An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery

Correlation of the AOFAS scores with a generic health QUALY score in foot and ankle surgery

BACKGROUND

The American Orthopaedic Foot and Ankle Score (AOFAS) is one scoring system used to assess and monitor the progress of patients after foot and ankle surgery. The aim of this study was to evaluate the trend of the AOFAS score over a period of time and correlate it with the QUALY score, which is a valid and reliable scoring system.

METHODS

All patients undergoing surgery by one foot and ankle surgeon between January, 2001, and July, 2003, were reviewed. The preoperative AOFAS and QUALY and postoperative scores at 3, 6 and 12 months, and yearly were collected prospectively.

RESULTS

This study includes 204 operative procedures in 159 patients. The mean age of the patients was 51.9 (range 12 to 89) years. The AOFAS scores increased from a mean of 45.5 preoperatively to 76.5 at 3 months and reached a peak of 81.5 at 6 months and then started to decrease to 79.2 at 12 months. This fall, though seemingly marginal, was significant (p < 0. 01). This trend seems to be consistent for all the procedures. The 6-month AOFAS score was found to have a higher correlation with the final QUALY score (r(2) = 0.423) than the 12-month AOFAS score (r(2) = 0.326).

CONCLUSIONS

The AOFAS score has low levels of correlation with the validated generic health QUALY score. Our study suggests that scores collected preoperatively, at 6 and 12 months after surgery, and annually there after may be best. The 3-month score may not be necessary. We recommend that a generic health score such as the QUALY score be used in conjunction with the AOFAS score to reflect outcome.

Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints

BACKGROUND

The purpose of this study was to identify subtypes of atraumatic osteoarthritis of the tarsometatarsal joints based on accompanying foot deformities and to determine whether concurrent procedures done for each subtype were effective.

METHODS

The study included 59 patients (67 feet) with atraumatic tarsometatarsal joint osteoarthritis treated with tarsometatarsal fusion. The average patient age was 60.2 years with 40.6 months followup. Patients were evaluated with radiographs, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, the Foot Function Index, and the Short Form-36 Health Survey Questionnaire (SF-36).

RESULTS

Four main subtypes were identified based on associated foot deformities: pes planovalgus (27), hallux valgus (11), in-situ without deformities (eight), and rockerbottom (five). Plantar-medial closing-wedge resection was used to correct rockerbottom deformity. For pes planovalgus deformity, a medial sliding calcaneal osteotomy was done. Lateral column lengthening with medial sliding calcaneal osteotomy was done for tarsometatarsal osteoarthritis with severe pes planovalgus, and triple arthrodesis was done for rigid pes planovalgus. Tarsometatarsal osteoarthritis with hallux valgus deformity was corrected with the Lapidus procedure. There were 29 complications, most commonly sesamoid pain. The pes planovalgus group showed significant radiographic improvements in four of five parameters measured. AOFAS scores improved from retrospectively assigned preoperative 34.1 points to postoperative 83.9 points. The Foot Function Index showed a high satisfaction rate (86.6%). SF-36 scores averaged 50.6 postoperatively.

CONCLUSIONS

When feet with atraumatic tarsometatarsal osteoarthritis are classified into four main categories based on associated deformities, appropriate concurrent procedures can be done with high satisfaction and improved function scores. Pes planovalgus feet, in particular, may benefit from concurrent procedures with improved radiographic measures.

Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales

This study evaluates the criterion validity of the subjective component of the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scales by correlating scores obtained with these rating scales to scores obtained with the Foot Function Index (FFI) in patients with foot and ankle conditions. To date, the AOFAS scoring scales have not been shown to provide valid information despite their popularity. The FFI, on the other hand, has previously been shown to provide valid information in regard to conditions affecting the foot and ankle. A moderately strong inverse criterion validity correlation (Pearson correlation coefficient = -0.68) was shown when preoperative patients were administered both the AOFAS and FFI questionnaires, and the resultant scores were compared. Test-retest reliability measurements showed no significant difference (P = .27) between preoperative AOFAS scale scores measured at least 2 weeks apart. Construct validity was shown (P = .006) when dependent preoperative and postoperative (at least 3 months) AOFAS scale scores were compared, indicative of the clinical rating scales' ability to discriminate and predict quality of life related to foot and ankle conditions. The moderate level of correlation, satisfactory degree of reliability, and responsiveness (ability to distinguish differences between preoperative and postoperative conditions in the same patient) observed in this study suggest that the subjective component of the AOFAS clinical rating scales provides quality-of-life information that conveys acceptable validity regarding conditions affecting the foot and ankle.

Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure

BACKGROUND

Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray.

METHODS

Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet).

RESULTS

Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads.

CONCLUSIONS

First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.

Mid-term results of titanium hemi-great toe implants

BACKGROUND

We reviewed the mid-term results of metatarsophalangeal hemiarthroplasty with titanium hemi-great toe implants. This study may help with future prosthetic design and evaluation leading to improved management and patient satisfaction.

METHODS

Ten of 12 patients were contacted more than 2.5 years after surgery. Their charts were reviewed, and they were evaluated clinically and radiographically.

RESULTS

All patients were improved and satisfied in the first 5 years after surgery, but subsidence and lucency in all patients and a painful fracture in one patient bring long-term implant survival into question. The ultimate longevity of the implant and its long-term functionality should be questioned.

CONCLUSIONS

Metallic hemi-great toe implants have satisfactory mid-term results. Improved prosthetic design may lead to less implant subsidence and stem lucency.

First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery

BACKGROUND

The results of first metatarsophalangeal (MTP) joint arthrodesis as a specific treatment for failed hallux valgus correction has not been previously reported. We evaluated the results of first metatarsophalangeal (MTP) joint arthrodesis as a treatment for failed hallux valgus surgery.

METHODS

The records of the senior author (MJC) were reviewed to identify patients treated for symptomatic failed hallux valgus procedures with arthrodesis of the first metatarsophalangeal joint over a 20-year period. Twenty-nine patients (33 feet) were available for followup examination. The patients completed a visual analog pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, and a patient satisfaction scale at the final followup. Radiographs were obtained of both feet.

RESULTS

The average followup was 8 (1 to 22) years. The average pain score improved from 7 to 3 points. The mean AOFAS score was 73 points at followup. Patient satisfaction was excellent for 13 feet (39%), good in 11 (33%), fair in eight (24%), and poor in one (3%). The mean hallux valgus angle was 16 degrees, with an intermetatarsal angle of 8 degrees. There were three asymptomatic and one symptomatic nonunions. Twenty-two feet (67%) had corrective procedures performed on the lesser toes at the time of the first MTP joint arthrodesis.

CONCLUSIONS

First MTP joint arthrodesis is a reliable option for revision after failure of surgical treatment of hallux valgus. This procedure can be used to treat a number of failure modes following initial hallux valgus surgery including recurrence, hallux varus, cock-up deformity, degenerative arthritis of the MTP joint, and associated transfer lesions beneath the lesser metatarsals. First MTP joint arthrodesis can be used after failed proximal and distal osteotomies, arthrodesis of the metatarsocuneiform joint, McBride procedure, exostectomy, and resection arthroplasty. Revision procedures have poorer clinical outcomes than successful primary hallux valgus procedures.

Poor agreement between prospective and retrospective assessment of hallux surgery using the AOFAS Hallux Scale

BACKGROUND

Retrospective assessment of preoperative status is common in nonprospective study designs. The aim of this study was to test the hypothesis that prospective and retrospective evaluations of the preoperative patient condition in hallux surgery gives equal results and therefore can be used interchangeably.

METHODS

One hundred and fifty-nine consecutive feet with hallux surgery were analyzed prospectively. Parallel to routine evaluation of the preoperative status, the AOFAS Hallux Scale was recorded prospectively. Two years after surgery, the medical records were re-evaluated for retrospective reconstruction of the AOFAS score. Simultaneously all patients were asked to assess their preoperative status retrospectively.

RESULTS

Using the medical charts for retrospective assessments, the preoperative status was estimated too low compared to prospective evaluation. This effect was even more pronounced with the patients' own retrospective assessment of their preoperative status. Linear regression coefficient for prospective and retrospective data showed moderate correlation with r = 0.59 for the AOFAS Score using the medical charts and poor correlation of r = 0.24 using the patients' own retrospective assessments. Spearman's rank correlation index was p = 0.57 and p = 0.23, respectively. The coefficient of repeatability according to Bland and Altman was 25.7 and 48.7 points, respectively, for the AOFAS score. The difference between the mean values of prospective and retrospective assessment was 5.6 (13.0) points. This means that a retrospectively evaluated AOFAS Score may be 31.3 points below or 20.1 points above prospective assessments (61.6 points below or 35.7 points above compared to the patients' own retrospective self-assessments). Agreement between individual items using Kappa statistics showed poor results except for metatarsophalangeal joint motion.

CONCLUSIONS

Prospectively and retrospectively evaluated AOFAS scores cannot be used interchangeably for clinical outcome evaluations. Retrospective scoring gives worse results even when evaluated using conscientiously recorded medical charts and therefore leads to overestimation of the effect of surgery. These data support prospective study designs to ensure the best outcome analysis for clinical evaluation of hallux surgery.

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system

BACKGROUND

The aim of this study was to report the five scales comprising the rating system that the Japanese Society for Surgery of the Foot (JSSF) devised (JSSF standard rating system) and the newly offered interpretations and criteria for determinations of each assessment item.

METHODS

We produced the new scales for the JSSF standard system by modifying the clinical rating systems established by the American Orthopaedic Foot and Ankle Society (AOFAS scales) and the Japanese Orthopaedic Association's foot rating scale (JOA scale). We also provided interpretations of each assessment item and the criteria of determinations in the new standard system.

RESULTS

We improved the ambiguous expressions and content in the conventional standard rating systems so they would be easily understood by Japanese people. The result was five scales in total. Four were designed for use specifically for ankle-hindfoot, midfoot, hallux metatarsophalangeal-interphalangeal, and lesser metatarsophalangeal-ineterphalangeal sites; and the fifth was for the foot and ankle with rheumatoid arthritis. Furthermore, we described interpretations and criteria for determinations with regard to evaluation items in each scale.

CONCLUSIONS

Conventionally, the AOFAS scales or the JOA scale have been separately applied depending on the sites or disorders concerned, but it was often difficult to decide on scores during practical evaluations because of differing expressions in different languages and also because of ambiguity in the interpretation of each evaluation item and in scoring standards as well. JSSF improved these scales and added definite interpretations of evaluation items as well as criteria for the rating (to be reported here in part I). Because these steps were expected to improve the reliability of outcomes assessed by each scale, we examined the reliability in scores of the newly developed scales, which are reported in part II (in this issue).

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders II: interclinician and intraclinician reliability and validity of the newly established standard rating scales and Japanese Orthopaedic Association rating scale

BACKGROUND

This study evaluated the validity and inter- and intraclinician reliability of (1) the Japanese Society of Surgery of the Foot (JSSF) standard rating system for four sites [ankle-hindfoot (AH), midfoot (MF), hallux (HL), and lesser toe (LT)] and the rheumatoid arthritis (RA) foot and ankle scale and (2) the Japanese Orthopaedic Association's foot rating scale (JOA scale).

METHODS

Clinicians from the same institute independently evaluated participating patients from their institute by two evaluations at a 1- to 4-week interval. Statistical evaluation was as follows. (1) The intraclass correlation coefficient (ICC) was calculated from data collected from at least two examinations of each patient by at least two evaluating clinicians (Data A). (2) Total scores for the two evaluations were determined from the distribution of differences in data between the two evaluations (Data B); each item was evaluated by determining Cohen's coefficient of agreement. (3) The relation between patient satisfaction and total score was investigated only for patients who underwent surgery (Data C). Spearman's rank correlation coefficient was obtained.

RESULTS

Participants were 65 clinicians and 610 patients, including those with disorders of the AH (313), MF (47), HL (153), and LT (50) and those with RA (47). From Data A, the ICC was high for AH and HL by JSSF scales and for AH, MF, and LT by the JOA scale. From Data B, the coefficient showed high validity for both scales for AH, with almost no difference between the two scales; the validity for HL was higher with the JOA scale than with the JSSF scale. From Data C, correlations were significant between patient satisfaction and outcome for AH and HL by the JSSF scales and for AH, HL, and LT by the JOA scale.

CONCLUSIONS

The validity of both scales was high. Clinical evaluation of the therapeutic results using these scales would be highly reliable.

Age-adjusted baseline data for women with hallux valgus undergoing corrective surgery

BACKGROUND

Functional and health-related quality-of-life data on a population of patients with hallux valgus are lacking. Similarly, the correlation of the severity of the deformity with these measures is unknown.

METHODS

Two hundred and eighty-five women with an average age of forty-nine years who were scheduled for bunion surgery were enrolled in the study. The patients completed a baseline American Academy of Orthopaedic Surgeons (AAOS) foot and ankle outcomes questionnaire, which includes the Short Form-36 (SF-36) and a specific lower-extremity section on the foot and ankle. Preoperative radiographic data with regard to the hallux valgus angle and the intermetatarsal angle were stratified into groups according to the severity of the deformity (mild, moderate, or severe). The data were then stratified into age-groups consistent with those reported for the SF-36, and the results were compared with the SF-36 scores for the general population. The global foot and ankle score and the shoe comfort score were compared with general population scores that were published previously. The severity of the preoperative deformity was correlated with the baseline scores.

RESULTS

General health scores were noted to be relatively stable throughout the age-groups for patients with bunions, with the older groups demonstrating better scores than the general population. Bodily pain scores were consistently worse for patients with a bunion through all age-groups compared with the general population. The average global foot and ankle score and the shoe comfort score were significantly lower (p < 0.001 for both) for the patients with a bunion than for the general population. The severity of the preoperative deformity did not correlate with any of the outcome scores.

CONCLUSIONS

The bodily pain score from the SF-36 appears to be a sensitive measure of problems experienced by patients undergoing bunion surgery. Surprisingly, the severity of the deformity as measured radiographically did not correlate with any of the fifteen scores measured. These data may serve as a baseline for clinical hallux valgus studies with use of the SF-36 or the AAOS outcomes questionnaire.

Triple arthrodesis in adults with non-paralytic disease. A minimum ten-year follow-up study

BACKGROUND

The triple arthrodesis was developed to treat sequelae of neurologic disorders affecting the hindfoot. Today, the typical adult patient undergoing this procedure has degenerative disease, usually not related to a neurologic disorder. The purpose of this study was to investigate the long-term outcome of triple arthrodesis in this patient population.

METHODS

Twenty-seven adult patients (thirty-one feet) who had undergone triple arthrodesis for the treatment of chronic hindfoot pain and had been followed for a minimum of ten years completed an outcomes questionnaire, and twenty-two patients (twenty-six feet) were available for physical examination, radiographs, and functional testing. The mean age of the patients who were examined was forty-five years at the time of the surgery, and the mean duration of follow-up of those patients was fourteen years (range, eleven to eighteen years).

RESULTS

Twenty-five (93%) of the patients were satisfied with the result of the treatment. However, only eleven (41%) reported that they could perform moderate activity with mild or no pain in the foot and ankle. Twenty patients (74%) reported moderate-to-severe difficulty with, or an inability to negotiate, uneven surfaces. The mean Short Form-36 (SF-36) physical component outcomes score was 35.2 points, well below the mean of 50 points for the United States population. The SF-36 score was significantly lower for patients with systemic inflammatory disease (primarily rheumatoid arthritis). There was an average 12 degrees (27%) loss of plantar flexion but no significant loss of dorsiflexion compared with the untreated foot. Severe arthrosis developed in seven of the twenty-six ankles, in seven naviculocuneiform joints, and in six tarsometatarsal joints. Some patients had severe arthrosis at more than one level, and three patients later required an ankle arthrodesis. There were no nonunions or revisions of the triple arthrodeses. The average patient performances on the six-minute walk and the 3-m up-and-go functional tests were well below the age-controlled means.

CONCLUSIONS

Triple arthrodesis may provide patients with substantial long-term relief of preoperative symptoms. However, there may also be adverse consequences, particularly degenerative changes in adjacent joints, that may be reasons for orthopaedic surgeons to consider alternatives to triple arthrodesis when feasible.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

A meta-analysis of outcome rating scales in foot and ankle surgery: is there a valid, reliable, and responsive system?

BACKGROUND

Rating scales that are valid, reliable, and responsive communicate the severity of a functional problem, facilitate the accurate study of treatment modalities, and provide a common language for those involved in research. The purpose of this study was to determine which outcome rating scales are currently used in the foot and ankle literature and to identify rating scales with proven reliability, validity, and responsiveness.

METHOD

A meta-analysis of the foot and ankle literature from 1990 to 2001 was done. All referenced rating scales were reviewed to determine if any had proven to be reliable, valid, or responsive.

RESULTS

Forty-nine different rating scales were identified. The most frequently referenced scales were the subscales of the American Orthopaedic Foot and Ankle Society (AOFAS). No rating scale was identified that demonstrated reliability, validity, and responsiveness in patients with a variety of foot and ankle conditions.

CONCLUSIONS

The development of a reliable, valid, and responsive rating scale would have value not only in assessing patient outcomes but also in reporting the results of clinical studies in foot and ankle surgery.

Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy

BACKGROUND

To assess the efficacy of surgical correction of stage II tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular, the authors retrospectively reviewed results of treatment of stage II posterior tibial tendon deficiency in 129 patients for whom surgery was performed between 1990 and 1997.

METHODS

The indication for surgery included tendon weakness, flexible deformity, and foot pain refractory to nonsurgical treatment. All patients had a painful flexible flatfoot without fixed forefoot supination deformity (stage II). A medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular were done. The patients were examined, radiographs were obtained, and isokinetic evaluation of both feet was performed at a mean of 5.2 years postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form Health Surgery (SF-36) were used to evaluate patients postoperatively.

RESULTS

The mean AOFAS score at follow-up was 79 points (range, 54-93). There were seven significant complications in six patients. Isokinetic inversion and plantarflexion power and strength were symmetric with the contralateral limb in 95 patients, mildly weak in 18 patients, and moderately weak in eight patients. Subtalar joint motion was normal in 56 (44%), slightly decreased in 66 (51%), and moderately decreased in seven patients (5%). Correction was significant (p < .05) in all four radiographic parameters evaluated. Patients were entirely satisfied (118 patients), partially satisfied (seven patients), or dissatisfied (four patients). Further, 125 (97%) experienced pain relief, 121 (94%) showed improvement of function, 112 (87%) experienced improvement in the arch of the foot, and 108 (84%) were able to wear shoes comfortably without shoe modifications or orthotic arch support.

CONCLUSIONS

The surgical correction of stage II posterior tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications and a high patient satisfaction rate.

Total ankle replacement in patients with rheumatoid arthritis

Patients with rheumatoid arthritis commonly experience involvement of the ankle and hindfoot. Severe pain and functional limitations may develop as a result of tibiotalar arthritis, requiring surgical treatment. The advantages of total ankle arthroplasty over ankle arthrodesis include preservation of motion and decreased stresses on the midfoot and subtalar joints. Previous experience with early design ankle replacements revealed high complication rates and as much as 75% of component loosening. Modern ankle implants have been designed to achieve uncemented fixation with less articular constraint. Patients with rheumatoid arthritis who had total ankle replacement using two different types of second-generation ankle implants were examined clinically and radiographically. The average postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 81 of a possible 100, at a mean of 6.4 years after surgery. Radiographically, 88.5% of implants were stable without evidence of subsidence at a mean of 6.3 years. Three tibial components had subsided at an average of 7 years. There was evidence of tibial osteolysis with the Buechel Pappas Low Contact Stress implant in 11.5% of patients. Total ankle replacement in patients with rheumatoid arthritis, using a second-generation prosthesis, can provide reliable relief of pain and good functional results at intermediate-term followup, although the incidence of osteolysis warrants close followup.

Salvage of a failed Keller resection arthroplasty

BACKGROUND

A number of typical complications have been associated with Keller resection arthroplasty. Recurrent valgus deformity, cock-up deformity, and a flail toe may be difficult problems for the treating surgeon because options for salvage are limited. In this study, we evaluated arthrodesis of the first metatarsophalangeal joint as a salvage technique following a failed Keller procedure. In addition, the outcomes of motion-preserving procedures were reviewed in a separate series.

METHODS

Arthrodesis of the first metatarsophalangeal joint was performed in twenty-eight patients (twenty-nine feet, group A), and either a repeat Keller procedure or an isolated soft-tissue release was performed in eighteen patients (twenty-one feet, group B). The patients were evaluated at least twenty-four months postoperatively, with a personal interview and a clinical examination with use of a modification of the hallux metatarsal-interphalangeal scale. Radiographs were also made for the group treated with the arthrodesis.

RESULTS

In group A, the average duration of follow-up was thirty-six months and fusion was achieved in twenty-six of the twenty-nine feet. Satisfaction was excellent or good in twenty-three cases, and the postoperative score according to the modified hallux metatarsal-interphalangeal scale averaged 76 points (maximum, 90 points). A repeat arthrodesis was necessary in five feet because of malposition or pseudarthrosis. In group B, the average duration of follow-up was seventy-four months. Satisfaction was excellent or good in only six cases, and the patient was dissatisfied in eleven cases. The score according to the modified hallux metatarsal-interphalangeal scale averaged 48 points. Valgus deviation and cock-up deformity had recurred in the majority of the feet at the time of follow-up.

CONCLUSIONS

Although it is more technically demanding, we recommend arthrodesis for salvage following a failed Keller procedure since it may be associated with a higher rate of patient satisfaction and better clinical results.

Outcome of resection of a symptomatic os trigonum

BACKGROUND

While an os trigonum at the posterolateral aspect of the talus is usually asymptomatic, this inconsistently present accessory bone has been associated with persistent posterior ankle pain, which has been described as the os trigonum syndrome. We present the clinical results of excision of the os trigonum through a posterolateral approach and report several factors affecting the clinical outcome.

METHODS

During a five-year period from 1994 through 1999, forty-one patients had a failure of nonoperative treatment of os trigonum syndrome and underwent excision of a symptomatic os trigonum. In all cases, the os trigonum syndrome was diagnosed on the basis of the history, physical examination, and radiographs. Postoperatively, the patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. A questionnaire was used to evaluate the effect of several factors on the clinical outcome.

RESULTS

The average duration of follow-up was forty-four months. The postoperative AOFAS score averaged 87.6 points. The thirty-three patients who had had symptoms for two years or less prior to the surgery had an average postoperative score of 90 points compared with 78 points for the eight patients who had had preoperative symptoms for more than two years (p = 0.011). Eight patients had sural nerve sensory loss, which was temporary in four and permanent in four. A superficial wound infection developed in one patient, and reflex sympathetic dystrophy developed in another.

CONCLUSIONS

An os trigonum that is persistently symptomatic after a minimum three-month trial of nonoperative treatment can be excised through a posterolateral approach with highly satisfactory results. The main complication of this procedure is sural nerve injury.

First metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy for treatment of hallux valgus: an intermediate-term retrospective outcomes study

The authors present a retrospective study of 14 patients (20 feet) treated with first metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy and distal soft tissue alignment for hallux valgus associated with hypermobility of the first ray and an increased proximal articular set angle. The purpose of this study was 3-fold: (1) to determine clinical outcome of this procedure combination, (2) to evaluate the effect of this procedure on the radiographic parameters of hallux valgus, and (3) to determine the degree of first ray shortening. At a mean 50.1 months postoperatively, patients were evaluated according to the American Orthopedic Foot and Ankle Society's Hallux-First Metatarsophalangeal-Interphalangeal Clinical Rating Scale. Preoperative and follow-up radiographs were compared for changes in the following measurements: 1-2 intermetatarsal angle (IMA), hallux abduction angle (HAA), proximal articular-set angle (PASA), and metatarsal protrusion distance (MPD). Statistical analysis using the Student t test showed a significant increase in total scores from a mean 43.6 to 92.6 of 100. A significant decrease was found in the IMA from a mean 16.9 degrees to 7.1 degrees, in the HAA from a mean 37.1 degrees to 5.2 degrees, in the PASA from a mean 20.3 degrees to 3.4 degrees (P <.001), and a significant change in the was found in the MPD of 7.7 mm (P <.001). Given the high rating scale scores, first ray shortening did not appear to hamper our patients' clinical outcome.