Association Between Patient Factors and Outcome of Synthetic Cartilage Implant Hemiarthroplasty vs First Metatarsophalangeal Joint Arthrodesis in Advanced Hallux Rigidus

BACKGROUND

We evaluated data from a clinical trial of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis to determine the association between patient factors and clinical outcomes.

METHODS

Patients ≥18 years with hallux rigidus grade 2, 3, or 4 were treated with synthetic cartilage implant MTPJ1 hemiarthroplasty or arthrodesis. Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) sports and activities of daily living (ADL) scores, and Short Form-36 Physical Function (SF-36 PF) subscore were obtained preoperatively, and at 2, 6, 12, 24, 52, and 104 weeks postoperatively. Final outcome data, great toe active dorsiflexion motion, secondary procedures, radiographs, and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. The composite primary endpoint criteria for clinical success included VAS pain reduction ≥30%, maintenance/improvement in function, no radiographic complications, and no secondary surgical intervention at 24 months. Predictor variables included hallux rigidus grade; gender; age; body mass index (BMI); symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, range of motion (ROM), and pain. Two-sided Fisher exact test was used ( P < .05).

RESULTS

Patient demographics and baseline outcome measures were similar. Success rates between implant MTPJ1 hemiarthroplasty and arthrodesis were similar ( P > .05) when stratified by hallux rigidus grade, gender, age, BMI, symptom duration, prior MTPJ1 surgery status, and preoperative VAS pain, hallux valgus, and ROM.

CONCLUSION

Synthetic cartilage implant hemiarthroplasty was appropriate for patients with grade 2, 3, or 4 hallux rigidus. Its results in those with associated mild hallux valgus (≤20 degrees) or substantial preoperative stiffness were equivalent to MTPJ1 fusion, irrespective of gender, age, BMI, hallux rigidus grade, preoperative pain or symptom duration.

LEVEL OF EVIDENCE

Level II, randomized clinical trial.

2017 Roger A. Mann Award Winner

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus (HR) is a very common symptomatic problem affecting one in 40 patients over the age of 50 years. A variety of treatment options exist and, as is common in surgery, grading systems are used to assess severity of the condition and aid in the guidance of treatment. The most commonly used grading system for HR uses radiographic images, great toe range of motion and clinical symptoms. This study examines the relationship of radiographic and motion findings to observed intra-operative cartilage loss in patients with HR and explores hallux rigidus grade and cartilage loss as predictive variables for treatment outcomes.

Methods:

A prospective, randomized non-inferiority study examining outcomes of arthrodesis compared to hemiarthroplasty of the first metatarsal phalangeal joint (Cartiva®) was performed.2 All randomized and treated patients were included in this study. Patients underwent pre-operative clinical examination, including measures of joint motion, radiographic assessment and HR grade. Operatively, observations of cartilage loss on the metatarsal head and opposing proximal surfaces were recorded. All patients’ data, irrespective of treatment, were aggregated and Spearman Rank Correlation coefficients used to assess for strength of correlation of active peak dorsiflexion and cartilage loss to HR grade. Outcomes data were then separated by treatment group and two-sided Fisher’s Exact test assessed these variables’ impact on clinical success (p<0.05).

Results:

In 202 patients, 59 (29%), 110 (55%), and 33 (16%) were classified as Coughlin1 Grades 2, 3, and 4, respectively. There was no correlation between grade and active peak dorsiflexion (-0.02, p=0.78). While rank correlations between grade and cartilage loss on the proximal phalanx and metatarsal head statistically significantly differed from zero, the magnitudes of the correlations were small, 0.176 (p=0.01) and 0.224 (p=0.001), respectively (Table 1). Among Grade 4 patients, 36.4% had no metatarsal cartilage remaining; but this was also found in 8.5% of Grade 2 patients. Similarly, 52.5% of Grade 2 patients had ≥50% metatarsal cartilage remaining; but this was also found in 21.2% of Grade 4 patients. None of the observed factors were significantly associated with likelihood of achieving composite success.

Conclusion:

This study examines the relationship of motion and intra-operative cartilage loss findings with a commonly used clinical and radiographic grading system for hallux rigidus. This study population included only candidates with HR considered a candidate for arthrodesis based on review of clinical symptoms however the Grade assigned maybe Coughlin Grade 2, 3 or 4. Irrespective of the Grade, positive outcomes were demonstrated within both treatment groups. The weak correlations of preoperative motion and intra-operative cartilage loss to grade suggests that clinical symptoms should be a significant determinant guiding the treatment option rather than radiographic or range of motion factors.

Incidence and Complications of Open Hip Preservation Surgery: An ABOS Database Review

Hip preservation surgery encompasses various surgical procedures that have the goal of decreasing the progression of osteoarthritis, preserving normal hip function, and delaying the need for arthroplasty. These procedures can encompass arthroscopic, open, and combined techniques. This study investigated the trends and complications associated with open hip preservation surgery performed by candidates undergoing Part II of the American Board of Orthopaedic Surgery examination. The American Board of Orthopaedic Surgery Part II surgeon case database was queried from the years 2003 to 2013 for Current Procedural Terminology (CPT) codes related to open hip preservation surgery in patients 10 years and older. Patient demographics, fellowship training, geographic location, and complications were extracted from the database. These data were analyzed to determine the incidence by year of individual procedures and complications. During the study period, 644 cases (352 male, 292 female; mean age, 29.7 years) and 730 CPT codes were reported. The most commonly reported fellowship was pediatric orthopedics. No trend was observed in the overall incidence of these surgeries, but there was an increase in the number of cases performed in the Midwest. There were 212 reported complications, with a rate of 33% per case, or 29% per CPT code (range, 12.5%-100% per CPT code). Complications reported ranged from infection to death. The incidence of complications over time showed no discernible trend. Based on the results of this study, the yearly incidence and complications associated with open hip preservation surgery performed by surgeons undergoing board certification should continue at a predictable rate. [Orthopedics. 2017; 40(1):e109-e116.].

Clinical Outcomes of Nonunions of Hindfoot and Ankle Fusions

BACKGROUND

While nonunion after foot and ankle fusion surgery has been associated with poor outcomes, we are not aware of any longitudinal study on this subject. Thus, we prospectively evaluated the impact of nonunion on clinical outcomes of foot and ankle fusions and identified potential risk factors for nonunion after these procedures.

METHODS

Using data from a randomized clinical trial on recombinant human platelet-derived growth factor-BB (rhPDGF-BB; Augment Bone Graft, BioMimetic Therapeutics), union was defined either by assessment of computed tomography (CT) scans at 24 weeks by a reviewer blinded to the type of treatment or by the surgeon's composite assessment of clinical and radiographic findings at 52 weeks and CT findings at 24 or 36 weeks. The nonunion and union groups (defined with each assessment) were then compared in terms of clinical outcome scores on the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS), Foot Function Index (FFI), and Short Form-12 (SF-12) as well as age, sex, body mass index (BMI), smoking status, diabetes status, work status, and arthrodesis site.

RESULTS

Blinded CT assessment identified nonunion in 67 (18%) of 370 patients, and surgeon assessment found nonunion in 21 (5%) of 389 patients. Postoperatively, the nonunion group scored worse than the union group, regardless of the method used to define the nonunion, on the AOFAS-AHS and FFI, with mean differences of 10 and 12 points, respectively, when nonunion was determined by blinded CT assessment and 19 and 20 points when it was assessed by the surgeon. The nonunion group also had worse SF-12 Physical Component Summary scores. Differences between the union and nonunion groups were clinically meaningful for all outcome measures, regardless of the nonunion assessment method. The concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well) was not supported. Patients with nonunion were more likely to be overweight, smokers, and not working.

CONCLUSIONS

This prospective longitudinal study demonstrated poorer functional outcomes in patients with a nonunion after foot and ankle fusion, regardless of whether the diagnosis of nonunion was based on CT only or on combined clinical, radiographic, and CT assessment.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Science Behind Wear Testing for Great Toe Implants for Hallux Rigidus

Various methods of repairing damaged articular cartilage surfaces have been proposed and a variety of implant materials have been tried in an attempt to decrease pain and improve function after cartilage repair. The hydrogel made of polyvinyl alcohol and saline is a unique material used as an implant in the great toe for advanced stage arthritis.

The Science Behind Surgical Innovations of the Forefoot

One of the areas of foot and ankle surgery that has had particular attention over the last 5 years has been forefoot surgery. Common procedures include correction of the lessor metatarsophalangeal joints and hammertoe deformities, specifically metatarsal shortening osteotomies and proximal interphalangeal joint fusions. The goals of these surgeries are to improve patient function and allow patients to fit into shoes more comfortably in metatarsal shortening and hammertoe.

The prevention of diabetic foot ulceration: how biomechanical research informs clinical practice

Background

Implementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines.

Objectives

The first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration.

Discussion

Research demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes.

Conclusion

Continued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

Preoperative PROMIS Scores Predict Postoperative Success in Foot and Ankle Patients

BACKGROUND

The use of patient-reported outcomes continues to expand beyond the scope of clinical research to involve standard of care assessments across orthopedic practices. It is currently unclear how to interpret and apply this information in the daily care of patients in a foot and ankle clinic. We prospectively examined the relationship between preoperative patient-reported outcomes (PROMIS Physical Function, Pain Interference and Depression scores), determined minimal clinical important differences for these values, and assessed if these preoperative values were predictors of improvement after operative intervention.

METHODS

Prospective collection of all consecutive patient visits to a multisurgeon tertiary foot and ankle clinic was obtained between February 2015 and April 2016. This consisted of 16 023 unique visits across 7996 patients, with 3611 new patients. Patients undergoing elective operative intervention were identified by ICD-9 and CPT code. PROMIS physical function, pain interference, and depression scores were assessed at initial and follow-up visits. Minimum clinically important differences (MCIDs) were calculated using a distribution-based method. Receiver operating characteristic (ROC) curves were calculated to determine whether preoperative PROMIS scores were predictive of achieving MCID. Cutoff values for PROMIS scores that would predict achieving MCID and not achieving MCID with 95% specificity were determined. Prognostic pre- and posttest probabilities based off these cutoffs were calculated. Patients with a minimum of 7-month follow-up (mean 9.9) who completed all PROMIS domains were included, resulting in 61 patients.

RESULTS

ROC curves demonstrated that preoperative physical function scores were predictive of postoperative improvement in physical function (area under the curve [AUC] 0.83). Similarly, preoperative pain interference scores were predictive of postoperative pain improvement (AUC 0.73) and preoperative depression scores were also predictive of postoperative depression improvement (AUC 0.74). Patients with preoperative physical function T score below 29.7 had an 83% probability of achieving a clinically meaningful improvement in function as defined by MCID. Patients with preoperative physical function T score above 42 had a 94% probability of failing to achieve MCID. Patients with preoperative pain above 67.2 had a 66% probability of achieving MCID, whereas patients with preoperative pain below 55 had a 95% probability of failing to achieve MCID. Patients with preoperative depression below 41.5 had a 90% probability of failing to achieve MCID.

CONCLUSION

Patient-reported outcomes (PROMIS) scores obtained preoperatively predicted improvement in foot and ankle surgery. Threshold levels in physical function, pain interference, and depression can be shared with patients as they decide whether surgery is a good option and helps place a numerical value on patient expectations. Physical function scores below 29.7 were likely to improve with surgery, whereas those patients with scores above 42 were unlikely to make gains in function. Patients with pain scores less than 55 were similarly unlikely to improve, whereas those with scores above 67 had clinically significant pain reduction postoperatively. Reported prognostic cutoff values help to provide guidance to both the surgeon and the patient and can aid in shared decision making for treatment.

LEVEL OF EVIDENCE

Level II, prognostic study.

The Importance of Sufficient Graft Material in Achieving Foot or Ankle Fusion

BACKGROUND

Nonunion, an important complication following foot and ankle arthrodesis, causes substantial morbidity and disability. In patients undergoing hindfoot and ankle arthrodesis, autogenous bone graft (autograft) or a suitable alternative is often used to promote osseous fusion across the joint. This study assessed the importance of adequate graft material in the fusion space to achieve joint fusion during ankle and hindfoot arthrodesis.

METHODS

This study used data from a previously published clinical trial of grafting material (recombinant human platelet-derived growth factor-BB with beta-tricalcium phosphate [rhPDGF-BB/β-TCP] or autograft) for healing in hindfoot and ankle arthrodesis to correlate the amount of graft fill at 9 weeks with ultimate healing. Patients who received supplemental graft material for ankle or hindfoot arthrodesis for end-stage ankle or hindfoot arthritis were stratified according to nonunion risk factors and surgical fusion site. Patients underwent arthrodesis using standard rigid internal fixation. Graft fill was defined as "adequate" if the material occupied ≥50% of the cross-sectional area of the fusion space on a computed tomography (CT) scan made at 9 weeks. Fusion was defined as osseous bridging of ≥50% of each articulation on a CT scan made at 24 weeks. Three hundred and seventy-nine patients with 573 joints (383 managed with rhPDGF-BB/β-TCP and 190 managed with autograft) that underwent arthrodesis had complete follow-up with 9-week and 24-week CT scans available.

RESULTS

Overall, 472 (82%) of 573 joints had adequate graft fill; of those, 383 (81%) were successfully fused at 24 weeks compared with 21 (21%) of 101 joints without adequate graft fill (p < 0.0001). Absolute fusion rate differences (joints with adequate fill minus those without adequate fill) were consistent across joints (61% to 63%) and for graft materials. The overall odds ratio (OR) of successful fusion in joints with adequate graft fill compared with those without adequate graft fill was 16.4 (95% confidence interval, 9.6 to 27.9).

CONCLUSIONS

This study demonstrates an association between the amount of graft material and successful hindfoot and ankle arthrodesis. Graft material filling of ≥50% of the fusion space at 9 weeks, regardless of type or origin, was associated with significantly higher fusion rates at 24 weeks.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

2016 J. Leonard Goldner Award - Can Initial PROMIS Scores Predict Outcome for Foot and Ankle Patients?

Category:

Other

Introduction/Purpose:

The use of patient reported outcomes continues to expand beyond the scope of clinical research to involve standard of care assessments across orthopaedic practices. It is currently unclear how to interpret and apply this information in the daily care of patients. We examined the relationship between patient reported outcomes (PROMIS Physical Function, Pain Interference and Depression scores) obtained at initial visit as a predictor of outcome at a minimum of 7 month follow up.

Methods:

Prospective collection of all consecutive patient visits to the University of Rochester Orthopaedic foot and ankle clinic was initiated on April 2015. Data through December 2015 was classified as new or follow up and operative or non-operative based on ICD-9 and CPT codes. 17,019 patient visits were collected on 7,265 patients, of which 4,213 were new patients. PROMIS physical function, pain interference, and depression scores were assessed at initial and follow up visits. Only patients with a minimum of 7 months (mean 8.2) follow up who completed all PROMIS domains were included, resulting in 262 patients (69 operative, 193 non-operative). PROMIS scores are normalized to a US population with an average score of 50 and a standard deviation of 10. Statistical analysis using student t-tests and linear regression were performed to determine if the initial PROMIS scores were predictive of patient reported outcomes at final follow up.

Results:

There were no differences between operative and non-operative treatment groups in initial PROMIS scores or change in scores at follow up (p>0.40). Patients with higher baseline pain were likely to experience less pain over time (r=0.63, p < 0.01). Similarly, patients with higher baseline depression were likely to experience decreased depression over time (r =0.52, p < 0.01). Patients with lower baseline physical function were likely to improve over time whereas patients with higher baseline physical function were likely to worsen over time (r=0.68, p< 0.01). Specifically, all patients with baseline physical function score less than 28 improved over time, while all patients with a score greater than 52 worsened (Figure 1).

Conclusion:

Physical function, pain, and depression trends did not vary between operative and non-operative patients at 8.2 month follow up. Patients with high initial pain and depression were likely to have improvements in pain and depression over time. Similarly, patients with low initial physical function were likely to have improved physical function. However, despite treatment, patients with above average initial physical function did not experience improvement in physical function, suggesting these patients are more challenging to treat. This information demonstrates that baseline patient reported outcomes are predictive of improvement in outcomes over time, and could assist in the treatment decision process.

Intermediate Outcomes of Hydrogel Implant for Hallux Rigidus

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is the most common arthritic condition of the foot. Although a variety of great toe implants have been tried in an attempt to maintain toe motion, the majority have failed. In these cases, salvage to arthrodesis is more complicated and with a prolonged recovery. This prospective study assesses the intermediate efficacy and safety of a small (8/10 mm) hydrogel implant requiring minimal bone resection for moderate to severe hallux rigidus.

Methods:

Patients who underwent 1st MTP hemiarthroplasty with an organic polymer-based biomaterial implant (Cartiva), with at least five-year follow-up were contacted. Patients underwent a physical exam, and completed a pain visual analog scale (VAS) scale, SF-36, patient satisfaction questions, and the Foot and Ankle Ability Measure (FAAM).

Results:

Twenty-nine patients were available, with two lost to follow-up. The average time of follow-up was 5.3±0.5 years. The average age was 55.6±8.4, with 24(80%) females. The average VAS for pain improved from 64.6(±11.8) to 5.2(± 9.4) (p < 0.001). The average FAAM scores were: ADL subscale: 62.1(±16.4) to 95.8%(± 7.2) (p < 0.001); and Sports subscale: 40.2(±15.1) to 91.3%(±11.2) (p < 0.001); The average FAAM scores at follow-up for: Level of function during sports: 91.9%(±10.7); and Current level of function: 92.5%(±10.6). 69.2% of patients reported their level of function as normal, 26.9% nearly normal, and 3.8% abnormal function. Patients had 17.7 degrees of dorsiflexion, with a range of 12.7 to 22.7 degrees. Average peak dorsiflexion was 28.2°(±8.8). 92.3% stated they would undergo the procedure again.

Conclusion:

This study reports the mid-term results of an organic polymer-based biomaterial hemiarthroplasty implant for the management of hallux rigidus. Overall patients were very satisfied with the procedure. At an average of five years, patients are functioning very well, with limited pain and maintained motion of the 1st MTP joint. These results are promising as a viable alternative to fusion of the 1st MTP joint for management of moderate to severe hallux rigidus.

Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus

BACKGROUND

Although a variety of great toe implants have been tried in an attempt to maintain toe motion, the majority have failed with loosening, malalignment/dislocation, implant fragmentation and bone loss. In these cases, salvage to arthrodesis is more complicated and results in shortening of the ray or requires structural bone graft to reestablish length. This prospective study compared the efficacy and safety of this small (8/10 mm) hydrogel implant to the gold standard of a great toe arthrodesis for advanced-stage hallux rigidus.

METHODS

In this prospective, randomized non-inferiority study, patients from 12 centers in Canada and the United Kingdom were randomized (2:1) to a synthetic cartilage implant or first metatarsophalangeal (MTP) joint arthrodesis. VAS pain scale, validated outcome measures (Foot and Ankle Ability Measure [FAAM] sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment, and safety parameters were evaluated. Analysis was performed using intent-to-treat (ITT) and modified ITT (mITT) methodology. The primary endpoint for the study consisted of a single composite endpoint using the 3 primary study outcomes (pain, function, and safety). The individual subject's outcome was considered a success if all of the following criteria were met: (1) improvement (decrease) from baseline in VAS pain of ≥30% at 12 months; (2) maintenance of function from baseline in FAAM sports subscore at 12 months; and (3) absence of major safety events at 2 years. The proportion of successes in each group was determined and 1-sided 95% confidence interval for the difference between treatment groups was calculated. Noninferiority of the implant to arthrodesis was considered statistically significant if the 1-sided 95% lower confidence interval was greater than the equivalence limit (<15%). A total of 236 patients were initially enrolled; 17 patients withdrew prior to randomization, 17 patients withdrew after randomization, and 22 were nonrandomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

RESULTS

VAS pain scores decreased significantly in both the implant and arthrodesis groups from baseline at 12 and 24 months. Similarly, the FAAM sports and activity of daily living subscores improved significantly at 12 and 24 months in both groups. First MTP active dorsiflexion motion improvement was 6.2 degrees (27.3%) after implant placement and was maintained at 24 months. Subsequent secondary surgeries occurred in 17 (11.2%) implant patients (17 procedures) and 6 (12.0%) arthrodesis patients (7 procedures). Fourteen (9.2%) implants were removed and converted to arthrodesis, and 6 (12.0%) arthrodesis patients (7 procedures [14%]) had isolated screws or plate and screw removal. There were no cases of implant fragmentation, wear, or bone loss. When analyzing the ITT and mITT population for the primary composite outcome of VAS pain, function (FAAM sports), and safety, there was statistical equivalence between the implant and arthrodesis groups.

CONCLUSION

A prospective, randomized (2:1), controlled, noninferiority clinical trial was performed to compare the safety and efficacy of a small synthetic cartilage bone implant to first MTP arthrodesis in patients with advanced-stage hallux rigidus. This study showed equivalent pain relief and functional outcomes. The synthetic implant was an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion. The percentage of secondary surgical procedures was similar between groups. Less than 10% of the implant group required revision to arthrodesis at 2 years.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Randomized, Prospective Study of the Order of Preoperative Preparation Solutions for Patients Undergoing Foot and Ankle Orthopedic Surgery

BACKGROUND

Surgical site infection is routinely cited as the most common complication following orthopedic foot and ankle surgery. Our institution uses 4% chlorhexidine gluconate followed by 70% isopropyl alcohol to reduce skin bacterial loads prior to surgery. These solutions have potential synergistic qualities to prevent a postoperative infection. The purpose of this study was to determine if the order of these solutions has a significant effect on the residual bacterial pathogens load following operative site preparation for foot and ankle surgery, as evidenced by positive culture swabs.

METHODS

A total of 95 consecutive patients, undergoing surgery of the foot and ankle with a single surgeon, were prospectively randomized to 1 of 2 operative preparation groups: isopropyl alcohol (IPA) group, whose operative site preparation consisted of a 4% chlorhexidine application followed by alcohol rinse (49 patients), and chlorhexidine gluconate (CHG) group, which had 46 patients undergo operative site preparation using alcohol followed by chlorhexidine. A total of 4 aerobic culture specimens were obtained from the third web space of the operative foot on each patient: (1) prior to operative site preparation, (2) after the prep was completed, (3) after completion of the procedure, and (4) after the incision was closed. Each patient was then followed for 6 months postoperatively to monitor the operative site. Medical comorbidities were also analyzed.

RESULTS

The average time for IPA procedures was 52 minutes vs 54 for CHG (ns). There was no difference between groups with respect to diabetes, tobacco use, obesity, race, or immunosuppression. Both groups had 100% bacterial growth from specimens obtained prior to operative site preparation (P > .05). For all postpreparation swabs, 19.0% (28/147) of the IPA cultures were positive compared to 10.9% (15/138) from the CHG group cultures (P = .07). The amount of patients with positive culture results favored the CHG group at each collection point: 6.5% (3/46) versus 25% (12/49) after draping (P = .02); 15% (7/46) versus 33% (16/49) after completion of the surgery (P = .05); and 20% (9/46) versus 35% (17/49) after skin closure (P = .07). One operative site infection was seen in the first 30 days following surgery for each treatment group, each treated with oral antibiotics. No additional skin or wound complications were encountered during the 6-month study follow-up.

CONCLUSION

Postoperative infection rates following foot and ankle orthopedic surgery was low. Both chlorhexidine and isopropyl alcohol solutions were effective methods in reducing operative site bacterial colonization when combined. In this study, applying isopropyl alcohol solution followed by the chlorhexidine solution was more effective in reducing positive bacterial cultures taken after operative site preparation. No difference in clinical wound infection rate was seen.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Individual metatarsal and forefoot kinematics during walking in people with diabetes mellitus and peripheral neuropathy

The purpose of this study was to compare in-vivo kinematic angular excursions of individual metatarsal segments and a unified forefoot segment in people with Diabetes Mellitus and peripheral neuropathy (DMPN) without deformity or ulceration to a healthy matched control group. Thirty subjects were recruited. A five- segment foot model (1st, 3rd, and 5th metatarsals, calcaneus, tibia) was used to examine relative 3D angular excursions during the terminal stance phase of walking. Student t-tests were used to assess group differences in kinematics. Pearson correlations and cross-correlations were used to assess relationships between the motion of the individual metatarsals and the unified forefoot. Significant reductions of DMPN group sagittal plane angular excursions were detected in all individual metatarsals and the unified forefoot (p < 0.01). Frontal plane 3rd metatarsal excursion was reduced (p = 0.04) in the DMPN group. The 3rd and 5th metatarsal and the unified forefoot excursions were reduced (p ≤ 0.02) in the DMPN group in the transverse plane. In both groups, coupling of individual metatarsal and unified forefoot motion was strongest in the sagittal plane. This study illustrates that multiple individual metatarsals have reduced motion in people with DMPN. Differences in the magnitude and coupling between individual metatarsal motion and unified forefoot motion supports the use of a two segment forefoot modeling approach in future kinematic analyses. Further study is recommended to determine if the observed kinematic profile is related to the development and location of deformity and tissue breakdown in people with DMPN.

Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons

BACKGROUND

This study compared the use of reverse and hemishoulder arthroplasty for the treatment of proximal humeral fractures among orthopedic surgeons taking part II of the American Board of Orthopaedic Surgery board examination. We hypothesized that the use of reverse shoulder arthroplasty for fractures in the elderly is increasing amongst newly trained orthopedic surgeons.

MATERIALS AND METHODS

We queried the American Board of Orthopaedic Surgery database for the cases of proximal humeral fractures treated with arthroplasty submitted between 2005 and 2012. We evaluated the prosthesis used, patient-specific factors, complications, and the difference in use by shoulder fellowship-trained surgeons.

RESULTS

From 2005 to 2012, 5395 board-eligible orthopedic surgeons submitted cases to the database. Of these, 435 (mean, 54 per year) were proximal humeral fractures treated with arthroplasty. The overall incidence of reverse shoulder arthroplasty for fracture increased from 2% to 4% during 2005 to 2007 to 38% in 2012. Shoulder surgeons treated 5 times more proximal humeral fractures with shoulder arthroplasty and were also more than 20 times more likely to use a reverse implant (P < .0001). The difference in complication rates between reverse and hemishoulder arthroplasty was not significant (P = .49). Patients who received a hemiarthroplasty tended to be younger (mean age, 70.8 vs 75.7 years; P = .0015).

CONCLUSIONS

Overall, the use of a hemiarthroplasty for fracture is still more common (62% in 2012), although the relative proportion of reverse implants is rising. Among shoulder surgeons, more than 50% of the arthroplasties performed for fractures during the past 3 years (2010-2012) have been reverse arthroplasties.

Psychometric Comparison of the PROMIS Physical Function CAT With the FAAM and FFI for Measuring Patient-Reported Outcomes

BACKGROUND

Selecting optimal patient-reported outcome (PRO) instruments is critical to improving the quality of health care. The purpose of this study was to compare the reliability, responsiveness, and efficiency of three PRO measures: the Foot and Ankle Ability Measure-Activity of Daily Living subscale (FAAM_ADL), the Foot Function Index 5-point verbal rating scale (FFI-5pt), and the PROMIS Physical Function computerized adaptive test (PF CAT).

METHODS

Data were aggregated from 10 clinical sites in the AOFAS's National Orthopaedic Foot and Ankle Research (OFAR) Network from 311 patients who underwent elective surgery for a disorder of the foot or ankle. Patients were administered the FAAM_ADL, FFI-5pt, and PF CAT at their preoperative visit and at 6 months after surgery. Reliabilities were evaluated using a Rasch model. Responsiveness was calculated using paired samples t test and efficiency was recorded as number of seconds to complete the instrument.

RESULTS

Similar reliabilities were found for the three instruments. Item reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were all .99. Pearson reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were .95, .93, and .96, respectively. On average, patients completed the FAAM_ADL in 179 seconds, the FFI-5pt in 194 seconds, and the PF CAT in 44 seconds, ( P < .001). The PF CAT and FAAM_ADL showed significant improvement ( P = .01 and P = .001, respectively) in patients' physical function after treatment; the FFI-5pt did not show improvement.

CONCLUSIONS

Overall, the PF CAT performed best in terms of reliability, responsiveness, and efficiency in this broad sample of foot and ankle patients. It can be a potential replacement for the conventional PRO measures, but further validation is needed in conjunction with the PROMIS Pain instruments.

LEVEL OF EVIDENCE

Level I, prospective comparative outcome study.

Establishing the relationship between clinical outcome and extent of osseous bridging between computed tomography assessment in isolated hindfoot and ankle fusions

BACKGROUND

Determining the success of joint fusion operations is often a diagnostic dilemma, and many factors may be considered. Most would agree that the broad categories of clinical success and radiographic success are likely most useful to determine the overall success of a joint fusion operation. Very little evidence exists to assist the surgeon in determining what constitutes a successful radiographic fusion. The aim of this study was to determine the extent of osseous bridging as measured by computed tomography (CT) that was associated with a good clinical outcome as measured by the 12-Item Short Form (SF-12), Foot Function Index (FFI), and American Orthopaedic Foot & Ankle Society (AOFAS) clinical outcomes questionnaires at 24 weeks.

METHODS

Patients who had isolated joint fusions were evaluated (n = 275) to determine the correlation of extent of osseous bridging with clinical outcome. The extent of osseous bridging across the joint in question was categorized as absent (0%-24%), minimal (25%-49%) moderate (50%-74%), or complete (75%-100%). Clinical outcome scores included the SF-12, FFI, and AOFAS outcomes score.

RESULTS

Patients evaluated to have at least minimal osseous bridging at fusion sites (25%-49%) on CT reported a clinically important improvement in SF-12, FFI, and AOFAS, whereas those with "absent" osseous bridging (0%-24%) did not report a clinically important improvement in outcome scores.

CONCLUSION

This study suggests that osseous bridging of greater than 25% to 49% at the fusion site measured by CT may be necessary to consider a hindfoot or ankle fusion clinically successful.

LEVEL OF EVIDENCE

Level IV, case series.

Survey on the need for bone graft in foot and ankle fusion surgery

BACKGROUND

Generally, autologous bone graft is felt to be an important treatment adjunct in the presence of structural deformity, surface irregularities, defects (due to trauma, surgery, or degenerative changes), or underlying comorbidities that predispose the patient to healing challenges. This study assessed the prognostic and predictive factors used in the clinical decision making for bone graft supplementation in foot and ankle fusion surgery.

METHODS

Utilizing standard survey research methodology, key-informant interviews, pretesting, and pilot testing; a survey was constructed. The survey consisted of a web-based 5-point Likert-type scale (never, seldom, sometimes, almost always, always) listing 14 clinical and 11 radiologic criteria that may influence the use of autologous bone grafting or other biologic augmentation in foot and ankle surgery. This survey was sent to Orthopaedic Foot and Ankle Surgeons in North America and Canada.

RESULTS

A total of 48 foot and ankle surgeons completed the blinded survey (73% response rate). More than 70% of responders felt bone graft was almost always (AA) or always (A) indicated in prior nonunion of the indicated joint (96%). Fewer than 50% of respondents felt poor soft tissue integrity (20%), prior foot and ankle infection (20%), and current foot and ankle infection (4%) needed bone graft. Radiologic factors marked as AA or A in over 70% of responders include radiographic evidence of nonunion (96%), avascular necrosis (87%), and others. Factors chosen as AA or A by fewer than 50% of surgeons include prior adjacent joint fusions (47%), intra-articular deformity (31%), and extra-articular deformity (13%).

CONCLUSIONS

There was some uniformity of agreement on the number of both clinical and radiologic factors that prompt a surgeon to utilize autologous bone graft to try to avoid the complication of nonunion. Surgeons may wish to consider these factors when making a decision on the use of bone graft to supplement fusion.