AOFAS Position Statement Regarding Patient-Reported Outcome Measures

Five-Year Results of the Salto XT Revision Ankle Arthroplasty

BACKGROUND

The treatment of failed ankle replacements is debated, and little is published about the medium- and long-term results of revision implants. We wanted to examine prosthesis survival and physical function at least 5 years after insertion of the Salto XT revision prosthesis.

METHODS

All consecutive patients operated with a Salto XT revision prosthesis underwent clinical and radiologic examinations preoperatively and after 3, 12, 24, and 60 months. Complications and reoperations are described, and changes in patient-reported outcome measures and clinical scores are reported.

RESULTS

Thirty patients were operated with a Salto XT revision prosthesis between March 2014 and March 2017. Three of these were revised (1 to a fusion and 2 to a new prosthesis), and 3 patients were reoperated with screw removal. A concurrent subtalar fusion was performed on 13 patients, and there was 1 case of likely nonunion after these procedures, but no reoperations. The mean AOFAS score increased from 39.2 (95% CI 30.8-47.5) preoperatively to 75.1 (95% CI 67.3-82.9) after 5 years, and the mean improvement was 34.2 points (95% CI 23.8-44.6). Mean EQ-5D increased from 0.36 (95% CI 0.30-0.42) preoperatively to 0.74 (95% CI 0.64-0.85) after 5 years, an improvement of 0.34 (95% CI 0.19-0.49). Radiolucent lines were present in all but 3 patients. Five-year prosthesis survival was 93% (83.6-100).

CONCLUSION

This is the first study to present medium-term results of this implant. We found good improvement in outcome scores and good implant survival, but also a high prevalence of radiolucent lines.

Comparing the Clinical Outcomes of Percutaneous Cheilectomy to Open Cheilectomy With Moberg Osteotomy for the Treatment of Hallux Rigidus

Background

Both an open cheilectomy with a Moberg osteotomy and percutaneous cheilectomy have been successfully used to treat hallux rigidus and preserve motion.However, there have been no studies that have compared these 2 procedures using validated patient-reported outcomes such as the Patient Reported Outcome Measurement Information System.

Methods

A retrospective review of hallux rigidus patients between January 2016 and July 2021 collected 48 percutaneous cheilectomy (PC) patients and 71 open cheilectomy with Moberg (OCM) patients. Preoperative and minimum 1-year postoperative PROMIS scores were collected.

Results

The OCM and PC cohorts did not have significant differences in their postoperative PROMIS scores. Both cohorts had modest but significant improvements postoperatively in the physical function, pain interference, and pain intensity domains. The OCM group had a larger degree of improvement in physical function, pain interference, and pain intensity (P = .015, .011, .001, respectively). No significant difference was identified in the reoperation rate.

Conclusion

Patients undergoing an OCM had worse preoperative PROMIS scores and a modestly greater change in patient-reported outcomes than patients undergoing a PC.

Level of Evidence

Level III, retrospective review.

Ankle ligament reconstruction-return to sport after injury scale and return to sports after ankle ligament reconstruction or repair-A systematic review

Purpose

To systematically review existing literature regarding the ankle ligament reconstruction-return to sport after injury (ALR-RSI) scale and to assess its correlation with Return to sport and functional outcomes as well as feasibility, reliability and consistency.

Methods

A systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) was conducted using PubMed, Embase and Cochrane Library. Studies that evaluated psychological readiness to return to sport after ankle ligament reconstruction or repair for the treatment of chronic lateral ankle instability using the ALR-RSI scale were included. The results from each study were pooled, and weighted means and overall rates were calculated.

Results

In total, 157 patients (53.2% male, mean age: 34.2 years) from three articles were included. Overall, 85.0% of patients reported successful return to sport, but only 48.9% of patients returned to the preoperative sporting level. All studies reported a significant difference in psychological scores between patients who returned to sport and those who did not. Pooled mean patient-reported outcome measures, reported as the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS, three studies) Score and Karlsson-Peterson Score (three studies), were 82.7 (range: 29-100) and 81.7 (range: 25-100), respectively. The ALR-RSI scale demonstrated strong correlations with the AOFAS Score and Karlsson-Peterson Score.

Conclusion

Patients who returned to sport after ankle ligament reconstruction or repair exhibited higher psychological readiness compared to those who did not. The ALR-RSI scale showed strong correlations with ankle function. Evaluation of psychological readiness using the ALR-RSI scale may provide an additional tool in the assessment of patients who underwent ankle ligament reconstruction or repair.

Level of Evidence

Level III, systematic review.

Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis

INTRODUCTION

The present meta-analysis evaluated current level I clinical trials which compared the use of a suture button (SB) versus syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. It was hypothesised that SB might achieve better PROMs along with a lower rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA statement. In August 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed. All the randomised controlled trials (RCTs) which compared SB versus SS fixation for syndesmosis injuries of the ankle were accessed. Data concerning the American Orthopaedic Foot & Ankle Society (AOFAS), and Olerud-Molander score (OMS) were collected at baseline and at last follow-up. Data on implant failure, implant removal, and joint malreduction were also retrieved.

RESULTS

Data from seven RCTs (490 patients) were collected. 33% (161 of 490) were women. The mean length of the follow-up was 30.8 ± 27.4 months. The mean age of the patients was 41.1 ± 4.1 years. Between the two groups (SB and SS), comparability was found in the mean age, and men:women ratio. The SS group evidenced lower OMS (P = 0.0006) and lower AOFAS (P = 0.03). The SS group evidenced a greater rate of implant failure (P = 0.0003), implant removal (P = 0.0005), and malreduction (P = 0.04).

CONCLUSION

Suture button fixation might perform better than the syndesmotic screw fixation in syndesmotic injuries of the ankle.

Differences in Baseline Physical Function and Mental Health PROM Scores in Patients With Foot and Ankle Conditions

BACKGROUND

This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated PROMIS scores and to compare the correlation between these 2 outcomes across common diagnoses. Additionally, it investigated the effects associated with chronic vs acute conditions and specific diagnoses on mental health.

METHODS

We reviewed baseline PROMIS Physical Function 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,245 patients with one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model including age, sex, language, race, ethnicity, education level, income, and Charlson Comorbidity Index was used to determine the associated effect of diagnosis on PGM score.

RESULTS

On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, whereas patients with hallux valgus had the highest (PF10a = 33.9 vs 46.7, P < .001). Patients with foot/ankle osteoarthritis had the lowest mean self-reported mental health, whereas patients with hallux rigidus had the highest (PGM = 49.9 vs 53.4, P < .001). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r = 0.511) and weakest in patients with ankle fractures (r = 0.232) or sprains (r = 0.280). Chronic conditions, including hammertoes (β = -5.1, 95% CI [-5.8, -4.3], P < .001), foot/ankle osteoarthritis (β = -5.0, 95% CI [-5.7, -4.3], P < .001), and hallux valgus (β = -4.8, 95% CI [-5.5, -4.1], P < .001) were associated with the largest negative effects on patients' mental health.

CONCLUSION

Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic conditions. The associations between diagnosis and mental health scores appear larger for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function.

A New Paradigm in Foot and Ankle Outcomes?: Away From Radiographs and Toward Patient-Centered Outcomes

Having reasonable outcome measures is essential to unbiased research. For years, provider-measured outcomes have been valued as they are more objective and convenient for investigators. However, with the popularity of patient-centered medical care delivery, patient-reported outcome measures are appropriately becoming more popular in foot and ankle research.

Clinical Outcomes and Registry Data in Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis consistently demonstrating good to excellent outcomes, even when considering factors such as deformity, patient age, bilaterality, and arthritis etiology. There is little consensus in the literature with regard to preferred patient-reported outcome metrics (PROMs) for assessing outcomes, although all metrics generally improve following TAA. Several countries have successful registries to track longevity of TAA in populations; however, PROMs are generally not successfully tracked in registries. A trend toward consensus on outcome metrics and collaborative registries is warranted to optimize patient selection and outcomes in TAA.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs

BACKGROUND

Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct.

METHODS

Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI).

RESULTS

The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates.

CONCLUSION

Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported.

LEVELS OF EVIDENCE

Level IV.

Functional outcomes of primary subtalar arthrodesis in sanders type IV calcaneal fractures, a case series

Background

Primary subtalar arthrodesis (PSTA) is a valid option in treating Sanders IV calcaneal fractures with few studies to assess its outcomes.

Methods

Seventeen patients with Sanders IV calcaneal fractures were managed by open reduction and primary subtalar arthrodesis. Functional outcomes were measured by AOFAS-AHS and FAAM-ADL. We also documented time to return to work, union rate, wound complications and the need for second surgeries.

Results

Fourteen patients were followed for two years. At final follow-up, the mean AOFAS-AHS score was 74.42 ± 1.95, while the mean FAAM- ADL score was 59.21 ± 1.6.

Conclusion

PSTA is a valid option in treating these severe fractures. It may reduce the overall disability time.

Reliability and Validity of the Turkish Version of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale

BACKGROUND

The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) scale is one of the most widely used outcome measures to evaluate hallux pathologies. This study aimed to translate the AOFAS Hallux MTP-IP scale into Turkish and investigate its psychometric properties.

METHODS

The psychometric properties of the Turkish version of the AOFAS Hallux MTP-IP (AOFAS Hallux MTP-IP-T) scale were tested in 66 patients with hallux pathologies (52 women; mean age, 47.64 ± 12.75 years). Cronbach's alpha was used to assess internal consistency. The intraclass correlation coefficient (ICC) was used to estimate test-retest. Construct validity was analyzed with the Turkish version of the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analogue Scale (VAS), and 12-item Short-Form Health Survey(SF-12).

RESULTS

The AOFAS Hallux MTP-IP-T scale had adequate internal consistency (α = 0.71) and test-retest reliability (ICC2,1 = 0.93 for pain, ICC2,1 = 0.97 for function, and ICC2,1 = 0.97 for total score). The AOFAS Hallux MTP-IP-T total score has a moderate to strong correlation with VAS-activity and MOXFQ (ρ = -0.77, P = .001; ρ = -0.69, P = .001, respectively). The weakest correlation was found between the AOFAS Hallux MTP-IP-T and the SF-12 mental component scale (ρ = 0.31, P = .01).

CONCLUSION

AOFAS Hallux MTP-IP-T has sufficient reliability and validity to evaluate Turkish-speaking individuals with a variety of forefoot pathologies including the hallux.

LEVELS OF EVIDENCE

Level II.

Hindfoot motion through helical axis image-based on dynamic CT scan using an original simulated weightbearing device

BACKGROUND

Determining the treatment of subtalar joint (STJ) instability requires a better understanding of the biomechanical principles underlying the condition and, a proper diagnosis. This study aimed to analyze "in vivo" the range of motion of the subtalar joint (STJ) measured on two (2D) and three dimensions (3D) image-based on CT Scan using an original device that maintains a simulated weightbearing. The secondary goal was to correlate the 2D and 3D measurement.

METHODS

An observational study was conducted, using an original Dynamic Simulated Weightbearing Device. Asymptomatic ankles were included. Each subject underwent a CT scan under mechanical stress and simulated weightbearing conditions, maintaining maximum eversion and inversion hindfoot positions. The images were obtained, combining both inversion and eversion positions in a single model, which allows for to calculation of the motion vector as well as the helical axis. The helical axis (rotation angle and translation distance), subtalar tilt, anterior drawer, and, subtalar and calcaneocuboid uncoverage were the determinations.

RESULTS

Forty asymptomatic ankles were included. The average range of motion of the STJ amounts to 31.5° ± 9.1° of rotation and 1.56 ± 0.8 mm of translation distance. The anterior drawer and subtalar uncoverage variables were statistically significantly related to each other (r = 0.57; P = 0.00001). However, these 2-D measured variables were not related to kinematic measures of rotation through the helical axis (3D) (p = 0.14; p = 0.19) CONCLUSIONS: The average range of motion of the STJ amounts to 31.5° ± 9.1° of rotation and 1.56 ± 0.8 mm of translation distance. We found no significant correlation between 2D and 3D measurements. In our opinion, the rotation angle and translation distance should be considered the most accurate measurements and should be calculated on every STJ instability for comparison with the asymptomatic population LEVEL OF EVIDENCE: Observational study.

LEVEL OF EVIDENCE III

Hemiepiphysiodesis for juvenile hallux valgus deformity: A systematic review

BACKGROUND

Among the numerous surgical interventions for correcting hallux valgus deformity in skeletally immature patients, hemiepiphysiodesis is a simple technique with a low complication rate yet its effectiveness remains unclear. This systematic review evaluates hemiepiphysiodesis of the first metatarsal for treating juvenile hallux valgus (JHV) deformities with respect to radiological outcomes, postoperative clinical outcomes, and postoperative complications.

METHODS

EMBASE, MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) database were searched from inception to September 15th, 2022, for studies investigating hemiepephysiodesis for JHV and its effect on clinical and radiological outcomes. The search, data extraction and methodologic assessment were performed in duplicate for all included studies.

RESULTS

Six studies out of 488 with a total of 147 feet in 85 patients were included in the final qualitative synthesis. The American Orthopaedic Foot & Ankle Society hallux metatarsophalangeal interphalangeal scale (AOFAS Hallux MTP-IP scale) was used in two studies. The mean pooled preoperative score was 62.2 ± 8.9 and improved to 88.6 ± 4.8 postoperatively in 33 patients. All six studies reported significant improvement in the hallux valgus angle (HVA) from mean preoperative angle of 29.2° ± 3.7-23.8° ± 4.5° postoperatively, while the intermetatarsal angle (IMA) preoperative and postoperative means corrected from 13.9° ± 1.1-11.4° ± 1.2°, respectively. Out of 147 feet, 21 (14.2%) had reported complications including recurrence and need for revision surgery.

CONCLUSION

This systematic review confirms that hemiepiphysiodesis of the first metatarsal in patients with JHV has improved clinical and radiological outcomes.

LEVEL OF EVIDENCE

Level IV, Systematic review.

High complication rates following revision first metatarsophalangeal joint arthrodesis: a retrospective analysis of 79 cases

BACKGROUND

The most common indications for revision of first metatarsophalangeal joint (MTPJ) arthrodesis are symptomatic failures of prior arthrodesis, failed hallux valgus correction, and failed MTPJ arthroplasty implants. However, the outcomes of revision MTPJ arthrodesis have rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTPJ arthrodesis following different primary procedures.

METHODS

A retrospective review of revision MTPJ arthrodesis cases between January 2015 and December 2019 was performed. The radiographic results, patient-reported outcomes, and rates of complications, subsequent revisions, and nonunions, were analyzed and compared preoperatively and postoperatively. A multivariate analysis was utilized to determine risk factors for complications and reoperations.

RESULTS

This study yielded a total of 79 cases of revision MTPJ arthrodesis. The mean follow-up time was 365 days (SD ± 295). The overall complication rate was 40.5%, of which the overall nonunion rate was 19.0%. Seven cases (8.9%) required further revision surgery. The multivariate analysis revealed that Diabetes mellitus was associated with significantly higher overall complication rates (p = 0.016), and nonunion was associated with "in-situ" joint preparation techniques (p = 0.042). Visual Analog Scale (VAS) significantly improved postoperatively (p < 0.001); However, PROMIS-10 physical health and PROMIS-10 mental health did not change significantly during the study period.

CONCLUSION

Treatment of MTPJ surgery failures is a clinical challenge in orthopedic surgery. In our study, revision of first MTPJ surgery resulted in higher nonunion rates and overall complication rates compared to typical outcomes from primary MTPJ arthrodesis. Diabetes, Tobacco use, and "in-situ" joint preparation technique were found to be independent risk factors for complications and reoperations.

LEVEL OF EVIDENCE

III-Retrospective Cohort Study.

Outcome measures in clinical studies of ankle osteoarthritis: a systematic review

OBJECTIVE

To explore and describe the outcome measures reported in primary research of ankle osteoarthritis (OA) and to propose aligned health-related domains.

METHODS

Six databases were searched, and studies were screened by two independent reviewers. Studies of participants with ankle OA who were> 18 years of age and reported outcome measure data were included. Non-English, animal, cadaveric, reviews, and studies with< 5 participants were excluded. Outcome measures were examined for content and mapped to health-related domains.

RESULTS

1386 studies were identified, of which 547 met selection criteria - reporting 250 outcome measures. Most commonly reported measures were the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (n = 257 studies), plain radiographs to measure ankle alignment (n = 211), numerical rating scale for pain severity (n = 177) and goniometry to measure ankle range of motion (n = 148). Outcome measures were organised into 19 domains. The most common domains were pain severity (315 (58%) studies), ankle alignment (254 (46%)), ankle motion (181 (33%)), disability (169 (31%)) and health-related quality of life (128 (23%)). These domains fell into the Outcome Measures in Rheumatology (OMERACT) core areas of life impact and pathophysiological manifestations.

CONCLUSION

Many outcome measures are used in ankle OA research, most of which assess joint alignment, pain, and motion. Based on the outcome measures identified, we proposed 19 possible health-related domains, predominantly in the OMERACT core areas of life impact and pathophysiological manifestations of ankle OA. Clinicians and researchers can use this review in guiding selection of outcome measures.

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.

Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus

Background

Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM.

Methods

This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed.

Results

Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores.

Conclusion

In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains.

Level of Evidence

Level III, retrospective cohort study.

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.

Reliability, validity and clinical applicability of the German version of the European Foot and Ankle Society Score

BACKGROUND

Purpose of this study was an external evaluation of the recently developed European Foot and Ankle Society (EFAS) Score.

METHODS

From July 2021 to January 2022, all consecutive patients with foot and ankle disorders were asked to complete three validated questionnaires prior to the medical examination. Validity was evaluated with correlations between the EFAS Score, Manchester-Oxford Foot Questionnaire (MOxFQ) and Foot and Ankle Outcome Score (FAOS). Cronbach's alpha, floor and ceiling effects and the minimal important difference (MID) were determined.

RESULTS

In a total of 161 included patients, the EFAS Score demonstrated a very good correlation with the MOxFQ index score (r = 0.76, p < 0.001). There were no floor or ceiling effects. Cronbach's alpha was 0.863, and the MID amounts 3 points and 7 points for significant changes respectively.

CONCLUSION

In terms of reliability and validity, the EFAS Score demonstrated good to excellent psychometric values. A change of 7 points or more in the EFAS Score in longitudinal examinations is clinically highly relevant.

Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue

PURPOSE

Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants.

METHODS

64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test.

RESULT

Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found.

CONCLUSION

Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

Functional outcomes of all-inside arthroscopic anterior talofibular ligament repair with loop suture versus free-edge suture

Background

Anatomic repair of anterior talofibular ligament (ATFL) is used to manage chronic lateral ankle instability (CLAI). However, the optimal suture configuration used to repair the ATFL is not yet determined. It remains unclear whether suture configuration affects clinical outcomes in such patients.

Purpose

To compare the functional outcomes of all-inside arthroscopic ATFL repair using either a loop suture and or a free-edge suture configuration in CLAI patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

This retrospective cohort study included 71 patients with CLAI who had undergone an all-inside arthroscopic ATFL repair procedure with either loop suture (n = 36) or free-edge suture (n = 35) from February 2016 to July 2018. Comparable pre-operatively, the Visual analogy score (VAS), American Orthopedic Foot and Ankle Society scoring system (AOFAS), Karlsson Ankle Functional Score (KAFS) scoring system, Anterior Talar Translation (ATT) and Active Joint Position Sense (AJPS) were used to evaluate postoperative ankle function.

Results

There were no postoperative wound complications, implant reactions, or neurological or vascular injuries. Postoperative hospitalization, VAS, AOFAS, KAFS, AJPS and the time of return to sport were similar between the loop suture group and free-edge suture group. Requiring a longer procedure time, patients with loop suture configuration achieved better ATT.

Conclusion

All-inside arthroscopic ATFL repair procedure for CLAI treatment provides better ATT and comparable functional outcomes when a loop suture configuration is used instead of a free-edge suture configuration. A statistical difference in ATT was observed. Given the relatively short follow-up, it is questionable whether this will have any clinical relevance.

Clinical Outcomes of Revision Surgery Using a Dorsal Approach After Failed Primary Interdigital Neuroma Excision

BACKGROUND

Revision neurectomy may be approached with either a dorsal or a plantar incision. Although a plantar approach is more commonly described, few studies have investigated outcomes following a dorsal revision neuroma excision. In this study, we performed a case series on a group of patients who underwent revision neuroma excision through a dorsal approach and reported complications and outcomes using validated patient-reported outcome measures (PROMs).

METHODS

This retrospective case series included 10 patients who underwent a dorsal-approach revision neuroma excision and had preoperative and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Complications including neuroma recurrence and continued unresolved pain were obtained from the electronic medical record. Preoperative and postoperative PROMIS scores were compared to assess improvement in PROMs.

RESULTS

There were significant improvements in the PROMIS pain interference (P = .026), pain intensity (P = .008), and global physical health (P = .017) domains. One patient experienced recurrence of their neuroma 4 years after surgery.

CONCLUSION

This case series provides preliminary data indicating that revision neurectomy using a dorsal approach leads to satisfactory outcomes in pain-related PROMs. Further research with comparative study designs is necessary to determine if one approach is superior to the other.

LEVELS OF EVIDENCE

Level IV: Retrospective.

Navigated and Robot-Assisted Technology in Total Knee Arthroplasty: Do Outcome Differences Achieve Minimal Clinically Important Difference?

BACKGROUND

In total knee arthroplasty (TKA), computer-assisted navigation (N-TKA) and robotic-assisted methods (RA-TKA) are intended to increase precision of mechanical and component alignment. However, the clinical significance of published patient-reported outcome measure (PROM) differences in comparison to conventional TKA (C-TKA) is unknown.

METHODS

A systematic review was performed to identify all studies reporting perioperative PROMs for either primary N-TKA or RA-TKA with a C-TKA comparison cohort with a minimum 1-year follow-up. Relative improvements in PROMs for the two cohorts were compared to published minimal clinically important difference (MCID) values.

RESULTS

After systematic review, 21 studies (N = 3,214) reporting on N-TKA and eight studies (N = 1,529) reporting on RA-TKA met inclusion criteria. Eighteen of 20 studies (90%) reported improved radiographic outcomes with N-TKA relative to C-TKA; five of five studies reported improved radiographic outcomes with RA-TKA relative to C-TKA. Five of 21 studies (24%) reported statistically significant greater improvements in clinical PROMs for N-TKA relative to C-TKA, whereas only two (10%) achieved clinical significance relative to MCID on a secondary analysis. One of 8 studies (13%) reported statistically significant greater improvements in PROMs for RA-TKA relative to C-TKA, whereas none achieved clinical significance relative to MCID on a secondary analysis. No studies reported a significant difference in revision rates.

CONCLUSION

While most studies comparing RA-TKA and N-TKA with C-TKA demonstrate improved radiographic alignment outcomes, a minority of studies reported PROM differences that achieve clinical significance. Future studies should report data and be interpreted in the context of clinical significance to establish patient and surgeon expectations for emerging technologies.

Relationship Between Preoperative PROMIS Scores and Postoperative Outcomes in Hallux Rigidus Patients Undergoing Cheilectomy

BACKGROUND

Previous studies have demonstrated that preoperative patient-reported outcome measures are associated with postoperative outcomes in foot and ankle surgery, and also in specific procedures such as bunionectomy, flatfoot reconstruction, and total ankle replacement. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, pain intensity, and depression scores were associated with the ability of patients undergoing cheilectomy for hallux rigidus to achieve a minimal clinically important difference (MCID) of improvement.

METHODS

This retrospective study included preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 125 feet in 118 patients undergoing cheilectomy collected from an institutional review board (IRB)-approved foot and ankle registry database. MCIDs were established using distribution-based methods to determine clinical significance of improvements in PROMIS scores. Receiver operating characteristic (ROC) curves and area under the curve analyses were used to determine which preoperative PROMIS scores were associated with patients meeting the MCID.

RESULTS

ROC analysis found statistically significant areas under the curve (AUCs) for the physical function domain (AUC 0.71), pain intensity (AUC 0.70), and depression (AUC 0.79) PROMIS domains. Subsequent analyses were unable to identify clinically useful 95% sensitivity and specificity preoperative thresholds, with the exception of the 95% sensitivity PROMIS physical function threshold. A preoperative physical function score of greater than 53.2 resulted in a 63% probability of achieving the MCID. The pain interference PROMIS domain did not demonstrate a statistically significant AUC.

CONCLUSION

Preoperative PROMIS physical function, pain interference, pain intensity, and depression scores are minimally associated with preoperative to 2-year postoperative improvement in patients undergoing cheilectomy. It may be difficult to determine which patients improve from a cheilectomy based on the severity of symptoms they exhibit preoperatively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The use of patient-reported outcome measures in the literature on traumatic foot fractures: A systematic review

INTRODUCTION

Adequate foot function is paramount in daily activities, yet the incidence of foot fractures shows a rising trend. Patient-reported outcome measures are increasingly used for research; however, the use of a wide variety of available instruments is undesirable. In the current study, an overview is provided of patient-reported outcome measures used in clinical research evaluating outcomes of foot fractures. Tools are provided to choose the most adequate instrument in future research.

METHODS

To identify the instruments, a systematic review was performed using PubMed, Embase, and the Cochrane Library. Articles published since 2000, reporting on traumatic foot fractures and/or their posttraumatic sequelae, and using a minimum of one condition- or region-specific patient-reported outcome measure were included. Forty-nine instruments were identified, used 636 times collectively. These instruments were evaluated on frequency of use, bones or joints analyzed with the instruments, the type and amount of contained items, and existing literature on their psychometric properties.

RESULTS

The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was used predominantly (AOFAS Ankle-Hindfoot Scale; n = 243, 38.2%), followed by the Maryland Foot Score (n = 90, 14.2%). Twenty-seven instruments were included for further analysis. The majority included questions on mobility (27/27) and pain (24/27). Tools to select an adequate instrument for new research are presented in the appendices.

DISCUSSION

Controversy surrounds the AOFAS Ankle-Hindfoot Scale as other authors have found that its psychometric properties, indicating it measures what it is supposed to measure adequately, are flawed.

CONCLUSION

A multitude of specific patient-reported outcome measures concerning foot fractures exists. Furthermore, the predominantly used instrument is deemed insufficient regarding quality as found by other studies. A valid, reliable, and responsive patient-reported outcome measure for clinical research on foot fractures is necessary. The most adequate existing ones for future research on different topics can be found through the tools provided.

Functional Outcomes and Quality of Life in Patients With Post-Traumatic Arthrosis Undergoing Open or Arthroscopic Talocrural Arthrodesis-A Retrospective Cohort With Prospective Follow-Up

Fusion remains the gold standard for post-traumatic osteoarthritis after ankle fractures in many institutes. Patient-reported outcomes on long-term quality of life and functionality of talocrural arthrodesis remain relatively unknown. In literature, low patient numbers and inadequate outcome measures provide a poor foundation for patient expectation management. Additionally, the surgical approach is often omitted. This study presents a retrospective cohort of patients who underwent open or arthroscopic talocrural arthrodesis for post-traumatic arthritis between 2008 and 2019 with prospective follow-up by questionnaire. Participants completed the EuroQol 5-dimensional 3-level questionnaire (EQ-5D-3L^TM), EuroQol Visual Analogue Scale (EQ-VAS^TM), Foot and Ankle Outcome Score Dutch Language Version (FAOS-DLV), and 4 additional questions. Thirty-five patients were included in the cohort and 32 were included for follow-up. Trauma mechanism was mainly a low fall or motor vehicle accident causing a talocrural fracture-dislocation in most cases. For open versus arthroscopic treatment respectively, patients reported a median EQ-5D-3L^TM index of 0.775 and 0.775, EQ-VAS^TM of 80 and 88, FAOS-DLV of 57.0 and 63.9, and satisfaction of 90 and 88 out of 100 after a median of 6.0 and 6.5 years. This study is unique as it is the largest series on patient-reported outcomes in patients with post-traumatic arthrosis with validated questionnaires. In general, patients were satisfied with relatively high questionnaire scores, especially concerning pain and daily living. These functional scores are of importance when setting patient expectations regarding talocrural arthrodesis and recovery. Additionally, the subscale values may help preoperatively in weighing the intervention's advantages and disadvantages for individual patients.

First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques

Background

First metatarsophalangeal joint arthrodesis is commonly performed for symptomatic end-stage hallux rigidus. It has been postulated to produce good results in the literature. Various fixation techniques offer differences in union rates, complications and functional outcomes, stirring debates about which produces the best outcomes for patients. Therefore, this review aims to synthesise and compare the outcomes of modern fixation techniques used for first metatarsophalangeal joint (FMPJ) arthrodesis.

Methods

The electronic database searched were PubMed, CINAHL, Cochrane Library, and Google Scholar. The critical appraisal skills programme tool for cohort study was used. The interventions consisted of screw(s), plate(s), and staple(s). Studies comprising outdated fixation techniques such as suture, metallic wire, external fixation, Rush rods or Steinmann pins were excluded. Participants were adults over 18 years, undergoing FMPJ arthrodesis in the UK. Studies with the population consisting primarily of revision cases, patients with rheumatoid arthritis or diabetes were excluded.

Results

Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days. Staples had the highest union rate of 98.2% at mean union time of 84 days, followed by plates (95.2%, 92 days), and finally screws (94.9%, 71 days). The overall complication incidence is 5.8%. All of the fixation techniques produced good functional outcomes postoperatively.

Conclusions

Whilst staple techniques showed the highest union rate, plating techniques are preferable over screws or staples for better results across several outcome measures, including reduced complication incidence, stability, early ambulation, and good functional outcome. The Manchester-Oxford Foot Questionnaire and EuroQol-5Dimensional are recommended as measurement tools to assess functional outcomes following FMPJ arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00540-9.

Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection

PURPOSE

Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures.

METHODS

A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO.

RESULTS

The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%).

CONCLUSION

Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.

Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation

AIMS

To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF).

METHODS

A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications.

RESULTS

In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop.

CONCLUSION

Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion.

LEVEL OF EVIDENCE

IV Systematic review including case series.

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.

Preoperative Evaluation of the Lower Extremity-Specific PROMIS Mobility Bank in Patients with ACL Tears

Purpose

The purpose of this study was to preoperatively assess the Patient-Reported Outcomes Measurement Information System (PROMIS) Item Bank v2.0–Mobility in patients with anterior cruciate ligament (ACL) tears to (1) determine construct validity by correlating with legacy patient-reported outcomes (PROs), (2) evaluate test burden, (3) determine the presence of floor or ceiling effects, and (4) revisit the conventional threshold for inclusiveness (floor/ceiling effects) in the modern era of computer adaptive testing (CAT)–based PROs.

Methods

Patients at a large academic musculoskeletal specialty center diagnosed with ACL tears indicated for surgery were administered the following outcomes measures before surgery: PROMIS Mobility CAT, PROMIS Pain Interference CAT (PROMIS PI), International Knee Documentation Committee (IKDC), the Marx Knee Activity Rating Scale (Marx), and Single Assessment Numeric Evaluation (SANE). Construct validity was evaluated using Spearman correlation coefficients. Correlation strengths were defined as high (≥0.7), high-moderate (0.61-0.69), moderate (0.4-0.6), moderate-weak (0.31-0.39) and weak (≤0.3). Number of questions to completion were recorded as a marker of test burden. The percentage of patients scoring at the extreme high (ceiling) or low (floor) of each measure was recorded to measure inclusivity.

Results

A total of 1126 patients were evaluated. The mean number of questions answered (± standard deviation) was 4.7 ± 2.1 for PROMIS Mobility and 4.5 ± 1.9 for PROMIS PI. PROMIS Mobility demonstrated a high correlation with IKDC, (r = 0.81, P < .001), a high-moderate correlation with PROMIS PI (r = −0.63), and a moderate correlation with SANE (r = 0.46, P < .01). Neither PROMIS Mobility nor PROMIS PI met conventional criteria for floor or ceiling effects (>15%).

Conclusions

The PROMIS Mobility measure maintains construct validity, because its scores correlate strongly with other PROs measuring physical function with high efficiency among preoperative patients with ACL injuries. Although ceiling effects of PROMIS Mobility CAT were below the conventional significance threshold of 15% at the preoperative timepoint in this population, this study provides critical feedback for redesigning the Mobility bank.

Level of Evidence

Level III (Diagnostic study).

Posterior Ankle Decompression With Os Trigonum or Stieda Process Resection in Dancers: Case Series Report and Review of the Literature

This case series reports the outcome of posterior ankle decompression and os trigonum or Stieda process resection utilizing an open posterolateral approach in 54 professional, pre-professional, and dedicated recreational dancers. All procedures were performed by a single surgeon at the same facility between 2008 and 2018. The surgical technique is described in detail. Data related to results of the surgery were gathered via follow-up questionnaire and verified by referencing the patients' medical records. Outcomes were self-assessed in terms of categories ranging from excellent through moderate to poor. Eighty-nine percent of the dancers (N = 48 of 54) chose excellent or good, 11% (N = 6) chose moderate, and none selected poor. These results were compared with those achieved in 17 previous studies reporting the use of both open (posterolateral and posteromedial) and arthroscopic/endoscopic techniques in dancers. This comparison found similarly favorable reported outcomes, but also great variation in methodology for determining patient reported outcomes (PROs). While the preferred surgical technique for posterior ankle decompression remains controversial, the open posterolateral approach utilized in this series resulted in high expectation of return to dance with minimal complications. The need for a dancer-specific PRO tool is discussed.

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.

Screw versus suture button in treatment of syndesmosis instability: Comparison using weightbearing CT scan

BACKGROUND

The superiority of screw or suture button fixation for syndesmotic instability remains debatable. Our aim is to compare radiographic outcomes of screw and suture button fixation of syndesmotic instability using weight bearing CT scan (WBCT).

METHODS

Twenty patients with fixation of unilateral syndesmotic instability were recruited and divided among two groups (screw = 10, suture button = 10). All patients had WBCT of both ankles ≥12 months postoperatively.

RESULTS

In suture button group, injured side measurements were significantly different from normal side for syndesmotic area (P = 0.003), fibular rotation (P = 0.004), anterior difference (P = 0.025) and direct anterior difference (P = 0.035). In screw group, syndesmotic area was the only significantly different measurement (P = 0.006).

CONCLUSION

While both screw and suture button didn't completely restore the syndesmotic area as compared to the contralateral uninjured ankle, external malrotation of the fibula was uniquely associated with suture button fixation.

LEVEL OF EVIDENCE

III Retrospective Cohort Study.

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of infection, extruded talus and complex pilon fractures

INTRODUCTION

The treatment of complex pilon fractures and talus fracture-dislocations present several challenges, like avoiding infection, achieving union, management of bone loss and function preservation.

METHODS

Retrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0 - 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates. Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score, AOS) were the secondary measures.

RESULTS

Eradication and prevention of deep infection was achieved in all cases. Radiological union was achieved at a mean of 9 months (range 5 - 17). Solid AA was achieved in 12 of 14 cases using the TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone transport, mean of 63 mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 - 16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 - 77.5) with 69.3% of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 - 10). Minimum follow up time was 12 months (range 12 - 56).

CONCLUSION

AA using TSF can be considered for complex pilon fractures and extruded talus. It has shown to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and possibly not using bone graft. Patients must be aware that while treatment of these injuries will be prolonged and carries the risk of many potential complications, it provides a good alternative to amputation.

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.

Radiographic and Clinical Outcomes of Hallux Valgus and Metatarsus Adductus Treated With a Modified Lapidus Procedure

BACKGROUND

Previous studies have found an increased rate of deformity recurrence in hallux valgus (HV) patients with concomitant metatarsus adductus (MA) undergoing metatarsal osteotomies. The purpose of this paper was to determine if there were radiographic or clinical outcome differences between HV patients with and without MA undergoing a modified Lapidus procedure.

METHODS

One hundred forty-seven feet that underwent a modified Lapidus procedure for HV were divided into 2 groups based on their preoperative modified Sgarlato's angle: (1) the MA group had an angle ≥20 degrees and (2) the HV-only group had an angle <20 degrees. HV angle (HVA) and intermetatarsal angle (IMA) were measured on preoperative and ≥5-month postoperative weightbearing radiographs. Patient-Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were obtained preoperatively and postoperatively.

RESULTS

Patients in the MA group had a significantly higher mean postoperative HVA (10.8 vs 7.5 degrees; P = .038). There was a trend toward higher PROMIS PI scores in the MA group at 1 year postoperatively (51.9 vs 47.6; P = .088). Patients in the MA group were more likely to have a revision surgery (7.3% vs 0%; P = .021), and there was a trend toward those patients having a higher recurrence rate (17.1% vs 6.6%; P = .064).

CONCLUSION

Despite potentially worse postoperative outcomes in patients with HV and MA who undergo a modified Lapidus procedure, the recurrence rates reported here are lower than those reported in the literature for patients with MA undergoing metatarsal osteotomies, indicating that a modified Lapidus procedure may be an acceptable choice in these patients.

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.

Symptom cluster profiles following traumatic orthopedic injuries: A protocol

Traumatic injuries affect millions of Americans annually, resulting in $671 billion in healthcare costs and lost productivity. Postinjury symptoms, like pain, sleep disturbance, anxiety, depression, and stressor-related disorders are highly prevalent following traumatic orthopedic injuries (TOI) and may contribute to negative long-term outcomes. Symptoms rarely present in isolation, but in clusters of two or more symptoms that co-occur to affect health in aggregate. Identifying symptom cluster profiles following TOI may identify those at highest risk for negative outcomes. Dysregulation of brain-derived neurotrophic factor (BDNF) is a potential biological mechanism responsible for symptom cluster profile membership after TOI and may be targeted in future precision-health applications. The purpose of this paper is to present the protocol of a cross-sectional study designed to identify symptom cluster profiles and measure the extent to which the BDNF val66met mutation and serum concentration of BDNF are associated with membership in symptom cluster profiles. We plan to recruit 150 TOI survivors within the first 72 h of injury. The study aims are to (1) describe TOI survivors' membership in symptom cluster profiles, indicated by pain, sleep disturbance, and symptoms of anxiety, depression, and stressor-related disorders, immediately following a TOI; (2) examine associations between demographic and clinical factors and symptom cluster profile membership among TOI survivors; (3) test the hypothesis that low serum concentrations of BDNF are associated with membership among symptom cluster profiles following TOI; and (4) test the hypothesis that the presence of the val66met mutation on one or both alleles of the BDNF gene is associated with membership among symptom cluster profiles following TOI.

Radiographic and Clinical Outcomes of the Salto Talaris Total Ankle Arthroplasty

BACKGROUND

The Salto Talaris is a fixed-bearing implant first approved in the US in 2006. While early surgical outcomes have been promising, mid- to long-term survivorship data are limited. The aim of this study was to present the survivorship and causes of failure of the Salto Talaris implant, with functional and radiographic outcomes.

METHODS

Eighty-seven prospectively followed patients who underwent total ankle arthroplasty with the Salto Talaris between 2007 and 2015 at our institution were retrospectively identified. Of these, 82 patients (85 ankles) had a minimum follow-up of 5 (mean, 7.1; range, 5-12) years. The mean age was 63.5 (range, 42-82) years and the mean body mass index was 28.1 (range, 17.9-41.2) kg/m². Survivorship was determined by incidence of revision, defined as removal/exchange of a metal component. Preoperative, immediate, and minimum 5-year postoperative AP and lateral weightbearing radiographs were reviewed; tibiotalar alignment (TTA) and the medial distal tibial angle (MDTA) were measured to assess coronal talar and tibial alignment, respectively. The sagittal tibial angle (STA) was measured; the talar inclination angle (TIA) was measured to evaluate for radiographic subsidence of the implant, defined as a change in TIA of 5 degrees or more from the immediately to the latest postoperative lateral radiograph. The locations of periprosthetic cysts were documented. Preoperative and minimum 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscales were compared.

RESULTS

Survivorship was 97.6% with 2 revisions. One patient underwent tibial and talar component revision for varus malalignment of the ankle; another underwent talar component revision for aseptic loosening and subsidence. The rate of other reoperations was 21.2% (n = 18), with the main reoperation being exostectomy with debridement for ankle impingement (n = 12). At final follow-up, the average TTA improved 4.4 (± 3.8) degrees, the average MDTA improved 3.4 (± 2.6) degrees, and the average STA improved 5.3 (± 4.5) degrees. Periprosthetic cysts were observed in 18 patients, and there was no radiographic subsidence. All FAOS subscales demonstrated significant improvement at final follow-up.

CONCLUSIONS

We found the Salto Talaris implant to be durable, consistent with previous studies of shorter follow-up lengths. We observed significant improvement in radiographic alignment as well as patient-reported clinical outcomes at a minimum 5-year follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ankle Arthrodesis Through a Fibular-Sparing Anterior Approach

BACKGROUND

The open anterior approach to ankle arthrodesis offers a technique that provides several advantages for surgeons, such as easier visualization of the joint for deformity correction and preservation of the malleoli for potential future conversion to total ankle arthroplasty. The purpose of this study was to evaluate clinical, radiographic, and functional outcomes in a large series of patients undergoing open ankle arthrodesis via a fibular-sparing anterior approach.

METHODS

A retrospective review was performed of patients undergoing primary ankle arthrodesis with a single fellowship-trained foot and ankle orthopedic surgeon between 2009 and 2017. Patients were excluded if an approach other than anterior was performed. Patient-reported outcome measures (Foot and Ankle Ability Measure-Activities of Daily Living [FAAM-ADL], Short-Form 12 [SF-12], and visual analog scale [VAS] pain) were subsequently collected at a minimum of 24 months (2 years) following index surgery, along with outcome satisfaction and likelihood to repeat surgery. Fusion of the tibiotalar joint at the time of last radiographic follow-up was also assessed. Paired t tests were performed to assess change in pre- to postoperative outcomes, while linear regression analysis was performed to identify any patient factors associated with outcomes. Eighty-one patients, including 31 women and 50 men, with a mean age of 51.5 years and a mean follow-up of 58.9 (range, 24-104) months, were included.

RESULTS

Sixty-two patients reported significant improvement in mean FAAM-ADL (P < .0001), SF-12 Physical Composite Scale (P < .0001), and VAS pain (P < .0001), while the SF-12 Mental Composite Scale also improved, though not significantly (P = .2854). Twelve patients (14.8%) experienced complications following their arthrodesis procedure. Seventy-nine patients (97.5%) achieved fusion at their last radiographic follow-up. Multiple linear regression analysis revealed age (B = 0.071 [0.004, 0.128]; P = .0373) to have a positive association with postoperative VAS pain.

CONCLUSION

Ankle arthrodesis utilizing a fibular-sparing anterior approach combined with the transarticular screw fixation technique offers surgeons several advantages, along with a low postoperative complication rate, high rate of radiographic evidence of joint fusion, and substantially large improvement in pain and functional levels.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Functional Comparison of Horizontal Mattress Suture Versus Free-Edge Suture in the All-Inside Arthroscopic Broström-Gould Procedure for Chronic Lateral Ankle Instability

Objective

To compare the clinical outcomes of horizontal mattress suture vs free‐edge suture in the all‐inside arthroscopic Broström–Gould procedure.

Methods

This retrospective cohort study included 68 chronic lateral ankle instability (CLAI) patients who underwent either a horizontal mattress suture or a free‐edge suture all‐inside arthroscopic Broström–Gould procedure from January 2014 to January 2017. Patients were divided into two groups based on the suture fashion during the all‐inside arthroscopic Broström–Gould procedure. In the horizontal mattress suture group (n = 31), anchor sutures were used to suture the ATFL, capsule, and inferior extensor retinaculum in horizontal mattress suture fashion. In the free‐edge suture group (n = 37), anchor sutures were used to suture the ATFL, capsule, and inferior extensor retinaculum in free‐edge suture fashion. The Visual Analogue Scale (VAS) score, the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), Anterior Talar Translation (ATT), the rate of return to sports, and ankle proprioceptive recovery were compared in both groups.

Results

The operative times and duration of hospitalization between the two groups were comparable (all P > 0.05). The VAS, AOFAS, ATT, the rate of return to sports, and ankle proprioceptive recovery were comparable between the horizontal mattress suture and free‐edge suture groups at 1 and 2 years after surgery. Patients of the free‐edge suture group achieved better KAFS 1 and 2 years after the surgery compared with those of the horizontal mattress suture group. In both groups, incisions were healed by first intention, and complications such as infection, implant reactions, tendon injury, and nervous or vascular injuries were not observed. The ankle proprioceptive recovery in horizontal mattress suture and free‐edge suture groups showed no significant differences at 1 and 2 years after surgery. The mean time of the return to full activity for patients in the horizontal mattress suture group was 10.38 ± 2.02 (range 8 to 12) weeks vs 8.63 ± 2.31 (range 8 to 12) weeks for those in the free‐edge suture group (P = 0.001, power = 0.907). The exercise participation rates were comparable between groups (P > 0.05). At the 2‐year follow‐up, all patients regained normal activities and ankle stability, and no recurrence of CLAI or revision surgery was recorded.

Conclusion

All‐inside arthroscopic Broström–Gould surgery for the treatment of CLAI ensures a better functional effect (KAFS) and better recovery time when free‐edge suture is used instead of horizontal mattress suture.

Effectiveness of hallux valgus surgery on patient quality of life: a systematic review and meta-analysis

Background and purpose - The quality of life (QoL) of patients with hallux valgus (HV) usually improves postoperatively. Evidence regarding the effect of HV surgery on different domains of patient QoL remains inconclusive. This systematic review and meta-analysis estimates the effect of HV surgery on patient QoL through distinguishing effects on physical domains (comprising physical function and body pain domains) using the EuroQol-5D, short form (SF) health survey-12, and SF-36 QoL scales and a visual analogue scale (VAS) score and mental and social domains using QoL scales.Patients and methods - MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to March 2019 for studies on the effect of HV surgery on patient QoL. A standardized mean difference score was calculated for each specific QoL domain (mental, social, pain, physical, and VAS) using Cohen's d index. The pooled effect size (ES) was estimated using a random-effects model based on the DerSimonian and Laird method.Results - From 12 published studies selected, the estimated pooled ES for QoL was 1.01 (95% confidence interval [CI] 0.52-1.51; I² = 87%) for body pain and 0.43 (CI 0.31-0.55, I² = 35%) for physical function. Regarding the composite mental and social domains of QoL, the pooled ES estimates were 0.24 (CI 0.00-0.47, I² = 80%) and 0.42 (CI 0.21-0.63, I² = 6.4%), respectively. The pooled difference in means for the VAS score was -4.1 (CI -4.5 to -3.6, I² = 90%).Interpretation - Our data showed that HV surgery decreased patients' perceptions regarding pain. Furthermore, the data confirmed that HV surgery increased patients' QoL, particularly concerning physical and social domains.

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury

BACKGROUND

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma.

METHODS

In total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested.

RESULTS

AOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach's alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample.

CONCLUSIONS

Our data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.

Visual Analog Pain Scores Reported to a Nurse and a Physician in a Postoperative Setting

Background:

The purpose of this study was to compare postoperative foot and ankle patient-reported visual analog pain scores (VAS) to nursing staff and the treating surgeon during a single encounter. Prior literature established preoperative patients reported higher pain scores to a surgeon as compared to nursing staff. We hypothesized that there will be no differences in postoperative patients’ pain scores when reporting to nursing staff vs a surgeon.

Methods:

This study was a retrospective cohort of 201 consecutive postoperative foot and ankle patients with 3 follow-up encounters treated by a single surgeon. The patients were asked to rate their pain intensity using the VAS with 0 “no pain” and 10 “worst pain” at 2, 6, and 12 weeks postoperatively by a nurse and surgeon.

Results:

At all time intervals, the mean pain score was significantly higher when reported to the surgeon, although these were not clinically relevant. The mean scores at 2 weeks were 2.8 reported to the surgeon and 2.5 reported to the nurse (P < .001). The mean scores at 6 weeks were 2.0 reported to the surgeon and 1.8 reported to the nurse (P = .002). The mean scores at 12 weeks were 2.3 reported to the surgeon and 2.0 reported to the nurse (P = .005).

Conclusion:

This study found that postoperative foot and ankle patients did not overemphasize their VAS pain scores to the physician vs nursing staff. These findings contrast with our 2 previous studies that found preoperative and nonoperative patients reported clinically significant higher scores to the surgeon.

Level of Evidence:

Level III, comparative study.

Functional Results of All-Inside Arthroscopic Broström-Gould Surgery With 2 Anchors Versus Single Anchor

BACKGROUND

The all-inside arthroscopic Broström-Gould technique gained particular attention among clinicians and researchers due to its high rate of satisfactory results. Thus far, there is a lack of evidence regarding the differences in clinical outcomes between the use of 1 anchor and 2 anchors. The purpose of this study was to compare the differences in clinical function and activity levels in patients treated with 1 or 2 anchors in all-inside arthroscopic Broström-Gould surgery for chronic lateral ankle instability (CLAI).

METHODS

The data of 75 patients with CLAI (unilateral) admitted from May 2013 to July 2016 were retrospectively analyzed. All patients were treated with all-inside arthroscopic Broström-Gould surgery. The patients were divided into a single-anchor group (n = 36) and double-anchor group (n = 39) according to the number of anchors used. There was no statistical difference in general characteristics between the 2 groups before surgery. After 36 to 72 months of follow-up, the pain visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Foot and Ankle Outcome Score (FAOS) were used to evaluate and compare the clinical function results between the 2 groups.

RESULTS

The incidence of wound complications; reaction to the suture; injury to the nerve, blood vessel, or tendon; and length of postoperative hospitalization were similar between the 2 groups. At the last follow-up, there was no significant difference in the VAS and AOFAS scores between single- and double-anchor groups, but the KAFS and FAOS in the double-anchor group were significantly higher than in the single-anchor group. Additionally, more patients in the double-anchor group returned to preinjury sports activities.

CONCLUSION

All-inside arthroscopic Broström-Gould surgery for the treatment of CLAI yielded a better functional effect and better recovery to preinjury mobility when 2 anchors were used instead of a single anchor.

LEVEL OF EVIDENCE

Level III, comparative study.

Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study

Background

Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication.

Methods

This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points.

Results

The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance.

Conclusion

Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis.

Level of evidence

Level II, prospective single cohort study.

Operative Intervention Does Not Change Pain Perception in Patients With Diabetic Foot Ulcers

Researchers investigated pain perception in patients with diabetic foot ulcers (DFUs) by analyzing pre- and postoperative physical function (PF), pain interference (PI), and depression domains of the Patient-Reported Outcome Measurement Information System (PROMIS). They hypothesized that 1) because of painful diabetic peripheral neuropathy (DPN), a majority of patients with DFUs would have high PROMIS PI scores unchanged by operative intervention, and 2) the initially assessed PI, PF, and depression levels would be correlated with final outcomes. Seventy-five percent of patients with DFUs reported pain, most likely because of painful DPN. Those who reported high PI and low PF were likely to report depression. PF, PI, and depression levels were unchanged after operative intervention or healing of DFUs.