The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle

Using PROMIS Scores to Provide Cost-Conscious Follow-up After Foot and Ankle Surgery

BACKGROUND

National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores.

METHODS

Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates.

RESULTS

Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively.

CONCLUSION

Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Isolated Talonavicular Arthrodesis as Treatment for Flexible Progressive Collapsing Foot Deformity: A Case Series

Background

For the younger, more active patient with flexible symptomatic progressive collapsing foot deformity (PCFD), joint-sparing procedures may be preferred to preserve functional motion. Isolated talonavicular (TN) arthrodesis has been described for treatment of rigid and flexible PCFD for patients that are older and less active whose deformity is still correctable through the TN joint. The purpose of this study was to evaluate radiographic and clinical outcomes in patients with PCFD treated with isolated triplanar correction with a TN joint arthrodesis.

Methods

Forty-nine patients (53 feet) with flexible PCFD underwent isolated TN arthrodesis. Weightbearing radiographs were performed pre- and postoperatively, and measurements included lateral talar-first metatarsal angle, calcaneal pitch, TN coverage angle, and the anteroposterior (AP) talar-first metatarsal angle. The Foot and Ankle Ability Measure (FAAM) and Veterans-Rand 12-Item Health Survey (VR-12) scores were also collected.

Results

Thirty-five females and 14 males were evaluated with a mean age of 63 years, at an average follow-up of 41.3 months. Significant improvements were found radiographically. Lateral radiographs demonstrated improvements in lateral talar-first metatarsal angle from 25.2 degrees preoperatively to 9.5 degrees postoperatively (P < .001) and calcaneal pitch from 14.9 degrees preoperatively to 17.5 degrees postoperatively (P < .001). AP radiographs showed the TN coverage angle improving from 35.0 degrees to 4.9 degrees postoperatively (P  < .001) and AP talar-first metatarsal angle improving from 17.3 degrees to 5.9 degrees postoperatively (P < .001). Clinical outcomes were improved in the FAAM pain score (48.6 to 39.2, P = .130), FAAM ADL score (53.8 to 69.2, P = .002), FAAM Sport score (29.5 to 40.7, P = .099), and the overall FAAM score (47.7 to 63.1, P = .006). Patient satisfaction with medical care was 85.2/100 postoperatively.

Conclusion

Isolated TN arthrodesis is a viable surgical option for older, lower-demand patients with flexible PCFD. This study demonstrated significant improvements in radiographic alignment and FAAM scores. Comparative studies with other surgical procedures should be performed to determine which is the best technique for older, lower-demand patients with flexible PCFD.

Level of Evidence

Level III, retrospective cohort study.

Validation of the Foot and Ankle Outcome Score (FAOS) for Osteochondral Lesions of the Ankle

BACKGROUND

The purpose of this study was to validate the Foot and Ankle Outcome Score (FAOS) for osteochondral lesions of the talus (OLTs). We hypothesize that the FAOS will meet all 4 psychometric criteria for validity in this patient population.

METHODS

From 2008 to 2014, a total of 208 patients with OLTs were included in the construct validity portion of the study. All patients completed FAOS and 12-Item Short-Form Health Survey (SF-12) scores. Twenty additional patients were prospectively recruited and were asked to complete questionnaires to determine the relevance of each of the FAOS questions as it related to their OLT. Forty-four patients completed the FAOS 1 month after the first FAOS to assess reliability via Spearman correlation coefficient. Responsiveness of the FAOS was assessed with 54 patients who had both preoperative and postoperative FAOS scores via Student paired t test with significance determined as P < .05. In total, 229 unique patients were included in this study.

RESULTS

Statistically significant associations were found between all FAOS and SF-12 subscales (P < .01). The FAOS symptoms subscale demonstrated the lowest correlation with the SF-12 physical health domains. No floor or ceiling effects were identified. Weak correlations were calculated between the 5 FAOS subscales and the SF-12 mental component summary score. All FAOS domains met the threshold for acceptable content validity (score > 2.0). All FAOS subscales demonstrated acceptable test-retest reliability, with ICC values ranging from 0.81 (ADL) to 0.92 (Pain).

CONCLUSION

This study demonstrates the acceptable yet moderate construct and content validity, reliability, and responsiveness of the FAOS for patients with OLTs of the ankle joint. We endorse the use of the FAOS in evaluating ankle OLTs in both the research and clinical setting and consider it a useful patient-reported, self-administered instrument following surgical intervention.

LEVEL OF EVIDENCE

Level IV, retrospective case study.

Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

BACKGROUND

Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation.

METHODS

New foot and ankle patients completed PROMIS physical function (PF), pain interference (PI), and depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). Responses to the CG-CAHPS questions and PAM were compared between the 2 groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored.

RESULTS

After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses nor PAM scores between the 2 groups (P > .05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate "top box" scores for the understanding domain of the CG-CAHPS question (OR 0.51, P < .001) and had decreased odds of high patient activation compared to control subjects (OR 0.67; P = .005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (P = .09).

CONCLUSION

Highly rated foot and ankle surgeons who show and discuss PROM results may not improve patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROM discussions are most beneficial and how best to present PROMs data, as we suspect that how the information was presented-and not the use of PROMs-resulted in our findings. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession

BACKGROUND

There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession.

METHODS

The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic.

RESULTS

We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001).

CONCLUSION

In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Comparing Patient-Reported Outcomes Measurement Information System Computer Adaptive Testing With Existing Measures After Operative Interventions for Extremity Fractures

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS) enables the use of computer adaptive testing (CAT). The aim of this prospective cohort study was to compare the most commonly used disease-specific instruments with PROMIS CAT questionnaires in patients with trauma.

METHODS

All patients with trauma (ages 18-75) who underwent an operative intervention for an extremity fracture between June 1, 2018, and June 30, 2019, were included. The disease-specific instruments were the Quick Disabilities of the Arm, Shoulder, and Hand for upper extremity fractures and the Lower Extremity Functional Scale (LEFS) for lower extremity fractures. Pearson's correlation (r) between the disease-specific instruments and the PROMIS CAT questionnaires (PROMIS Physical Function, PROMIS Pain Interference, and PROMIS Ability to Participate in Social Roles and Activities) was calculated at week 2, week 6, month 3, and month 6. Construct validity and responsiveness were calculated.

RESULTS

A total of 151 patients with an upper extremity fracture and 109 patients with a lower extremity fracture were included. At month 3 and month 6, the correlation was strong between the LEFS and PROMIS Physical Function (r = 0.88 and r = 0.90, respectively), and at month 3, the correlation was strong between the LEFS and PROMIS Social Roles and Activities (r = 0.72). At week 6, month 3, and month 6, there was a strong correlation between the Quick Disabilities of the Arm, Shoulder, and Hand and PROMIS Physical Function (r = 0.74, r = 0.70, and r = 0.76, respectively).

CONCLUSIONS

The PROMIS CAT measures are acceptably related to existing non-CAT instruments and may be a useful tool during follow-up after operative interventions for extremity fractures.

Empfehlung für Fragebögen zur Untersuchung der Fuß- und Sprunggelenkfunktion vom Research-Komitee der AGA

Das standardisierte Erheben von Behandlungsergebnissen findet immer mehr Einzug in die moderne Medizin. Hierbei ist vor allem das subjektive Ergebnis aus Patientensicht und die damit häufig einhergehende Zufriedenheit mit der medizinischen Behandlung in den Fokus gerückt. Dies hat in den letzten Jahren nicht nur in der akademischen Landschaft, sondern auch auf gesundheitspolitischer Ebene deutlich an Bedeutung gewonnen. Dies bedeutet, dass das Behandlungsergebnis immer mehr Einfluss auf die Vergütung der Leistungserbringer erhält, auch „value-based healthcare“ genannt. Insbesondere in der Orthopädie und Traumatologie gibt es dabei zahlreiche gelenkspezifische Messinstrumente (Fragebögen, Scores oder „patient-reported outcome measures“ [PROMs]), wobei in der Fuß- und Sprunggelenkchirurgie hierfür eine Vielzahl an Fragebögen verfügbar ist, die sich jedoch häufig sehr heterogen und selten pathologiespezifisch darstellen. In Anbetracht der derzeitigen Mannigfaltigkeit an PROMs in der aktuellen Literatur ist es deshalb von Interesse, die wissenschaftliche Qualität zu prüfen und gleichzeitig die Forschungskommunikation zu vereinheitlichen, indem etablierte und gemäß akademischen Gütekriterien ausgewählte Fragebögen zum Einsatz kommen. Ziel ist es, valide, verlässliche und möglichst repräsentative Daten zu gewinnen, um eine akkurate Darstellung der tatsächlichen Ergebnisse zu erreichen. Dies bedingt neben qualitativen Kriterien auch immer kompakte und leicht verständliche Fragenkataloge, um so eine möglichst hohe Rücklaufquote zu generieren. Schließlich sollte auch immer eine Einschätzung der klinischen Relevanz der erhaltenen Ergebnisse stattfinden. Hierfür hat sich der kleinste vom Patienten als klinische Veränderung wahrgenommene Wert des jeweiligen PROM („minimal clinically important difference“, MCID) durchgesetzt. Für den Fuß- und Sprunggelenkbereich werden dabei vom Research Komitee der AGA unter Berücksichtigung dieser Kriterien folgende Messinstrumente empfohlen: FAOS (Foot and Ankle Outcome Score) zur Beurteilung der allgemeinen Schmerzsymptomatik und Funktion sowie der EQ-5D-Fragebogen zur Beurteilung der Lebensqualität. Zwar kann aufgrund fehlender Datenlage keine pathologiespezifische Empfehlung abgegeben werden, jedoch ist der FAOS für eine Vielzahl von Fuß- und Sprunggelenkpathologien validiert und liegt zudem in deutscher Sprache vor.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS

Background

Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms.

Methods

From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used.

Results

A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores.

Conclusion

Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms.

Level of Evidence

Level III, case-control study.

Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair

BACKGROUND

There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques.

METHODS

A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution's registry. Demographics and complications were recorded.

RESULTS

PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection).

CONCLUSION

Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

What patient factors and Patient-Reported Outcomes Measurement Information System domains are associated with worse pain coping in pediatric orthopaedic patients in the United States?

We sought to better understand the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) mobility, pain interference (PI) and depressive symptoms scores, as well as determine what patient factors and PROMIS domains were associated with worse pain coping (PROMIS PI), in a pediatric orthopaedic population. Between 27 August 2015 and 30 April 2019, new pediatric orthopaedic patients 18 years or younger (or their guardians as a proxy) were asked to complete PROMIS mobility, PI and depressive symptoms domains at an academic medical center pediatric orthopaedic clinic. Pearson correlation coefficients (r) were calculated between each PROMIS domain. Linear multivariate regression analysis was used to determine patient characteristics and PROMIS domains associated with presenting PROMIS PI scores. There was a strong-moderate correlation between PROMIS mobility and PI (r = -0.66, P < 0.001), while the correlation between PROMIS mobility and depressive symptoms was moderate-poor (r = -0.38, P < 0.001). There was a moderate correlation between PROMIS depressive symptoms and PI (r = 0.54, P < 0.001). In multivariate linear regression analysis, female gender (β = 0.82, P < 0.001), self-reported black race (β = 0.94, P < 0.001), Medicaid insurance (β = 0.82, P < 0.001) and worsening depressive symptoms (β = 0.33, P < 0.001) were associated with worse pain coping mechanisms, while increasing mobility (β = -0.47, P < 0.001) was associated with better pain coping mechanisms. Poor mobility and worse depressive symptoms are associated with worse pain coping mechanisms. Additionally, Medicaid insurance status, black race and female gender are also associated with worse physical limitations secondary to pain.

Influence of Complications and Revision Surgery on Fulfillment of Expectations in Foot and Ankle Surgery

BACKGROUND

Fulfillment of patients' expectations following foot and ankle surgery has been previously studied, and shown to be an effective modality in assessing patient-reported outcomes (PROs). Although this assessment has been shown to correlate well with patient satisfaction and other validated PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients' expectations.

METHODS

Preoperatively, patients completed a validated Foot and Ankle Expectations Survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (return to operating room for revision, deep infection). FP in patients with a complication was compared to patients who did not experience a complication. In addition, the Foot and Ankle Outcomes Score (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication: 25 major (19 revisions, 6 deep infections requiring irrigation and debridement), 4 minor (4 superficial infections requiring antibiotics), and 2 major and minor (revision and superficial infection). Average time from complication to completion of fulfillment survey was 15 (±3.6) months. The groups were similar in diagnoses.

RESULTS

Complications were associated with significantly worse FP (0.69 ± 0.45 vs 0.86 ± 0.40, P = .02). Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP (P < .001). FAOS domains were similar between groups preoperatively; postoperatively, patients without complications had significantly higher Activities of Daily Living and Quality of Life scores (P < .05). Demographically, there was no difference in age, sex, body mass index, Charlson Comorbidity Index, depression/anxiety, or pain management between the 2 groups.

CONCLUSION

Our data suggests that postoperative complications following foot and ankle surgery were associated with worse patient-reported fulfillment of their operative expectations even after recovery from the initial surgery and complication. This finding is independent of preoperative expectations, and correlates with patient satisfaction with their procedure. Therefore, while patient-perceived fulfillment following foot and ankle surgery is multifactorial, the incidence of a postoperative complication negatively impacts fulfillment as well as satisfaction following surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative series.

Preoperative PROMIS Physical Function Scores Predict Postoperative Outcomes Following Total Ankle Replacement

BACKGROUND

Despite good evidence that supports significant improvements in pain and physical function following a total ankle replacement (TAR) for end-stage ankle arthritis, there is a subset of patients who do not significantly benefit from surgery. The purpose of this study was to perform a preliminary analysis to determine if preoperative Patient-Reported Outcome Measurement Information System (PROMIS) scores could be used to predict which patients were at risk of not meaningfully improving following a TAR.

METHODS

Prospectively collected preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 111 feet in 105 patients were included in the study. Significant postoperative improvement was defined using minimal clinically important differences (MCIDs). Logistic regression models and area under the curve (AUC) analyses were used to determine whether preoperative PROMIS scores were predictive of postoperative outcomes.

RESULTS

Receiver operating characteristic curves found statistically significant AUCs for the PROMIS physical function (AUC = 0.728, P = .004), pain intensity (AUC = 0.720, P = .018), and depression (AUC = 0.761, P < .001) domains. The preoperative PROMIS pain interference domain did not achieve a statistically significant AUC.

CONCLUSION

Preoperative PROMIS physical function and pain intensity t scores may be used to predict postoperative improvement in patients following a fixed-bearing TAR; however, preoperative PROMIS pain interference scores were not good predictors. The results of this study may be used to guide research regarding patient-reported outcomes following TAR.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Preoperative Patient-Reported Outcome Measures Relationship With Postoperative Outcomes in Flexible Adult-Acquired Flatfoot Deformity

BACKGROUND

Previous studies have demonstrated that procedure-specific thresholds using preoperative patient-reported outcome scores may be used to predict postoperative outcomes. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) thresholds could be used to predict which patients would clinically improve at 2 years postoperatively following reconstruction of their flexible adult-acquired flatfoot deformity (AAFD).

METHODS

PROMIS physical function, pain interference, and depression scores were prospectively collected preoperatively and at a minimum of 2 years postoperatively for 75 feet with flexible AAFD. Minimal clinically important differences (MCIDs) were calculated to establish significant postoperative improvement. Receiver operating characteristic curves and area under the curve analyses were employed to determine whether preoperative PROMIS scores could be used to predict postoperative outcomes.

RESULTS

The PROMIS physical function receiver operating characteristic curve analysis (area under the curve = 0.913, P < .001) found that a preoperative PROMIS physical function score greater than 45.7 resulted in a 14.3% probability of achieving the MCID, whereas a preoperative score of less than 40.8 had a 97.7% probability of achieving the MCID. A preoperative PROMIS pain interference score (area under the curve = 0.799, P < .001) less than 54.1 had only a 23.1% probability of achieving the MCID at 2 years postoperatively.

CONCLUSIONS

Preoperative PROMIS physical function and pain interference scores could be used to predict postoperative improvement in patients with flexible AAFD. These results may help surgeons counsel patients regarding the anticipated benefit of surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Application of Computerized Adaptive Testing to the Foot and Ankle Ability Measure

BACKGROUND

Patient-reported outcome measures are an increasingly important tool for assessing the impact of treatments orthopedic surgeons render. Despite their importance, they can present a burden. We examined the validity and utility of a computerized adaptive testing (CAT) method to reduce the number of questions on the Foot and Ankle Ability Measure (FAAM), a validated anatomy-specific outcome measure.

METHODS

A previously developed FAAM CAT system was applied to the responses of patients undergoing foot and ankle evaluation and treatment over a 3-year period (2017-2019). A total of 15 902 responses for the Activities of Daily Living (ADL) subscale and a total of 14 344 responses for the Sports subscale were analyzed. The accuracy of the CAT to replicate the full-form score was assessed.

RESULTS

The CAT system required 11 questions to be answered for the ADL subscale in 85.1% of cases (range, 11-12). The number of questions answered on the Sports subscale was 6 (range, 5-6) in 66.4% of cases. The mean difference between the full FAAM ADL subscale and CAT was 0.63 of a point. The mean difference between the FAAM Sports subscale and CAT was 0.65 of a point.

CONCLUSION

The FAAM CAT was able to reduce the number of responses a patient would need to answer by nearly 50%, while still providing a valid outcome score. This measure can therefore be directly correlated with previously obtained full FAAM scores in addition to providing a foot/ankle-specific measure, which previously reported CAT systems are not able to do.

LEVEL OF EVIDENCE

Level IV, case series.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Overall Health and the Influence of Physical Therapy on Physical Function Following Total Ankle Arthroplasty

BACKGROUND

The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy.

METHODS

People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain T scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain T scores that scored below the population mean were examined with multiple linear regression or ordinal regression.

RESULTS

The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean [SD]: 40.0 [35.3] months). Physical function and ability to participate in social roles and activities domain T scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 [11.0] visits) and found it helpful (7.2 [3.0]). Participant characteristics were minimally predictive of physical function and social participation T scores. Number of physical therapy visits predicted physical function T scores (P = .03).

CONCLUSIONS

Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Relationship of Press Ganey Satisfaction and PROMIS Function and Pain in Foot and Ankle Patients

BACKGROUND

Patient satisfaction has garnered interest as a tool to measure health care quality. However, orthopedic studies in total joint arthroplasty, spine, and hand patients have offered conflicting relationships between Press Ganey (PG) satisfaction metrics and patient-reported outcome (PRO) measures. No prior study has assessed the relationship between PG and PROs in foot and ankle patients. Whether satisfaction and outcomes instruments, though, measure similar or differing aspects of the patient experience is unclear. Here, we tested if there was an association between Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes and PG satisfaction scores.

METHODS

PG and PROMIS outcomes data for new patient visits to an orthopedic foot and ankle clinic between 2015 and 2017 were retrospectively analyzed. Patients that completed PG satisfaction surveys were included for study. All patients who completed PG surveys and completed one or both PROMIS physical function (PF) or pain interference (PI) metrics administered by computerized adaptive testing were included. Negative binomial regressions were used to compare PRO scores to PG overall satisfaction and PG satisfaction with care provider, adjusting for patient characteristics. Results were reported as dissatisfaction score ratios, which represented the amount of PG dissatisfaction associated with a 10-point increase in PROMIS PF or PI. Of the 3984 new patient visits, only 441 completed the PG survey (11.3% response rate).

RESULTS

Ceiling effects were seen with PG data: 64% of patients reported perfect satisfaction with care provider and 27% had perfect overall satisfaction. Higher function on the PROMIS PF was weakly associated with increased overall satisfaction (ratio = 0.82, 95% CI: 0.68-0.99, P = .039) and increased satisfaction with care provider (ratio = 0.60, 95% CI: 0.40-0.92, P = .019). However, pain (PROMIS PI) was not associated with overall satisfaction or with satisfaction with care provider.

CONCLUSIONS

Based on our data here, patient satisfaction was weakly related to patient-reported function but not pain interference among this subset of new patients presenting to a foot and ankle clinic. Given our essentially negative findings, further study is needed to determine which aspects of the PG satisfaction and PROMIS scores track similarly. Further, our findings add to the growing literature showcasing limitations of the PG tool, including low response rates and notable ceiling effects. If satisfaction metrics and patient-reported outcomes capture differing aspects of the patient experience, we need to better understand how that influences the measurement of health care quality and value.

LEVEL OF EVIDENCE

Level III, comparative study.

Contribution of First-Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult-Acquired Flatfoot Deformity

Background:

Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. However, many surgeons surgically correct the deformity without directly addressing this joint. The purpose of this study was to examine the role of first-tarsometatarsal (TMT) fusion combined with subtalar fusion in correcting deformity at the NC joint.

Methods:

We retrospectively analyzed 40 patients (41 feet) who underwent first-TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed 6 radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1-year follow-up.

Results:

The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (P < .01). Overall, patients had statistically significant improvement in all PROMIS domains (P < .01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes.

Conclusions:

Our data suggest that when addressing painful collapse of the medial arch in patients with AAFD, fusion of the first-TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint in our patient cohort at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Although TMT fusion had no effect on NC deformity, residual or worsening NC deformity did not significantly affect clinical outcomes. In addition, the NCIA was found to be a reliable radiographic parameter to assess NC deformity in the presence of talonavicular and/or first-TMT fusion.

Level of Evidence:

Level III, retrospective comparative study.

Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection

BACKGROUND

Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers.

METHODS

We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded.

RESULTS

Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average.

DISCUSSION

In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation.

LEVEL OF EVIDENCE

IV, Case Series.

Symptom and Disability Measurement by Common Foot and Ankle-Specific Outcome Rating Scales

BACKGROUND

Well-designed foot and ankle clinical outcomes research requires region-specific subjective outcome measures. Many foot and ankle-specific instruments are now available. Determining which instruments to choose is daunting. We present a patient survey to determine the most relevant questions pertaining to them.

METHODS

Sixteen foot and ankle-specific outcome instruments were chosen based on popularity, emphasizing valid, reliable, responsive scores. Subjective portions were consolidated and given to 109 patients with osteochondral lesion of the talus (OLT) (39), ankle instability (35), and ankle arthritis (35). Outcome instruments were measured according to 4 criteria: number of questions endorsed by 51%, number with high mean importance, number with low mean importance, and number with the highest-ranking frequency importance product. Instruments were then ranked based on relative score, with the highest scores indicating the instrument was the most useful for that sample.

RESULTS

The Foot and Ankle Outcome Score (FAOS) achieved the highest score in all 4 categories for OLT, followed by Foot and Ankle Ability Measure (FAAM) and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Score. The FAOS achieved the highest score in all 4 categories for ankle instability, followed by FAAM and AAOS. For osteoarthritis, the FAOS achieved the highest relative score followed by FAAM and AAOS. The AOF, Ankle Osteoarthritis Score, and AAS are instruments commonly used that had lower relative scores.

CONCLUSION

The FAOS, FAAM, and AAOS Foot and Ankle Score contain several items important to patients with osteochondral lesions of the talus, ankle instability, and ankle osteoarthritis.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Position of the Posteromedial Ankle Structures in Patients Indicated for Total Ankle Replacement

Background:

The posteromedial ankle structures are at risk during total ankle replacement (TAR). The purpose of our study was to investigate the distance of these structures from the posterior cortex of the tibia and talus in order to determine their anatomy at different levels of bone resection during a TAR and whether plantarflexion of the ankle reliably moved these structures posteriorly.

Methods:

Ten feet in 10 patients with end-stage tibiotalar arthritis indicated for a TAR were included. Preoperative magnetic resonance images were obtained with the foot in a neutral position as well as in maximum plantarflexion to measure the distance of posteromedial ankle structures to the closest part of the posterior cortex of the tibia or talus. Wilcoxon signed-rank rests were used to investigate differences in these distances.

Results:

The mean distance from the posterior tibial cortex to the tibial nerve at 14 and 7 mm above the tibial plafond was 8.7 mm (range 5.0-11.8 mm) and 6.7 mm (range 2.7-10.6 mm), respectively, which represented a statistically significant movement anteriorly (P = .021). The posterior tibial artery was, on average, 8.0 mm (range 3.6-13.9 mm) and 7.2 mm (range 3.1-9.4 mm) from the posterior tibial cortex at 14 and 7 mm above the tibial plafond, respectively. Distal to the tibial plafond, the posterior tibial artery and flexor digitorum longus tendons moved posteriorly by less than 1 mm in plantarflexion (all P < .05); otherwise, plantarflexion of the ankle did not affect the position of the tibial nerve, posterior tibial tendon, or flexor hallucis longus.

Conclusion:

In patients with end-stage ankle arthritis, the tibial nerve and posterior tibial artery lie, on average, between 6.5 and 10 mm from the posterior tibial and talar cortices. Plantarflexion of the ankle did not reliably move the posteromedial ankle structures posteriorly.

Level of Evidence:

Level IV, case series, therapeutic

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

BACKGROUND

End-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care.

METHODS

This study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay.

RESULTS

Among the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants' LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS.

CONCLUSIONS

This study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.

Outcomes of Reconstruction of the Flexible Adult-acquired Flatfoot Deformity

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

METHODS

This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

RESULTS

Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

CONCLUSIONS

Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

LEVEL OF EVIDENCE

Level III, comparative study.

A Comparative Analysis of Clinical Outcomes in Noninsertional Versus Insertional Tendinopathy Using PROMIS

Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.

Patient-Reported Outcomes in Foot and Ankle Orthopedics

Patient-reported outcomes (PROs) are a measure of health care quality that reflect the patient's perceptions of their own health status. Recently, there has been a renewed interest in implementation of PROs into everyday clinical practice. There are many dozens of PROs available to foot and ankle surgeons with little consensus on which measures are most appropriate for a given condition. These measures vary widely in length, validity, and content. When integrating PROs into clinical practice, we recommend that clinicians should collect, at a minimum, validated PRO scores that assess pain, function, and general health. Furthermore, concise instruments should be used wherever possible to minimize patient burden, maximize patient engagement, and ensure meaningful data are collected. In the near future, outcomes registries employing computer adaptive testing will facilitate the routine collection of PRO data from all patients.

Level of Evidence

Level V, expert opinion.

Deltoid-Spring Ligament Reconstruction in Adult Acquired Flatfoot Deformity With Medial Peritalar Instability

BACKGROUND

A spring ligament tear is commonly present in advanced stages of adult acquired flatfoot deformity (AAFD). Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament, forming the tibiocalcaneonavicular ligament (TCNL). Adding allograft TCNL reconstruction to osseous correction has been suggested to augment medial peritalar stability in advanced AAFD with large spring ligament tears. We aimed to investigate the clinical and radiographic outcomes of TCNL reconstruction for flexible AAFD with medial peritalar instability.

METHODS

Fourteen feet in 12 patients who underwent osseous and TCNL reconstructions for advanced AAFD (stage IIB with large spring ligament tears or stage IV) were recruited for the study. The mean postoperative follow-up was 24 (range, 12-33) months. Pre- and postoperative clinical outcomes were assessed by the Foot and Ankle Ability Measure (FAAM), SF-36, and Patient-Reported Outcomes Measurement Information System (PROMIS). Correction of forefoot abduction and the sagittal arch were measured from pre- and postoperative weightbearing radiographs.

RESULTS

The FAAM Activities of Daily Living improved from 69.3 to 90.1 (P = .001). The SF-36 Physical Function (PF) and Pain subscales both improved significantly (39.4 to 87.8 and 44.6 to 93.1, respectively, P < .001 for each). The PROMIS PF improved from 38.2 to 46.8 (P = .002) and the PROMIS Pain Interference (PI) from 62.6 to 50.1 (P = .003). Radiographic measures showed an improved anterior-posterior (AP) talo-first metatarsal angle of 24.7 to 11.8 degrees (P < .001) and talonavicular coverage angle of 47.4 to 23.1 degrees (P < .01). An improved Meary's angle of 29.7 to 12.5 degrees (P < .001) and a calcaneal pitch angle of 11.7 to 16.9 degrees (P = .14) were noted in the lateral view.

CONCLUSION

Considering the anatomic characteristics of the deltoid-spring ligament complex, TCNL reconstruction may play a significant role in maintaining peritalar stability when performed with osseous correction. Deltoid-spring ligament (TCNL) reconstruction is a viable surgical option for those with advanced stage AAFD with medial peritalar instability that leads to improved functional and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients

BACKGROUND:

The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF).

METHODS:

Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria.

RESULTS:

PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code.

CONCLUSION:

PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management.

LEVEL OF EVIDENCE:

Level II, prognostic.

Reconstruction of digit planer injuries using component transfer of double second toes: A case report

The purpose of this report is to show that customized component second-toe transfers may improve functional and aesthetic outcomes following bone, soft tissue, and joint destruction of traumatically injured digits. A 22-year-old male sustained a planer injury resulting in loss of the distal volar soft tissues of the middle, ring, and small fingers, along with variable destruction of middle phalanges and distal interphalangeal joints. Simultaneous vascularized second-toe transfers were performed with customized joint and pulp reconstruction of middle and small fingers. The ring finger was salvaged using non-vascularized autologous bone graft and acellular dermal matrix. The patient had an uncomplicated postoperative course. Five-year strength, sensory and patient reported outcomes represent overall satisfactory results. Strength testing revealed the injured hand to perform within 90% strength of the uninjured side. Sensory outcomes showed present but diminished sensory perception in each of the injured digits. The patient's upper extremity function, physical health, quality of life, and foot health were overall acceptable, and he returned to using his hand for typing, writing, weight-lifting, and woodworking.

AOFAS Position Statement Regarding Patient-Reported Outcome Measures

Outcome measures evaluate various aspects of patient health, and when appropriately utilized can provide valuable information in both clinical practice and research settings. The orthopedic community has placed increasing emphasis on patient-reported outcome measures, recognizing their value for understanding patients' perspectives of treatment outcomes. Patient-reported outcomes are information directly reported by patients regarding their perceptions of health, quality of life, or functional status without interpretation by healthcare providers. The American Orthopaedic Foot & Ankle Society (AOFAS) supports the use of validated patient-reported outcome (PRO) instruments to assess patient general health, functional status, and outcomes of treatment. It is not possible to recommend a single instrument to collect quality orthopedic data as the selection is dependent on the population being examined and the question being asked. We support the use of the PROMIS Physical Function Computerized Adaptive Test (PF CAT) or Lower Extremity Computerized Adaptive Test (LE CAT), which can be assessed with other domains such as Pain Interference. In addition, a disease-specific measure can be used when available.

Determining Success or Failure After Foot and Ankle Surgery Using Patient Acceptable Symptom State (PASS) and Patient Reported Outcome Information System (PROMIS)

BACKGROUND

As the role of generic patient-reported outcomes (PROs) expands, important questions remain about their interpretation. In particular, how the Patient Reported Outcome Measurement Instrumentation System (PROMIS) t score values correlate with the patients' perception of success or failure (S/F) of their surgery is unknown. The purposes of this study were to characterize the association of PROMIS t scores, the patients' perception of their symptoms (patient acceptable symptom state [PASS]), and determination of S/F after surgery.

METHODS

This retrospective cohort study contacted patients after the 4 most common foot and ankle surgeries at a tertiary academic medical center (n = 88). Patient outcome as determined by phone interviews included PASS and patients' judgment of whether their surgery was a S/F. Assessment also included PROMIS physical function (PF), pain interference (PI), and depression (D) scales. The association between S/F and PASS outcomes was evaluated by chi-square analysis. A 2-way analysis of variance (ANOVA) evaluated the ability of PROMIS to discriminate PASS and/or S/F outcomes. Receiver operator curve (ROC) analysis was used to evaluate the ability of pre- (n = 63) and postoperative (n = 88) PROMIS scores to predict patient outcomes (S/F and PASS). Finally, the proportion of individuals classified by the identified thresholds were evaluated using chi-square analysis.

RESULTS

There was a strong association between PASS and S/F after surgery (chi-square <0.01). Two-way ANOVA demonstrated that PROMIS t scores discriminate whether patients experienced positive or negative outcome for PASS ( P < .001) and S/F ( P < .001). The ROC analysis showed significant accuracy (area under the curve > 0.7) for postoperative but not preoperative PROMIS t scores in determining patient outcome for both PASS and S/F. The proportion of patients classified by applying the ROC analysis thresholds using PROMIS varied from 43.0% to 58.8 % for PASS and S/F.

CONCLUSIONS

Patients who found their symptoms and activity at a satisfactory level (ie, PASS yes) also considered their surgery a success. However, patients who did not consider their symptoms and activity at a satisfactory level did not consistently consider their surgery a failure. PROMIS t scores for physical function and pain demonstrated the ability to discriminate and accurately predict patient outcome after foot and ankle surgery for 43.0% to 58.8% of participants. These data improve the clinical utility of PROMIS scales by suggesting thresholds for positive and negative patient outcomes independent of other factors.

LEVEL OF EVIDENCE

II, prospective comparative series.

Validation and Generalizability of Preoperative PROMIS Scores to Predict Postoperative Success in Foot and Ankle Patients

BACKGROUND

A recent publication reported preoperative Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) scores to be highly predictive in identifying patients who would and would not benefit from foot and ankle surgery. Their applicability to other patient populations is unknown. The aim of this study was to assess the validation and generalizability of previously published preoperative PROMIS physical function (PF) and pain interference (PI) threshold t scores as predictors of postoperative clinically meaningful improvement in foot and ankle patients from a geographically unique patient population.

METHODS

Prospective PROMIS PF and PI scores of consecutive patient visits to a tertiary foot and ankle clinic were obtained between January 2014 and November 2016. Patients undergoing elective foot and ankle surgery were identified and PROMIS values obtained at initial and follow-up visits (average, 7.9 months). Analysis of variance was used to assess differences in PROMIS scores before and after surgery. The distributive method was used to estimate a minimal clinically important difference (MCID). Receiver operating characteristic curve analysis was used to determine thresholds for achieving and failing to achieve MCID. To assess the validity and generalizability of these threshold values, they were compared with previously published threshold values for accuracy using likelihood ratios and pre- and posttest probabilities, and the percentages of patients identified as achieving and failing to achieve MCID were evaluated using χ² analysis.

RESULTS

There were significant improvements in PF ( P < .001) and PI ( P < .001) after surgery. The area under the curve for PF (0.77) was significant ( P < .01), and the thresholds for achieving MCID and not achieving MCID were similar to those in the prior study. A significant proportion of patients (88.9%) identified as not likely to achieve MCID failed to achieve MCID ( P = .03). A significant proportion of patients (84.2%) identified as likely to achieve MCID did achieve MCID ( P < .01). The area under the curve for PROMIS PI was not significant.

CONCLUSIONS

PROMIS PF threshold scores from published data were successful in classifying patients from a different patient and geographic population who would improve with surgery. If functional improvement is the goal, these thresholds could be used to help identify patients who will benefit from surgery and, most important, those who will not, adding value to foot and ankle health care.

LEVEL OF EVIDENCE

Level II, Prospective Comparative Study.

Patient-reported outcome measurements in clinical routine of trauma, spine and craniomaxillofacial surgeons: between expectations and reality: a survey among 1212 surgeons

OBJECTIVE

To gain information about the advantages/disadvantages of an implementation of patient-reported outcome measures (PROM) into the clinical routine of trauma/orthopaedic surgeons, and to identify the technical constraints confronting a successful implementation of PROMs.

DESIGN

Online survey.

PARTICIPANTS

Surgeons who are members of the AO Foundation.

MEASURES

Participants answered questions regarding demographics, their familiarity with specific and generic PROMs and the use of PROMs in clinical routine. Furthermore, reasons for/against using PROMs, why not used more often, prerequisites to implement PROMs into clinical routine and whether PROMs would be implemented if adequate tools/technologies were available, were solicited. Χ² tests and multivariable logistic regressions were conducted to evaluate the effect of the AO Region, surgeon specialisation, current position, clinical experience, and workplace on the familiarity with disease-specific PROMs, the familiarity with generic PROMs and the current use of PROMs. Exploratory factor analysis was used to identify issues underlying the extent of PROM usage.

RESULTS

1212 surgeons completed the survey (response rate: 6.8%; margin of error: ±2.72%): 54.2% were trauma/orthopaedic surgeons, 16.6% were spine surgeons, 27.9% were craniomaxillofacial surgeons and 16 had no defined specialty. Working in a certain AO Region, surgical specialisation and current workplace were associated with a higher familiarity of disease-specific PROMs and the use of PROMs in daily clinical routine (p≤0.05). Exploratory factor analysis identified four categories important for the use of PROMs and two categories preventing the use of PROMs. In case of the availability of an adequate tool, 66.2% of surgeons would implement PROMs in clinical routine.

CONCLUSIONS

Our survey results provide an understanding of the use of PROMs in clinical routine. There is consensus on the usefulness of PROMs. User-friendly and efficient tools/technologies would be a prerequisite for the daily use of PROMs. Additionally, educational efforts and/or policies might help.

EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS)

BACKGROUND

A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages.

METHODS

The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory.

RESULTS

Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed.

CONCLUSIONS

The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Implementation of Patient-Reported Outcomes Measurement Information System Data Collection in a Private Orthopedic Surgery Practice

BACKGROUND

The authors describe a method of collecting patient-reported outcomes (PROs) using computerized adaptive tests (CATs) in a high-volume orthopedic surgery practice with limited resources and no research coordinator.

METHODS

Patient-Reported Outcomes Measurement Information System CATs were collected prospectively for all clinic patients using a tablet and recorded in the electronic medical record. Scores were compared with validated national norms using single-variable t tests. Linear regression was used to assess age effects. Preoperative and postoperative pain scales were compared using paired t tests.

RESULTS

In total, 4,524 CATs were administered during 10,719 visits (42%), reaching 70% as more tablets were introduced. Completing the CATs required 157 seconds. Older patients took more time than younger ones ( P < .05). Compared with normalized t scores of 50 ± 10 for the US population, pain intensity was 48.0 (95% confidence interval [CI], 47.8-48.2), pain interference 58.9 (95% CI, 58.6-59.1), physical function 40.1 (95% CI, 39.9-40.3), global physical health 43.4 (95% CI, 41.9-44.9), and global mental health 41.1 (95% CI, 40.89-41.4) ( P < .05 for all). Age had a small effect on all domains ( P < .05). Approximately 20 patients would be required to demonstrate a 15% change for a 2-tailed, paired study with α = 0.05 and 80% power. After surgery, pain intensity improved from 51.9 ± 8.2 to 44.1 ± 8.5, pain interference improved from 62.5 ± 6.9 to 55.7 ± 8.4, and physical function improved from 37.3 ± 8.9 to 41.5 ± 7.9 ( P < .05 for all).

CONCLUSIONS

Using tablets to administer CATs and entering the data in the electronic medical record for later retrieval was an effective technique to collect PROs. An adequate number of tablets are needed for acceptable completion rates. Modest sample size requirements for comparative studies highlight the potential of these tools and techniques.

LEVEL OF EVIDENCE

Level II, Prospective Comparative Study.

Patient-Reported Outcomes in Foot and Ankle Surgery

Patient-reported outcomes (PROs) are a measure of health care quality that empower patients to share their health care perceptions with their providers. In orthopedic foot and ankle surgery, these measures can range from global assessments of pain or satisfaction to complex questionnaires designed to assess the function of specific anatomic regions or the recovery from specific procedures. This article seeks to characterize the use of PROs in foot and ankle surgery, describe some of the most commonly used measures, discuss implementation in everyday clinical practice, and explore the future of PROs in foot and ankle orthopedics.

Utility outcome assessment of pes planus deformity

BACKGROUND

Despite being a common condition, there are no objective measures in the literature to reflect the burden of pes planus on affected individuals. Our primary objective was to evaluate this burden by recruiting a sample from the general population using validated utility outcome measures.

METHODS

Participants were recruited online and filled a questionnaire to help measure the health burden of pes planus. Three recognized utility outcome scores were used to compare the health burden of monocular blindness, binocular blindness, and pes planus. These included the standard gamble (SG), time trade-off (TTO), and visual analogue score (VAS). Paired t test, independent t test, and linear regression were used for statistical analysis.

RESULTS

Ninety-two participants were included in the final analysis. The utility outcome scores (VAS, TTO, SG) for pes planus were 73±17, 0.90±0.08, and 0.88±0.12, respectively. The linear regression analysis showed that age was inversely proportional to the time trade-off. However, race, educational level, and income were not significant predictors of utility outcome score for pes planus.

CONCLUSIONS

This study shows that the perceived burden of living with pes planus is comparable to living with some debilitating conditions. Our participants were willing to sacrifice 3.6 years of life, and have a procedure with a theoretical 12% mortality risk to attain perfect health.

Assessment of Disease-Specific and General Patient-Reported Outcome Measures of Hearing Health

Objective To assess disease-specific (Inner EAR) and general (Patient-Reported Outcomes Measurement Information System [PROMIS]) health status in patients reporting hearing loss and whether there is enough correlation between scales such that the general instrument alone could suffice. Study Design Correlation analysis of prospective cohort data. Setting Tertiary care academic medical center. Methods Adults presenting with a chief complaint of hearing loss completed the Inner EAR scale and the PROMIS instrument. Summary statistics, including means, percentiles, and measures of variance, were calculated. The Spearman ρ statistic was used to test the null hypothesis that there were no correlations between the Inner EAR composite or global score and PROMIS scores. Results The mean Inner EAR composite score was 35.6, while the global item had a mean score of 4.8. Mean PROMIS-10 scores were 16.0 for physical health and 15.3 for mental health. The global item and social item had mean scores of 3.6 and 3.8, respectively. Inner EAR composite scores were significantly correlated with the PROMIS mental health summary scores (Spearman ρ = 0.3, P = .0066) and the PROMIS social item score (Spearman ρ = 0.4, P = .0005). The Inner EAR global item was moderately correlated with the PROMIS social item score (Spearman ρ = 0.3, P = .0118), while there was no significant correlation between the Inner EAR global item and the PROMIS physical health, mental health, or global item scores. Conclusions Inner EAR and a subset of PROMIS scores have weak to moderate correlations. Disease-specific assessment still confers independent value.

Association of Anxiety and Depression With Pain and Quality of Life in Patients With Chronic Foot and Ankle Diseases

BACKGROUND

The purposes of this study were to clarify the incidence of anxiety and depression among patients with chronic foot and ankle diseases and to examine the independent association of anxiety and depression with pain and quality of life.

METHODS

Patients who visited the foot and ankle clinic from April 2015 to November 2016 were recruited. Anxiety and depression in patients were assessed using the Hospital Anxiety and Depression Scale. Pain and quality of life were evaluated using the visual analog scale (VAS) and Self-Administered Foot Evaluation Questionnaire (SAFE-Q), respectively. Furthermore, patient characteristics, including age, sex, body mass index, pain in other body areas, social support, employment, and household income, were surveyed. A multiple regression analysis was performed to examine the independent association of anxiety and depression with pain and quality of life. A total of 250 patients were included in the analysis.

RESULTS

The prevalence of anxiety and depression was 30% and 27%, respectively. The VAS and all SAFE-Q subscale scores were significantly worse in patients with anxiety or depression than in patients without the same (median VAS 63 vs 49 for anxiety, P = .005; 68 vs 47 for depression, P < .001). Furthermore, the multiple regression analyses showed that the presence of anxiety ( P = .02) and depression ( P < .001) was independently associated with increased pain, and it led to low scores on all SAFE-Q subscales ( P < .001 for all subscales).

CONCLUSION

About 30% of patients with chronic foot and ankle disease had anxiety or depression. The presence of these psychological symptoms was independently associated with worse pain and impaired quality of life after controlling for patient characteristics. Clinicians need to recognize the possibility of concurrent anxiety and depression to provide a more holistic treatment for chronic foot and ankle disease.

LEVEL OF EVIDENCE

Level IV, case series.

PROMIS Pain Interference and Physical Function Scores Correlate With the Foot and Ankle Ability Measure (FAAM) in Patients With Hallux Valgus

BACKGROUND

Traditional patient-reported outcome instruments like the Foot and Ankle Ability Measure (FAAM) quantify patient disability but often are limited by responder burden and incomplete questionnaires. The Patient-Reported Outcome Measurement Information System (PROMIS) overcomes such obstacles through computer-adaptive technology and can capture outcome data from various domains including physical and psychosocial function. Prior work has compared the FAAM with PROMIS physical function; however, there is little evidence comparing the association between foot and ankle-specific tools like the FAAM with more general outcomes measures of PROMIS pain interference and depression in foot and ankle conditions.

QUESTIONS/PURPOSES

(1) We asked whether there was a relationship between FAAM Activities of Daily Living (ADL) scores with PROMIS physical function, pain interference, and depression in patients with hallux valgus. (2) Additionally, we asked if we could identify specific factors that are associated with variance in FAAM and PROMIS physical function scores in patients with hallux valgus.

METHODS

Eighty-five new patients with either a primary or secondary diagnosis of hallux valgus based on clinic billing codes from July 2015 to February 2016 were retrospectively identified. Patients completed FAAM ADL paper-based surveys and electronic PROMIS questionnaires for physical function, pain interference, and depression from new patient visits at a single time. Spearman rho correlations were performed between FAAM ADL and PROMIS scores. Analyses then were used to identify differences in FAAM ADL and PROMIS physical function measures based on demographic variables. Stepwise linear regressions then determined which demographic and/or outcome variable(s) accounted for the variance in FAAM ADL and PROMIS physical function scores.

RESULTS

FAAM scores correlated strongly with PROMIS physical function (r = 0.70, p < 0.001), moderately with PROMIS pain interference (r = -0.65, p < 0.001), and weakly with PROMIS depression (r = -0.35, p < 0.001) scores. Regression analyses showed that PROMIS pain interference scores alone were associated with sizeable portions of the variance in FAAM ADL (R² = 0.44, p < 0.001) and PROMIS physical function (R² = 0.57, p < 0.001) measures.

CONCLUSIONS

PROMIS function and pain measures correlated with FAAM ADL scores, highlighting the interrelationship of pain and function when assessing outcomes in patients with hallux valgus. PROMIS tools allow for more-efficient data collection across multiple domains and, moving forward, may be better poised to monitor changes in pain and function with time compared with traditional outcome measures like the FAAM.

CLINICAL RELEVANCE

The relationships shown here between PROMIS and FAAM scores further support the use of PROMIS tools in outcomes-based research. In patients with hallux valgus, pain-related disability appears to be a central feature of the patient-experience. Future studies should assess the association of various outcome domains on other common foot and ankle diagnoses.

Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score

INTRODUCTION

Classification systems for hallux rigidus imply that, as radiographic changes progress, symptoms will concurrently increase in severity. However, symptom intensity and radiographic severity can be discordant for many patients. We studied the correlation between hallux rigidus grades and the Foot and Ankle Ability Measure (FAAM) scores to better understand this relationship.

METHODS

We retrospectively reviewed weight-bearing radiographs of the foot and FAAM Activities of Daily Living (ADL) questionnaires for 84 patients with hallux rigidus. The Spearman rank coefficient was used to correlate clinical-radiographic hallux rigidus grade with FAAM ADL scores.

RESULTS

In 84 patients, the clinical-radiographic grade for hallux rigidus showed no relationship with FAAM ADL score (r = -0.10; P = 0.36) but did show moderate correlation with patient age (r = 0.63; P < 0.001).

DISCUSSION

Advancing radiographic changes in hallux rigidus did not correspond with patient symptoms as measured via FAAM ADL scores.

CONCLUSION

The reliability and validity of current grading criteria for hallux rigidus may require further exploration.

LEVEL OF EVIDENCE

Level III.

Psychometric evaluation of the pediatric and parent-proxy Patient-Reported Outcomes Measurement Information System and the Neurology and Traumatic Brain Injury Quality of Life measurement item banks in pediatric traumatic brain injury

PURPOSE

The primary objective is to provide evidence of convergent and discriminant validity for the pediatric and parent-proxy versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, Depression, Anger, Peer Relations, Mobility, Pain Interference, and Fatigue item banks, the Neurology Quality of Life measurement system (Neuro-QOL) Cognition-General Concerns and Stigma item banks, and the Traumatic Brain Injury Quality of Life (TBI-QOL) Executive Function and Headache item banks in a pediatric traumatic brain injury (TBI) sample.

METHODS

Participants were 134 parent-child (ages 8-18 years) days. Children all sustained TBI and the dyads completed outcome ratings 6 months after injury at one of six medical centers across the United States. Ratings included PROMIS, Neuro-QOL, and TBI-QOL item banks, as well as the Pediatric Quality of Life inventory (PedsQL), the Health Behavior Inventory (HBI), and the Strengths and Difficulties Questionnaire (SDQ) as legacy criterion measures against which these item banks were validated.

RESULTS

The PROMIS, Neuro-QOL, and TBI-QOL item banks demonstrated good convergent validity, as evidenced by moderate to strong correlations with comparable scales on the legacy measures. PROMIS, Neuro-QOL, and TBI-QOL item banks showed weaker correlations with ratings of unrelated constructs on legacy measures, providing evidence of discriminant validity.

CONCLUSION

Our results indicate that the constructs measured by the PROMIS, Neuro-QOL, and TBI-QOL item banks are valid in our pediatric TBI sample and that it is appropriate to use these standardized scores for our primary study analyses.

The Maryland Orthopaedic Registry (MOR): Design and baseline characteristics of a prospective registry

BACKGROUND

Utilization of patient-reported outcome tools allows a more accurate assessment of the efficacy of treatment, which is critical to comparative effectiveness research.

OBJECTIVES

The Maryland Orthopaedic Registry (MOR) was established to assess post-surgical outcomes related to patients' pain, functional status, met expectations, and satisfaction using an electronic data collection system. Secondary aims of the registry include assessment of patient expectations of treatment, activity level, and general health status.

METHODS

Adult patients enrolled in this prospective observational study completed self-report measures assessing pre-operative pain, function, treatment expectations, and activity levels during the perioperative period. MOR utilizes the Patient-Reported Outcomes Measurement Information System (PROMIS^®)'computer adaptive testing for physical function, pain interference, fatigue, social satisfaction, anxiety, and depression. Perioperative data is extracted from the medical record.

RESULTS

300 patients (40% of eligible) have been enrolled into the initial cohort. Most patients (94.1%) were aged 18-65, and 57% were male. Fifty-seven percent of enrollees were White, 33% Black, and 4% Asian. PROMIS physical function and social satisfaction were both more than half a standard deviation below the population mean. Participants reported PROMIS anxiety scores that were half a standard deviation above the population mean and pain interference scores that were more than a standard deviation above the mean. Physical function scores were significantly worse among participants with lower extremity orthopaedic issues, but scores on other measures were similar between participants undergoing lower or upper extremity surgery.

CONCLUSIONS

MOR provides a comprehensive assessment of patients undergoing orthopaedic surgery. The utilization of electronic clinical assessment tools as well as computer adaptive testing allows for time-efficient data collection. The diverse population is a particular strength of MOR.

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.