underlying bone remodeling, and progressive cartilage degradation. PTOA affects multiple tissues and appears to be more similar to rheumatoid arthritis than osteoarthritis with respect to inflammation. There is currently no treatment to delay or prevent PTOA after ACL injury. Since there is a larger and more persistent inflammatory response after ACL reconstruction than the initial insult of injury, treatment may need to be initiated after surgery, sustained over a period of time, and target multiple mechanisms in order to successfully alter the disease process. This study will assess whether a 6-month postoperative course of oral montelukast affects multiple PTOA mechanisms. Because montelukast administration can be safely sustained for long durations and offers a low-cost treatment option, should it be proven effective in the current trial, these results can be immediately incorporated into clinical practice. Trial registration ClinicalTrials.gov NCT04572256 . Registered on October 1, 2020.

Abstract Background Anterior cruciate ligament (ACL) and meniscus tears are common knee injuries. Despite the high rate of post-traumatic osteoarthritis (PTOA) following these injuries, the contributing factors remain unclear. In this study, we characterized the immune cell profiles of normal and injured joints at the time of ACL and meniscal surgeries. Methods Twenty-nine patients (14 meniscus-injured and 15 ACL-injured) undergoing ACL and/or meniscus surgery but with a normal contralateral knee were recruited. During surgery, synovial fluid was aspirated from both normal and injured knees. Synovial fluid cells were pelleted, washed, and stained with an antibody cocktail consisting of fluorescent antibodies for cell surface proteins. Analysis of immune cells in the synovial fluid was performed by polychromatic flow cytometry. A broad spectrum immune cell panel was used in the first 10 subjects. Based on these results, a T cell-specific panel was used in the subsequent 19 subjects. Results Using the broad spectrum immune cell panel, we detected significantly more total viable cells and CD3 T cells in the injured compared to the paired normal knees. In addition, there were significantly more injured knees with T cells above a 500-cell threshold. Within the injured knees, CD4 and CD8 T cells were able to be differentiated into subsets. The frequency of total CD4 T cells was significantly different among injury types, but no statistical differences were detected among CD4 and CD8 T cell subsets by injury type. Conclusions Our findings provide foundational data showing that ACL and meniscus injuries induce an immune cell-rich microenvironment that consists primarily of T cells with multiple T helper phenotypes. Future studies investigating the relationship between immune cells and joint degeneration may provide an enhanced understanding of the pathophysiology of PTOA following joint injury.

Introduction: Lacrosse has become an increasingly popular sport in recent decades with more players competing at the high school and collegiate levels. Along with the rise in popularity, lacrosse has also seen an increase in and evolution of common injuries experienced by players. Specifically, the incidence of shoulder instability episodes in lacrosse players has continued to increase over the years leading to a progressive focus in further understanding shoulder injuries in lacrosse. Objectives: Despite this recent focus, there remains a lack of substantial data regarding shoulder instability as it relates to lacrosse. Therefore, the objective of this study was to conduct an extensive literature review and provided an overview of many of the most recent concepts discussed surrounding shoulder instability in lacrosse players. Methods: Pubmed and Scopus databases were reviewed for relevant literature pertaining to the diagnosis, treatment, and rehabilitation of contact athletes with shoulder instability. Conclusion: Lacrosse players are at risk for shoulder instability due to the nature of the game. The biomechanics and contact aspect of the sport place a unique stress on the shoulder. Thus, there is an appropriate emphasis on how clinicians understand, diagnose, and treat shoulder instability in lacrosse players. This rise in popularity means every clinician involved in the treatment of athletes should be proficient in performing physical exam components specific to shoulder instability, develop their own treatment approach, and understand commonly used test batteries for determining an athlete...s return to sport.

Introduction: The annual incidence of sport-related concussion ranges from 1.6 to 3.8 million concussions per year representing a common injury in sports. Lacrosse is a rapidly growing sport for both men and women and these athletes are at risk for concussion. The mechanism of injury for concussion in the men's and women's game are different as are the rules and equipment requirements. Objectives: To report the epidemiology, pathophysiology, presentation, and management of sport-related concussion and to highlight recent rule changes for men's and woman's lacrosse in regards to concussion prevention. Methods: PubMed and Scopus databases were searched. All levels of evidence (I-IV) pertaining to concussions in men's and women's lacrosse players were analyzed and presented in this narrative review. Results: For all high school boys’ sports, lacrosse ranks number 3 for sports with the highest prevalence of concussions. Concussions most frequently result from athlete-to-athlete contact which represents 66.4% of the recorded concussions. For all high school girls’ sports, lacrosse ranks number 2 for sports with the highest prevalence of concussions. In women's lacrosse, stick or ball contact with the athlete's head is the most common mechanism of concussion, accounting for 72.7% of the recorded concussions. Conclusions: Both men's and women's lacrosse players are at risk for concussion, even though there are different mechanisms for this injury between the 2 games. Sports medicine providers should be knowledgeable on diagnosis, management and prevention when caring for lacrosse players. Protective equipment and rule changes are potential means to continue to protect these athletes and still need further investigation.

ABSTRACT: Introduction: Acute ankle sprains are one of the most common lower extremity injuries sustained by athletes and it is particularly common in sports such as lacrosse. The majority of ankle sprains affect the lateral ligaments; however, injuries can also occur to the medial ankle and the syndesmosis ligaments, commonly referred to as high ankle sprains. Objectives: The purpose of this review is to provide an overview of the management of ankle injuries in lacrosse players. Methods: Review of current literature was conducted using PubMed, Google Scholar, Cochrane Library, and Ovid. All published English articles related to ankle injuries in athletes, in particular soccer players, were selected. Results: Despite its high prevalence, a significant proportion of athletes experience residual symptoms and recurrence of injury, prolonging their ability to safely return to sport. Depending on the severity of injury, management often includes rehabilitation with conservative modalities, such as rest, ice, compression, elevation therapy, and adjunctive treatments like bracing, immobilization, and foot orthotics. Severe or refractory cases may warrant operative intervention. There remains significant emphasis on the importance of the rehabilitation process, regardless of whether conservative or surgical management is pursued. Conclusions: The decision to return to sport can be challenging and should involve a multidisciplinary approach, with the knowledge that there is a high rate of residual symptoms and injury recurrence.

Background: Patellar instability is a common problem in the active pediatric population. Physeal sparing medial patellofemoral ligament (MPFL) reconstruction using a soft suture anchor for femoral graft fixation has the proposed advantages of diminishing volumetric bony removal from the epiphysis, increasing the margin of safety with respect to notch, trochlear, and/or physeal damage, as well as reducing the risk of thermal damage to the physis during socket reaming. Indications: MPFL reconstruction is indicated in patients with recurrent patellar instability with MPFL tear or attenuation on magnetic resonance imaging or failure of conservative treatment. Physeal sparing techniques are necessary in the pediatric population to prevent growth disturbance and deformities that can lead to significant long-term disability. Technique Description: The patient was placed in supine position. Following examination under anesthesia, diagnostic arthroscopy was performed to assess for patellofemoral chondral defects. The surgical technique required 6 steps: (1) medial patellar dissection, (2) patellar anchor placement with 1.8-mm suture anchors, (3) medial femoral dissection over Schottle’s point, (4) femoral anchor placement using 2.8-mm double loaded anchor, (5) allograft femoral fixation, and (6) allograft patellar fixation. After skin closure, examination under anesthesia was repeated. Results: The patient was weight-bearing as tolerated immediately after surgery, using a brace for the first 6 weeks. Rehabilitation progressed from regaining range of motion, strengthening of the operative extremity, and returning to sport activities. In the senior author’s experience using this technique, there have been no recurrent patellar dislocations and no evidence of growth disturbance or angulation. One patient did find that the graft was prominent over the femoral epicondyle and returned to the operating room for debulking at 9 months postoperatively. Discussion/Conclusion: In conclusion, we propose that physeal sparing MPFL reconstruction using soft anchors for patellar and femoral fixation offers a simple and safe technique with reproducible anatomic graft placement and favorable clinical outcomes. This technique is technically simple and can be easily learned by surgeons familiar with adult MPFL reconstruction techniques. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: The quadrangular (or quadrilateral) space is defined by its anatomical borders and is the passageway for the axillary nerve and posterior circumflex humeral artery (PCHA). Quadrangular space syndrome (QSS) can present due to various compressive pathologies but is commonly seen in overhead athletes. Quadrangular space syndrome can present with neurogenic symptoms including pain and paresthesias, as well as vascular complications from compression of the PCHA including thrombosis, aneurysm formation, and distal emboli. Indications: Surgical decompression of the quadrangular space is indicated for severe neurogenic or vascular compromise in the case of QSS refractory to nonoperative treatment. Technique Description: After appropriate preoperative physical examination findings and trial of nonoperative treatment, including physical therapy and injections, surgical decompression was indicated. The posterior border of the deltoid was marked, and an incision centered over the posterior border of the deltoid lateral to the axillary fold was made. Posterior border of deltoid was identified and retracted, revealing the interval of the teres minor and major. The nerve to the teres minor was identified, protected, and fibrous bands compressing the nerve were released. The nerve to the teres minor was tracked deep to find the axillary nerve. This was identified and fibrous bands around the nerve were decompressed. The circumflex vessels were protected throughout. Following decompression of the nerves, there was free movement of the nerves indicating adequate surgical decompression. Results: Adequate surgical decompression of the axillary nerve and PCHA achieved with resolution of neurogenic symptoms of pain and paresthesias at first postoperative visit. Discussion/Conclusion: Quadrangular space syndrome is a rare disorder, can be difficult to diagnose, and is the cause of significant morbidity, particularly in overhead athletes. If symptoms persist after nonoperative treatment, operative decompression of the quadrangular space may be indicated. Adequate surgical decompression results in relief of neurogenic and vascular symptoms.

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual’s specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure. Level of Evidence: Level V, expert opinion.

Proximal hamstring injuries are common, and open surgical repair with suture anchors has been the gold standard when surgical intervention is warranted. Endoscopic techniques offer the opportunity of surgical repair with smaller incisions to limit complications and expedite rehabilitation. The purpose of this technique guide is to describe a modified endoscopic technique that allows a safe and anatomic repair of proximal hamstring injuries. The patient is positioned prone with the feet at the head of the bed, table in reverse Trendelenburg, and knees flexed to 90°. Four portals are used, 3 in horizontal alignment within the gluteal fold and 1 directly superior to the ischial tuberosity. The sciatic nerve is identified, dissected, and mobilized away from the operative field. Retraction sutures help retract the gluteus maximus and further protect the sciatic nerve. Dissection is within the interval between the conjoint and semimembranosus tendons. The tendons are freed and mobilized, the ischial tuberosity is decorticated, and an anatomic repair is performed via 4 suture anchors, 2 at each tendon footprint. Advancements in arthroscopy have permitted adequate visualization and exposure of the hamstring footprint, thus allowing for an anatomic repair with increased protection of the sciatic nerve and decreased resources and cost.

Background: The Cotton osteotomy, or dorsal-opening wedge osteotomy of the medial cuneiform (MC), is used to address medial column alignment to restore the static-triangle of support. There are many described techniques regarding the incision and osteotomy. Successful completion of the osteotomy requires knowledge of the anatomy, particularly the location of the medial dorsal cutaneous nerve (MDCN). This study describes the relationship between MDCN, tibialis anterior, extensor-hallucis-longus tendon, and ligamentous attachments to the MC. A technique to determine a safe location for the osteotomy is also described. Methods: Twelve fresh-frozen adult foot specimens were used for this study (7 male and 5 female). The MDCN and its branches were dissected and its relationship with the MC was documented. Osteotomy tilt angle and relationship to structures around the MC were measured. Results: MDCN traveled medially and distally over the dorsum of the MC, and a small branch to the MC was observed. The tilt angle was 80.1 ±1.4 degrees. There was no significant difference between the distance from the distal-articular surface to the midline of the cuneiform and to the interosseous ligament ( P = .69), or between the distance from the distal-articular surface to the second tarsometatarsal joint and to the origin of the Lisfranc ligament ( P = .12). Conclusions: The dorsal-medial-oblique incision effectively protected MDCN and the MC. We believe the osteotomy should be performed in the safe zone to maintain the stability of the opening wedge. Clinical relevance: The dorsal-medial-oblique incision could reduce the risk of injury to the MDCN and the tibialis-anterior tendon.

Background and purpose — In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST. Patients and methods — This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty. Results — Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66–0.76) and 0.77 (CI 0.71–0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer’s perspective, or $1,035 from the societal perspective. Interpretation — IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Background and purpose — Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods — Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results — Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation — Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.