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

Defining the patient acceptable symptom state using PROMIS following reconstruction of the progressive collapsing foot deformity

BACKGROUND

The patient acceptable symptom state (PASS) represents the threshold beyond which patients are satisfied with their outcome. This study aimed to define PASS thresholds for progressive collapsing foot deformity (PCFD) reconstruction using Patient-Reported Outcomes Measurement Information System (PROMIS) scores and anchor question responses.

METHODS

This retrospective study consisted of 109 patients who underwent flexible PCFD reconstruction, had preoperative and 2-year postoperative PROMIS scores, and 2-year postoperative anchor question responses. ROC curve analyses were performed to quantify PASS thresholds.

RESULTS

PASS thresholds for the PROMIS Physical Function (PF) and Pain Interference (PI) domains were found to be lower and higher, respectively, than population norms. Furthermore, patients with higher preoperative PROMIS PF scores or lower preoperative PROMIS PI scores had a significantly higher likelihood of achieving the PASS thresholds.

CONCLUSION

In addition to guiding future outcomes research, these results may help surgeons optimize treatment for PCFD and better manage patient expectations.

LEVEL OF EVIDENCE

III, retrospective cohort study.

What's the clinical significance of VAS, AOFAS, and SF-36 in progressive collapsing foot deformity

BACKGROUND

This study aimed to ascertain the minimal clinically important difference (MCID), and substantial clinical benefit (SCB) of the American Orthopedic Foot and Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Short Form-36 Health Survey (SF-36) in progressive collapsing foot deformity (PCFD) surgery.

METHODS

In this retrospective cohort study, a total of 84 patients with PCFD (84 feet) who underwent surgery between July 2015 and April 2021 were included. The study assessed the patients' subjective perception, as well as their VAS, AOFAS, and SF-36 scores at a minimum two-year follow-up, and these data were subjected to statistical analysis. The study utilized Spearman correlation analysis to determine the degree of correlation between patients' subjective perception and their VAS, AOFAS, and SF-36 scores. The minimal detectable change (MDC), MCID, and SCB for VAS, AOFAS, and SF-36 were calculated using both distribution- and anchor-based methods. The classification outcomes obtained from the distribution- and anchor-based methods were assessed using Cohen's kappa.

RESULTS

Based on the subjective perception of the patients, a total of 84 individuals were categorized into three groups, with 7 in the no improvement group, 14 in the minimum improvement group, and 63 in the substantial improvement group. Spearman's correlation analysis indicated that the patients' subjective perception exhibited a moderate to strong association with VAS, AOFAS, SF-36 PCS, and SF-36 MCS, with all coefficients exceeding 0.4. The MCID of VAS, AOFAS, SF-36 PCS, and SF-36 MCS in PCFD surgery were determined to be 0.93, 5.84, 4.15, and 4.10 points using the distribution-based method and 1.50, 10.50, 8.34, and 3.03 points using the anchor-based method. The SCB of VAS, AOFAS, SF-36 PCS, and SF-36 MCS in PCFD surgery were 2.50, 18.50, 11.88, and 6.34 points, respectively. Moreover, the preliminary internal validation efforts have demonstrated the practical application and clinical utility of these findings. With the exception of the distribution-based MCID of SF-36 PCS, which showed fair agreement, all other measures demonstrated moderate to almost perfect agreement.

CONCLUSIONS

The MDC, MCID, and SCB intuitively enhance the interpretation of VAS, AOFAS, and SF-36 in PCFD surgery, assisting all stakeholders to better understand the therapeutic benefits and limitations of clinical care, and thus to make a more rational decision. Each of these parameters has its own emphasis and complements the others. These parameters are recommended for evaluating the clinical relevance of the results, and their promotion should extend to other areas of foot and ankle surgery.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery

INTRODUCTION

Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.

MATERIALS AND METHODS

We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.

RESULTS

Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).

CONCLUSIONS

PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

Effect of Peritalar Subluxation Correction for Progressive Collapsing Foot Deformity on Patient-Reported Outcomes

BACKGROUND

Peritalar subluxation (PTS) is part of progressive collapsing foot deformity (PCFD). This study aimed to evaluate initial deformity correction and PTS optimization in PCFD patients with flexible hindfoot deformity undergoing hindfoot joint-sparing surgical procedures and its relationship with improvements in patient-reported outcome measures (PROMs) at latest follow-up. We hypothesized that significant deformity/PTS correction would be observed postoperatively, positively correlating with improved PROMs.

METHODS

A prospective comparative study was performed with 26 flexible PCFD patients undergoing hindfoot joint-sparing reconstructive procedures, mean age 47.1 years (range, 18-77). We assessed weightbearing computed tomography (WBCT) overall deformity (foot and ankle offset [FAO]) and PTS markers (distance and coverage maps) at 3 months, as well as PROMs at final follow-up. A multivariate regression model assessed the influence of initial deformity correction and PTS optimization in patient-reported outcomes.

RESULTS

Mean follow-up was 19.9 months (6-39), and the average number of procedures performed was 4.8 (2-8). FAO improved from 9.4% (8.4-10.9) to 1.9% (1.1-3.6) postoperatively (P < .0001). Mean coverage improved by 69.6% (P = .012), 12.1% (P = .0343) and 5.2% (P = .0074) in, respectively, the anterior, middle, and posterior facets, whereas the sinus tarsi coverage decreased by an average 57.1% (P < .0001) postoperatively. Improvements in patient-reported outcomes were noted for all scores assessed (P < .03). The multivariate regression analysis demonstrated that improvement in both FAO and PTS measurements significantly influenced the assessed PROMs.

CONCLUSION

This study demonstrated significant improvements in the overall 3D deformity, PTS markers, and PROMs following hindfoot joint-sparing surgical treatment in patients with flexible PCFD. More importantly, initial 3D deformity correction and improvement in subtalar joint coverage and extraarticular impingement have been shown to influence PROMs significantly and positively. Addressing these variables should be considered as goals when treating PCFD.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery

Patient-Reported Outcome Measurement Information System (PROMIS) has favorable psychometric and administrative properties in orthopaedic clinical research. It facilitates clinically meaningful data collection while minimizing administration time and survey fatigue and improving compliance. PROMIS is a critical component of patient-centered care and shared decision making, as it provides enhanced communication and engagement between patients and providers. As a validated instrument, it may also aid in measuring value-based health care quality. The goal of the current work is to provide an overview of PROMIS metrics used in orthopaedic foot and ankle, including advantages and disadvantages compared to legacy scales and PROMIS's applicability in specific foot and ankle conditions based on psychometric properties. We provide a review of the literature regarding the utilization of PROMIS as an outcome measure for specific foot and ankle procedures and conditions.

Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity

BACKGROUND

Population-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking.

METHODS

We analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014-2021.

RESULTS

625 feet with primary AAFD surgery were registered. Median age was 60 (range 16-83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis.

CONCLUSIONS

Patients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist.

LEVEL OF EVIDENCE

III.

Isolated Gastrocnemius Recession for Progressive Collapsing Foot Deformity

INTRODUCTION

Progressive collapsing foot deformity (PCFD) is frequently associated with a gastrocnemius contracture. Surgical treatment of PCFD often includes a gastrocnemius recession in addition to other corrective procedures, which typically requires a period of restricted weight bearing postoperatively. Isolated gastrocnemius recession may allow passive correction of the deformity, improve orthotic fit, and obviate the need for full reconstruction and restricted weight bearing. The goal of this study was to evaluate patient-reported outcomes after an isolated gastrocnemius recession for flexible PCFD in patients anticipated to have difficulty with postoperative restricted weight bearing.

METHODS

A total of 47 patients met the inclusion criteria: isolated gastrocnemius recession for flexible PCFD, no previous ipsilateral surgery, and more than 6 months of follow-up. Of 47 eligible patients, 29 (31 feet) participated. Available preoperative and postoperative patient-reported outcomes were gathered, including the Foot and Ankle Ability Measure Activities of Daily Living, visual analog scale, and the Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a. In addition, patients were asked about satisfaction, willingness to undergo the procedure again, and whether orthotics provided better relief.

RESULTS

At a mean of 5.1 (range, 0.6 to 9.0) years postoperatively, median Foot and Ankle Ability Measure Activities of Daily Living was 82.1, mean Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a was 44.2, and median visual analog scale was 10 (of 100). Sixty-nine percent of patients were either satisfied or very satisfied, 69% would undergo the procedure again, and 62% reported improved relief with use of orthotics postoperatively. Among the 47 eligible patients, there were 5 (11%) subsequent flatfoot reconstructions.

CONCLUSIONS

Isolated gastrocnemius recession for the management of flexible PCFD can be effective as this procedure demonstrated good outcomes scores with high procedural satisfaction and 11% of patients proceeding to subsequent flatfoot reconstruction. This alternative approach may be of particular value for patients anticipated to have difficulty with postoperative weight-bearing restrictions.

LEVEL OF EVIDENCE

:IV.

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.

Return to Physical Activity Following Flatfoot Reconstruction

BACKGROUND

Progressive collapsing foot deformity (PCFD) is a debilitating condition encompassing several interrelated, progressive deformities requiring a combination of reconstructive procedures. Few studies investigate returns to activity following flatfoot reconstruction, and existing studies only examine 1 or 2 of the numerous procedures employed. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible flatfoot deformity.

METHODS

Patients aged 18-60 years who underwent reconstructive surgery between February 16 and May 19 for symptomatic flexible-stage flatfoot deformity were identified by registry review. Eighty-two of 113 eligible patients (73%) were reached at a mean 2.9 years (range, 2.0-5.4) of follow-up with mean age at surgery of 48.9 years (range, 18-59). Returns to physical activity were evaluated with a sports-specific survey. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores.

RESULTS

Patients reported participation in 21 specific sports and activities. One-fourth (25.6%) of patients (21/82) reported increased difficulty with physical activities postoperatively, 15.9% reported equal difficulty, and 58.5% (48/82) reported decreased difficulty. Median return times were 9-12 months for participation and 12-18 months to reach maximum preoperative participation levels. Improvements in Physical Function (P= .001), Pain Interference (P < .001), Pain Intensity (P <.001), and Global Physical Health (P = .004) were associated with increased satisfaction with respect to sports and physical activities.

DISCUSSION

This study investigated participation in specific sports and physical activities following flatfoot reconstruction. Our findings suggest mixed outcomes, where many patients reported life-changing improvements but many also experienced prolonged pain and difficulty after surgery. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to athletic limitations.

CONCLUSION

Although flatfoot reconstruction can be a powerful tool to increase patients' capacity to engage in physical activity, in our cohort many patients had reduced physical activity outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Patient-Reported Outcomes of Primary Total Ankle Arthroplasty in Patients Aged <50 Years

Background:

Compared to more prevalent arthritic conditions, ankle arthritis is complicated by an earlier age of onset. Recently published data demonstrates excellent survivorship and complication rates in short-/midterm follow-up of younger patients who received a primary total ankle arthroplasty (TAA). Additionally, older TAA patients display comparable reported outcomes relative to hip/knee arthroplasty. However, there remains a paucity of literature surrounding the reported outcomes of younger patients undergoing TAA. Thus, our aim was to assess the reported outcomes of individuals aged <50 years receiving a primary TAA.

Methods:

A retrospective cohort analysis of adult patients <50 years who received a primary total ankle replacement was conducted. Patient demographics, diagnosis, treatment, and outcome characteristics were recorded from a chart review of 41 patients with at least 1 year of postoperative clinical follow-up. Postoperative reported outcomes were obtained via telephone interviews. Primary outcomes that were measured included emotional and physical health, activity limitation, ambulation, and global health. Measures used included the 36-Item Short Form Health Survey (SF-36), Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health, and Sickness Impact Profile Ambulation. The functional outcomes in our study sample were compared with age- and gender-matched norms from a general US population, and 95% CIs were calculated for each functional outcome mean. Student t test was used for continuous variables, and χ² analysis was used for categorical variables.

Results:

Thirty-one of 41 eligible patients were reached for interview. The average age at surgery was 39.7 years. Clinical and radiographic follow-up was a mean of 51.6 months and 31.2 months following TAA, respectively. General health as measured with the SF-36 was not significantly different from age-/gender-matched norms. Eighty-seven percent of patients would choose to have a TAA again. Although 58% reported being limited in vigorous activities, 61% were able to ambulate frequently for long periods of time. On average, the patients did not report ongoing pain, and only 16% reported fatigue that hindered activities. Eighty-one percent reported returning to full employment and performing their duties without difficulty, and 84% reported they resumed all normal social activities. Primary implant survivorship was 93%.

Conclusion:

Despite a younger age and potentially increased demands, patients aged <50 years undergoing primary TAA are generally satisfied with their index procedure at a mean follow-up of nearly 5 years. Our findings of positive outcomes on their health and well-being may improve surgeon insight for TAA as an alternative treatment for younger individuals with end-stage ankle arthritis.

Level of Evidence: Level IV, case series.

Predicting Clinically Relevant Patient-Reported Symptom Improvement After Carpal Tunnel Release: A Machine Learning Approach

BACKGROUND

Symptom improvement is an important goal when considering surgery for carpal tunnel syndrome. There is currently no prediction model available to predict symptom improvement for patients considering a carpal tunnel release (CTR).

OBJECTIVE

To predict using a model the probability of clinically relevant symptom improvement at 6 mo after CTR.

METHODS

We split a cohort of 2119 patients who underwent a mini-open CTR and completed the Boston Carpal Tunnel Questionnaire preoperatively and 6 mo postoperatively into training (75%) and validation (25%) data sets. Patients who improved more than the minimal clinically important difference of 0.8 at the Boston Carpal Tunnel Questionnaire-symptom severity scale were classified as "improved." Logistic regression, random forests, and gradient boosting machines were considered to train prediction models. The best model was selected based on discriminative ability (area under the curve) and calibration in the validation data set. This model was further assessed in a holdout data set (N = 397).

RESULTS

A gradient boosting machine with 5 predictors was chosen as optimal trade-off between discriminative ability and the number of predictors. In the holdout data set, this model had an area under the curve of 0.723, good calibration, sensitivity of 0.77, and specificity of 0.55. The positive predictive value was 0.50, and the negative predictive value was 0.81.

CONCLUSION

We developed a prediction model for clinically relevant symptom improvement 6 mo after a CTR, which required 5 patient-reported predictors (18 questions) and has reasonable discriminative ability and good calibration. The model is available online and might help shared decision making when patients are considering a CTR.

Use of Complementary and Integrative Health Therapies Prior to Intensive Functional Restoration in Active Duty Service Members with Chronic Pain

OBJECTIVE

Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response.

DESIGN

Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2).

SETTING AND SUBJECTS

Active duty service members with chronic pain.

METHODS

Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements.

RESULTS

A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status.

CONCLUSIONS

This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.

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.