A Systematic Review of the Outcome Evaluation Tools for the Foot and Ankle

Inconsistency in the Reporting Terminology of Adverse Events and Complications in Hallux Valgus Reconstruction: A Systematic Review

Surgical complications are inevitable in any surgical subspecialty. Throughout the years, many classification systems have been developed to better understand and report such complications. The aim of this systematic review is to investigate the variability and frequency of reporting terms used to describe adverse events and complications in hallux valgus reconstruction. We hypothesized that the terms used would be highly inconsistent, which further promotes a need for a standardized terminology reporting system. Studies related to hallux valgus reconstruction outcomes that met our predetermined inclusion criteria were investigated to identify and report the related adverse terms and complications. Adverse terms and complications were grouped into 9 categories. Of the 142 studies included, 376 distinct terms that described adverse events or complications related to hallux valgus reconstruction were identified. Of these, 73.4% (276/376) were mentioned only once in their respective studies. Five of 376 terms were mentioned in at least 25% of the papers, and only 2 of 376 were mentioned in at least 50%. The most frequently reported adverse events were "Recurrence," mentioned in 77 of 142 studies (54%), followed by "Nonunion," mentioned in 76 of 142 studies (53%). The most reported category was "Bone/Joint" with 135 related terms, mentioned in 135 of 376 of the papers (95.1%). The terminology used in reporting adverse events and complications in surgical hallux valgus correction was highly inconsistent and variable. This represents yet another barrier in accurate reporting of these terms, and subsequently a difficult analysis of the outcomes related to hallux valgus reconstruction. To overcome these challenges, we suggest developing a standardized terminology reporting system.Levels of Evidence: Level III; systematic review of Level III studies and above.

Non‑contact locking plate: A useful alternative to external fixation in second‑stage treatment of post‑traumatic tibial osteomyelitis

The treatment of infected tibial bone defects can be challenging for the orthopedic surgeon. Therefore, the aim of the present study was to compare the fixation endurance, bone union time, lower limb joint function and complications associated with different fixation methods in the treatment of bone defects caused by debridement in the treatment of post-traumatic osteomyelitis. The clinical data of 55 patients with infected bone defects of the lower extremities following traumatic injury, who had undergone radical debridement between January 2017 and September 2020, were retrospectively analyzed. The patients were divided into three groups according to the type of fixation during reconstruction, namely the external fixation (EX), internal fixation (IX) and non-contact locking plate (LP) groups. The demographic data, time to bone union, bacterial culture results, complications and Self-Rating Anxiety Scale (SAS) scores of the patients were compared among the three groups. The results indicated that the differences in time to bone union and recurrence rates of osteomyelitis among the three groups were not statistically significant. By contrast, functional status after surgery was significantly higher in the LP group compared with the EX group. In total, 8/22 patients (36.4%) in the EX group, 4/13 patients (30.8%) in the IX group and 4/20 patients (20.0%) in the non-contact LP group had shortened limbs and deformed tibia. The SAS assessment results revealed that patients in the non-contact LP group had the lowest rates of moderate and severe anxiety. In conclusion, the results of the present study demonstrate that the non-contact locking plate technique provided stable fixation without any contact between the implant and bone tissues. Therefore, this technique may be viable for use during the reconstruction stage of post-traumatic tibial osteomyelitis.

Comparative Studies of Bone Graft and Orthobiologics for Foot Ankle Arthrodesis: A Critical Review

Graft materials available to supplement hindfoot and ankle arthrodesis procedures include autologous (autograft) or allogeneic bone graft (allograft) but also bone graft substitutes such as demineralized bone matrix, calcium sulfate, calcium phosphate, and tricalcium phosphate/hydroxyapatite. In addition, biologic agents, such as recombinant human bone morphogenetic protein-2 or recombinant human platelet derived growth factor-BB (rhPDGF-BB), and preparations, including platelet-rich plasma or concentrated bone marrow aspirate, have been used to facilitate bone healing in ankle or hindfoot arthrodesis. The purpose of this review was to summarize the available clinical evidence surrounding the utilization and efficacy of the above materials and biological agents in ankle or hindfoot arthrodesis procedures, with emphasis on the quality of the existing evidence to facilitate clinical decision making.

Incorporating Research into a Busy Clinical Practice: A Practical Approach

Treating patients in clinic can be busy and stressful; however, utilization of well-planned strategic workflows that include the proper information for research studies can result in daily prospective data collection that will be subsequently amenable to retrospective analysis.

Quality of life and subjective donor-site morbidity in patients after a free fibula flap

INTRODUCTION

We evaluated the subjective donor-site morbidity and quality of life in patients with a free fibula flap (FFF) reconstruction in terms of self-reported symptoms, function and quality of life, and we compared inclusion vs. exclusion of the flexor hallucis longus (FHL) muscle in the graft, primary wound closure vs. skin graft and the occurrence vs. absence of donor-site complications.

METHODS

In this cross-sectional study, patients who underwent a mandibula or maxilla reconstruction with a FFF between 2011 and 2021, were included. Symptoms and function were measured with the Foot and Ankle Outcome Score (FAOS) and quality of life with both FAOS and a Visual Analogue Scale (VAS).

RESULTS

Thirty-four patients were included in the analyses (mean age 59 years, 59% males). Most patients underwent a mandibular reconstruction for a malignancy. The median FAOS domain scores ranged between 92.9 (interquartile range (IQR) 77.7-100.0) and 100.0 (IQR 88.2-100.0) points, and the median VAS score was 86.5 points. No statistically significant differences were found between inclusion vs. exclusion of the FHL, primary wound closure vs. graft and occurrence vs. absence of donor-site complications. An unfavorable trend was seen for inclusion of the FHL in the flap on recreational functioning, and quality of life.

CONCLUSION

Patients who underwent a FFF experience little donor-site morbidity and high quality of life, as measured by FAOS and VAS.

Outcomes of Revision Total Ankle Replacement

The objective of this study is to provide an up-to-date review of the outcomes of revision total ankle arthroplasty (TAA). Relevant studies published over the last decade were reviewed. Twelve studies were included. At a median follow-up of 4 years, the median survival and reoperation rates were 86% and 16%, respectively. Significant postoperative improvements in patient-reported outcome measures were recorded in 6 studies. Significant improvement in alignment was documented in 1 study only. Revision TAA is a safe procedure that can produce good outcomes. Nevertheless, data relating to long-term outcome are still limited in quantity and duration.

Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures

OBJECTIVES

To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings.

METHODS

DESIGN

Prospective cohort.

SETTING

Level 1 academic trauma center.

PATIENT SELECTION CRITERIA

Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort.

OUTCOME MEASURE AND COMPARISONS

MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts.

RESULTS

Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up.

CONCLUSIONS

Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography.

LEVEL OF EVIDENCE

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

Reliability and Validity of the Korean Version of Foot and Ankle Disability Index

The Foot and Ankle Disability Index (FADI) is one of the most commonly used tools for evaluating foot and ankle function. Due to the lack of a Korean version for properly evaluating Koreans, it was not possible to compare Korean data with data from other countries using FADI. Therefore, we created a Korean version of the FADI questionnaire and evaluated its reliability and validity. We translated the English version of FADI and FADI-sport into Korean and then back into English. The Korean version of the FADI and FADI-sport, the previously verified visual analog scale (VAS) score, and the previously validated Medical Outcomes Study Short-Form 36-item questionnaire (SF-36) were administered to outpatients with chronic foot and ankle pain. A total of 64 patients who visited the outpatient clinic for chronic foot and ankle pain from January 2023 to March 2023 were included. To evaluate test-retest reliability and internal consistency, we used the intraclass correlation coefficient and Cronbach's alpha, respectively. We also assessed the concurrent and construct validity of the Korean version of FADI and FADI-sport by comparing them with the VAS and SF-36. Cronbach's alpha values were 0.953 and 0.945 for the FADI and FADI-sport, respectively, indicating good internal consistency. The reproducibility was good, and a strong correlation was observed between FADI, VAS, and SF-36. Therefore, the validation of the Korean version of the FADI was successfully performed, and it is a reliable questionnaire for self-evaluation of a patient's foot and ankle condition.

Minimally Invasive Treatment of Inversion Shortening Calcaneal Fractures in the "Out-In" Position

OBJECTIVE

Heel fractures need extensive surgical incisions and are challenging to successfully reposition using traditional prying. The goal of this study is to evaluate the clinical effectiveness of using a Kirschner pin-guided distractor to treat inversion shortening calcaneal fractures in the "out-in" position.

METHODS

A total of 40 data from 37 patients with inversion shortened calcaneal fractures from January 2018 to March 2020 were reviewed. Preoperative lateral and axial X-rays and 3D CT were taken to assess the fracture type, and minimally invasive internal fixation was performed in the "out-in" position with distractor repositioning, and intraoperative and postoperative images were taken to assess fracture repositioning and fixation. During the follow-up period, the postoperative functional recovery status was assessed using the VAS score, AOFAS score, and FAOS score. Paired-samples t-test was used for all data comparisons.

RESULTS

All cases received a mean follow-up of 28.49 ± 3.25 months, and the mean fracture healing time was 7.84 ± 0.71 weeks. The postoperative images showed well-fixed fracture repositioning, and calcaneal height, length, width, and inversion angles were significantly improved. At the final follow-up, the calcaneal height, length, and width recovered from 39.35 ± 4.44mm, 79.35 ± 2.7mm, and 45.75 ± 2.87mm preoperatively to 50.93 ± 3.18mm, 82.23 ± 1.90mm, and 39.67 ± 1.58mm postoperatively (p < 0.001; p < 0.001; p < 0.001). The calcaneus inversion angle restored from 7.73° ± 2.26° to 3.80° ± 1.80° (p < 0.001). Böhler's angle and Gissane's angle improved from 13.13° ± 3.02° and 105.15° ± 8.94° to 27.95° ± 3.41° and 122.85° ± 5.54° (p < 0.001; p < 0.001). No non-healing fractures, osteomyelitis, or traumatic arthritis were observed.

CONCLUSION

Minimally invasive internal fixation with distractor repositioning in the "out-in" position is effective in the treatment of inversion shortening calcaneal fractures while restoring the anatomy and protecting the soft tissue.

Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up: A Pilot case series with a review of the literature

INTRODUCTION

Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg's disease.

METHODS

Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V.

RESULTS

No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics.

CONCLUSION

Modified Weil osteotomy is an effective treatment for advanced Freiberg's disease with good outcomes and few complications.

Outcomes following minimally invasive plate osteosynthesis (MIPO) application in tibial pilon fractures - A systematic review

BACKGROUND

This systematic review evaluates postoperative complications and functional outcomes of minimally invasive plate osteosynthesis (MIPO) for distal tibial pilon fractures. This paper aims to fill a key literature gap, as no previous reviews have specifically addressed MIPO for tibial pilon fractures or fractures other than those involving the humeral shaft.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was done using PubMed, Embase, Web of Science, and Scopus databases from 2000 to 2022. Inclusion criteria were MIPO treatment in skeletally mature patients, while exclusion criteria were non-English papers, conference abstracts, papers with multiple treatment modalities that didn't analyze MIPO outcomes separately, skeletally immature patients, case reports, and cohorts smaller than five patients. Unpublished papers were also searched using Clinical Trials. Data extraction included general study information, injury specification, outcome measures, and complications. Finally, a risk of bias assessment (RoB) was performed.

RESULTS

A total of 1732 studies were identified, of which 23 were included in this review, with 673 patients and 678 fractures analyzed. The mean follow-up ranged from 6 to 62.53 months, with most studies representing intermediate to long-term follow-up. Primary outcome measures showed that 87.33% achieved 'excellent to good' results, 8.67% achieved 'fair' results, and 4% achieved 'poor' results. Stratified by fracture type, 76.47%, 80.05%, and 76.92% of AO/OTA type A, B, and C fractures, respectively, achieved 'excellent to good' results. 35.06% of cases reported complications (236 in total). These included one case of deep infection (0.148%), 28 superficial wound infections (4.16%), 4 nonunion cases (0.59%), and 22 malunion instances (3.27%). RoB assessment showed that 52.17% had a moderate overall risk of bias, 39.13% had a serious overall risk of bias, and 8.7% had a critical overall risk of bias.

CONCLUSION

MIPO technique for pilon fractures showed good functional outcomes and reliability, with low complication rates and should be considered in cases where proper indirect reduction is possible. However, while the evidence is promising, further high-quality studies with larger sample sizes, longer-term follow-up, and comparison to other techniques are needed to evaluate the efficacy and safety of this technique.

LEVEL OF EVIDENCE

IV.

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.

Five-year clinical follow-up of arthroscopically treated chronic ankle instability

INTRODUCTION

Arthroscopic treatment of lateral ankle instability is a recent innovation. In 2014, a prospective study was initiated by the French Society of Arthroscopy demonstrating the feasibility, morbidity and short-term results of arthroscopic treatment of ankle instability.

HYPOTHESIS

The functional results of arthroscopic treatment of chronic ankle instability found after one year were maintained in the medium term.

MATERIAL AND METHODS

The prospective follow-up of the patients included in the initial cohort was continued. The Karlsson and AOFAS scores, as well as patient satisfaction, were assessed. The causes of failure underwent univariate and multivariate analyzes. The results of 172 patients were included (40.2% ligament repairs; 59.7% ligament reconstructions). The average follow-up was 5years. The average satisfaction was 8.6/10, the average Karlsson score was 85 points and the average AOFAS score was 87.5 points. The reoperation rate was 6.4% of patients. The failures were related to an absence of sports practice, a high BMI and female gender. A high BMI and the intense sports practice were associated to ligament repair failure. The absence of sports practice and the intraoperative presence of the anterior talofibular ligament were associated to ligament reconstruction failure.

DISCUSSION

Arthroscopic treatment of ankle instability confers high satisfaction in the medium term, as well as long-lasting results with a low reoperation rate. A more detailed evaluation of the failure criteria could help guide the choice of treatment between ligament reconstruction or repair.

LEVEL OF EVIDENCE

II.

Increased subtalar rotational motion in patients with symptomatic ankle instability under load and stress conditions

PURPOSE

Differentiating subtalar and ankle instability in the clinical setting is challenging. This study aims to analyze the rotational laxity of the subtalar joint bilaterally in patients with asymptomatic and symptomatic ankle instability under simulated load and stress-induced position of the subtalar joint.

METHODS

A case-control study was conducted using an adjustable load device (ALD). Patients with chronic ankle instability and healthy volunteers were included. Each subject underwent a CT scan under mechanical stress and simulated weight-bearing conditions, maintaining maximum eversion and inversion hindfoot positions. The images were obtained in a single model, allowing calculations of the motion vector as well as the helical axis. The helical axis was defined by a rotation angle and a translation distance.

RESULTS

A total of 72 feet were included in the study. Thirty-one patients with unilateral symptoms and five healthy controls were selected, defining two groups: symptomatic (n = 31) and asymptomatic (n = 41). An absolute difference of 4.6º (95%CI 2-11.1) rotation angle was found on the helical axis of the symptomatic vs. asymptomatic group (p = 0.001). No significant differences were detected in the translation distance (n.s.) between the groups. Additionally, a significant positive correlation was found between the rotation angle and translation distance through the helical axis in the asymptomatic group (r = 0.397, p = 0.027).

CONCLUSION

Patients with chronic ankle instability suspected of having subtalar joint instability showed a wider subtalar range of laxity in terms of rotation about the helical axis. Furthermore, differences in kinematics between symptomatic and asymptomatic hindfeet was demonstrated when both feet were compared.

LEVEL OF EVIDENCE

III.

Responsiveness of specific and generic patient-reported outcome measures in patients with plantar fasciopathy

PURPOSE

To evaluate and compare responsiveness characteristics for the Foot Function Index revised short form (FFI-RS), RAND-12 Health Status Inventory (RAND-12), and Numeric Rating Scale (NRS), in patients with plantar fasciopathy receiving non-surgical treatment.

MATERIALS AND METHODS

This study was conducted on a sub-group of patients from an ongoing randomised controlled trial. One-hundred fifteen patients were included. The patient-reported outcome measures (PROMs) were applied at baseline and after 6 months. Responsiveness was calculated using standardised response mean and area under the receiver operating characteristic (ROC) curve. ROC curves were used to compute the minimal important change (MIC) for the outcome measures.

RESULTS

The region specific FFI-RS had best responsiveness and the NRS at rest had lowest responsiveness.

CONCLUSION

FFI-RS were marginally more responsive than the other PROMs. Responsiveness and MIC estimates should be regarded as indicative rather than fixed estimates.

Foot and Ankle Outcome Score (FAOS): Reference Values From a National Representative Sample

Background

The Foot and Ankle Outcome Score (FAOS) is widely used in clinical practice and research. However, FAOS reference values are missing to aid interpretation. This study aimed to establish national record-based reference values for the FAOS.

Methods

A national representative sample of 9996 adult Danish citizens was derived from the Danish Civil Registration System. The FAOS questionnaire was sent to all participants, including 2 supplemental questions regarding previous foot and ankle problems and body mass index (BMI). A threshold of 10 FAOS points was predefined as a clinically relevant difference across all 5 subscales.

Results

A total of 2759 participants completed the FAOS. Mean age of participants was 60.5 years, and 51% were women. The mean FAOS subscale scores were as follows: pain, 87.1 (95% CI 86.4-87.8); symptoms, 85.1 (95% CI 84.5-85.8); activity of daily living (ADL), 88.9 (95% CI 88.2-89.6); sport and recreation function 78.5 (95% CI 77.4-79.6); and quality of life (QOL), 79.9 (95% CI 79.0-80.9). The mean difference between men and women was small and not clinically relevant (ranged from 0.9 in ADL to 3.4 in QOL). The largest differences in mean scores between age groups ranged from 4.3 in symptoms to 16.4 in sport/rec. Except for the subscale sport/rec, all age-related differences were below the predefined threshold of 10 for clinical relevance. The difference in mean subscale scores between the lowest BMI group (<24.7) and the obese group (>30) ranged from 19.6 in ADL to 39.1 in sport/rec.

Conclusion

We found in our population that BMI severely impacted FAOS scores. We recommend using BMI-specific reference FAOS values. Separate FAOS reference values for men and women appear not needed. Stratifying reference values for age is likely not needed except for the subscale sport and recreation function.

Level of evidence

Level III, cohort study.

Description of the Simple Ankle Value: A Simplified Patient-Reported Outcome Measure for the Assessment of Ankle and Hindfoot Function

Background

The Simple Ankle Value (SAV) is a patient-reported outcome measure (PROM) in which patients grade their ankle function as a percentage of that of their contralateral uninjured ankle.

Purpose/Hypothesis

The primary aims of this study were to validate the SAV and evaluate its correlation with other PROMs. It was hypothesized that the SAV would be seen as a valid score that provides results comparable with those of the Foot and Ankle Ability Measure (FAAM) and the European Foot & Ankle Society (EFAS) score.

Study Design

Cohort study (Diagnosis); Level of evidence, 2.

Methods

Patients seen for an ankle or hindfoot tissue were divided into those treated operatively and nonoperatively. A control group of patients treated for issues outside of the foot and ankle was also created. All patients completed the SAV followed by the FAAM and the EFAS scores. Patients treated operatively completed the questionnaires before surgery and 3 months after surgery. Patients treated nonoperatively completed the questionnaires twice 15 days apart. The correlation between the SAV score, the FAAM score, and the EFAS score was estimated with the Spearman correlation coefficient.

Results

A total of 209 patients (79 in the operative group, 103 in the nonoperative group, and 27 in the control group) were asked to complete the questionnaire, and all were included. The test-retest reliability of the SAV was excellent (intraclass correlation coefficient, 0.92; 95% CI, 0.88-0.94). No ceiling or floor effect was reported. Strong correlation was found between the SAV and the FAAM and EFAS scores. The SAV was able to discriminate patients from controls (54.18 ± 21.22 and 93.52 ± 9.589; P < .0001); however, SAV was not able to detect change from preoperative to 3 months postoperative (from 54.18 ± 21.22 to 62.53 ± 20.83; P = .44).

Conclusion

Our study suggests that the SAV is correlated with existing accepted ankle PROMs. Further work with this PROM is needed to validate the questionnaire.

Quo vadis, foot & ankle research? A review

Over the last two decades, there has been a growing emphasis on the publication quality in Foot & Ankle research. A level-of-evidence rating system for clinical scientific papers has been proposed by the Centre for Evidence-based medicine in Oxford, United Kingdom. As opposed to other subspecialities, foot & ankle surgery deals with a wide variety of clinical problems and surgical solutions, which in turn leads to a generally low number of patients available for study groups. However, level III and IV studies still have a valuable place in orthopaedic research, given the challenges in running high-level studies.The measurement of outcomes in medicine from the patients' perspective (PROMS:(patient reported outcome measures) has grown almost exponentially in all surgical specialties including foot & ankle surgery. There are many PROMs available to foot & ankle surgeons, but there is little consensus on which assessment is most appropriate for a given procedure or diagnosis. Their use in research and clinical practice offers many advantages in clinical practice and research, however, besides the advantages there are also some downsides.

Insertional Achilles Tendinopathy: Occupational Outcomes in the Military

A retrospective review of consecutive patients diagnosed with insertional Achilles tendinopathy (IAT) was performed. Outcomes included Visual Analog Scale (VAS) pain scores, return to run rates, and return to military duty rates. Our data analysis included 113 patients; 58 (55%) patients required surgery. Mean duration of follow-up was 42 months (range, 12-143). Mean age at the time of surgery was 37.2 years (range, 21-54). VAS scores significantly improved from 5.4 at the preoperative visit to 2.9 at 24 months. There was no significant improvement in VAS scores after the 3-month postoperative visit. Mean return to run time was 9 months (range, 4.5-16). At 1 year, 80% (46/58) of patients returned to military duty. Complications requiring return to the operating room were observed in 6 patients (9%). The high rate of return to duty and significant improvement in pain scores demonstrate that the surgical management of IAT is a viable treatment option for patients who could not otherwise remain on active duty. With that said, the complication rate of 27% is high. Patients and providers should consider the risks, benefits, and duration of therapy during their shared decision-making process.Level of Evidence: Level IV.

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.

Platelet-rich plasma injection for the treatment of ankle osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) injection for ankle osteoarthritis (OA) treatment showed contradictory results. This review was aimed to pool individual studies which assessed the efficacy of PRP for ankle OA treatment.

METHODS

This study was conducted following the preferred report items of systematic review and meta-analysis guideline. PubMed and Scopus were searched up to January 2023. Meta-analysis, or individual randomised controlled trial (RCT), or observational studies were included if they involved ankle OA with aged ≥ 18 years, compared before-after receiving PRP, or PRP with other treatments, and reported visual analog scale (VAS) or functional outcomes. Selection of eligible studies and data extraction were independently performed by two authors. Heterogeneity test using Cochrane Q test and the I²-statistic were assessed. Standardised (SMD) or unstandardised mean difference (USMD) and 95% confidence interval (CI) were estimated and pooled across studies.

RESULTS

Three studies from meta-analysis and two individual studies were included, which consisted of one RCT and four before-after studies with 184 ankle OAs and 132 PRP. The average age was 50.8-59.3 years, and 25-60% of PRP injected cases were male. The number of primary ankle OA was accounted to 0-100%. When compared to before treatment, PRP significantly reduced VAS and functional score at 12 weeks with pooled USMD of - 2.80, 95% CI - 3.91, - 2.68; p < 0.001 (Q = 82.91, p < 0.001; I² 96.38%), and pooled SMD of 1.73, 95% CI 1.37, 2.09; p < 0.001 (Q = 4.87, p = 0.18; I² 38.44%), respectively.

CONCLUSION

PRP may beneficially improve pain and functional scores for ankle OA in a short-term period. Its magnitude of improvement seems to be similar to placebo effects from the previous RCT. A large-scale RCT with proper whole blood and PRP preparation processes is required to prove treatment effects. Trial registration PROSPERO number CRD42022297503.

Patient-Reported Outcome Measures After Surgical Management of Unstable Lisfranc Injuries in Athletes

Background:

Athletes sustaining Lisfranc joint instability after a low-energy injury often undergo surgical fixation. Limited studies report validated patient-reported outcome measures (PROMs) for this specific patient population. Our purpose was to report PROMs of athletes experiencing instability after a low-energy Lisfranc injury and undergoing surgical fixation.

Methods:

Twenty-nine athletes (23 competitive, 6 recreational) sustained an unstable Lisfranc injury (14 acute, 15 chronic) and met our inclusion criteria. Injuries were classified as acute if surgically managed within 6 weeks. All athletes completed validated PROMs pre- and postoperatively. The cohort underwent various open reduction internal fixation methods. We evaluated outcomes with the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales.

Results:

Fourteen of 29 (48%) athletes reported PROMs at ≥2 years with a median follow-up time of 44.5 months. Substantial improvement for both FAAM ADL (50% vs 93%; P < .001) and sports (14.1% vs 80%; P = .002) subscales were found, when comparing preoperative to postoperative scores at ≥2 years.

Conclusion:

This study provides outcomes information for the young athletic population that were treated operatively for low-energy Lisfranc injury with apparent joint instability. Based on the FAAM sports subscale, these patients on average improved between their 6-month evaluation and their final ≥2 years but still scored 80% of the possible 100%, which indicates continued but “slight” difficulty with lower extremity function.

Level of Evidence:

Level IV, case series.

Effectiveness of dextrose prolotherapy for the treatment of chronic plantar fasciitis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically investigate the efficacy and safety of dextrose prolotherapy for treating chronic plantar fasciitis.

LITERATURE SURVEY

EMBASE, PubMed, Scopus, and Google Scholar (from inception to December 9, 2021).

METHODOLOGY

Comprehensive review of randomized controlled trials investigating dextrose prolotherapy for chronic plantar fasciitis was done. Two investigators independently screened the titles, abstracts, and full texts and extracted data from eligible studies. The changes in visual analog scale (VAS) pain score, foot function index (FFI), American Orthopaedic Foot and Ankle Society (AOFAS) score, and plantar fascia thickness were analyzed. Reports of complications of the procedure were collected.

SYNTHESIS

Eight randomized controlled trials (RCTs) were included in the meta-analysis, analyzing 444 patients in total. The subgroup analysis showed that at short-term follow-up (<6 months) dextrose prolotherapy was more effective in reducing VAS pain score compared to the non-active treatment control group including exercise and normal saline solution (NSS) injection. However, there was no difference in the change of VAS pain score between dextrose prolotherapy and active treatment control group, which included extracorporeal shock wave therapy (ESWT), steroid injection, and platelet-rich plasma (PRP) injection. Dextrose prolotherapy was more effective in reducing FFI, increasing AOFAS score, and reducing plantar fascia thickness at short-term (<6 months) follow-up compared to other comparators. For long-term (≥6 months) follow-up, there was no significant difference in the change in VAS pain score and FFI between the dextrose prolotherapy group and other comparators. No serious complication was reported.

CONCLUSIONS

Dextrose prolotherapy is an effective treatment of chronic plantar fasciitis to reduce pain, improve foot functional score, and decrease plantar fascia thickness at short-term follow-up. Further studies in larger populations are needed to identify the optimal treatment regimen including dextrose concentration, volume, injection site, injection technique, and the number of injections required. The long-term effects of these treatments also require further examination.

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.

Midterm Clinical and Radiographic Outcomes of the Calcaneal Z-Osteotomy for the Correction of Cavovarus Foot

Background

The Malerba calcaneal Z-osteotomy is an operative procedure to treat the hindfoot varus component of adult cavovarus deformity. Basic science studies support the corrective ability of this osteotomy. However, there have been no published midterm clinical and radiographic results. The purpose of this article is to describe the radiographic and clinical improvement in a series of patients treated with this osteotomy.

Methods

A retrospective chart review identified 14 feet in 12 patients from January 2013 to August 2018 who met minimal follow-up criteria. Preoperative visual analog scale (VAS) scores, Foot Function Index (FFI) scores, and American Orthopaedic Foot & Ankle Society (AOFAS) scores were compared with postoperative scores. Preoperative Meary angle, calcaneal pitch, and hindfoot alignment were also compared with postoperative measurements. Complications and radiographic union were recorded.

Results

At a mean of 80 months, VAS, FFI, and AOFAS scores improved from 7.86 to 1.64, 57.78% to 18.11%, and 39.57 to 80.71, respectively (all P < .001). At a mean of 15 months, Meary angle, calcaneal pitch, and hindfoot alignment improved from 11.14 to 6.64 degrees (P < .001), 30.93 to 27.43 degrees (P = .005), and 19.83 degrees varus to 8.50 degrees varus (P < .001). There was 1 nonunion and 1 postoperative sural nerve neuralgia, but both patients ultimately did well clinically. There were no instances of postoperative tarsal tunnel syndrome. All patients stated that they would have the procedure done again.

Conclusion

The calcaneal Z-osteotomy is an effective method to treat adult hindfoot cavovarus deformity. All patients had good clinical outcomes with minimal complications.

Level of Evidence

Level IV, case series.

A Systematic Review of Open and Minimally Invasive Surgery for Treating Recurrent Hallux Valgus

Background  Despite advancements in primary correction of hallux valgus (HV), significant rates of reoperation remain across common techniques, with complications following primary correction up to 50% according to some studies. 1 This study explored different methods of surgery currently used in treating HV recurrence specifically (for which literature on the subject has been limited), evaluating open and adapted minimally invasive surgical (MIS) primary techniques used for revision. Methods  In December 2020, literature search for both open and MIS surgical techniques in HV revision was conducted using PubMed, EMBASE, and MEDLINE library databases. Results and Conclusion  Of initial 143 publications, 10 were finally included for data synthesis including 273 patients and 301 feet. Out of 301 feet, 80 (26.6%) underwent revision with MIS techniques (involving distal metatarsal osteotomies). Those undergoing grouped MIS revisions had an average improvement of 38.3 in their American Orthopaedic Foot and Ankle Society score, compared to 26.8 in those using open techniques. Revision approaches using grouped MIS techniques showed a postoperative reduction in intermetatarsal angle and HV angle of 5.6 and 18.4 degrees, respectively, compared to 15.5 and 4.4 degrees, respectively, for open techniques. There are, however, limitations in the current literature on MIS techniques in revision HV surgery specifically. MIS techniques grouped did not show worse outcomes or safety concerns compared to open techniques.

Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis

INTRODUCTION

Osteoarthritis of the ankle is a major burden to affected patients. While tibio-talar arthrodesis has been the gold-standard regarding the treatment of osteoarthritis of the ankle joint for many years, at present total ankle arthroplasty (TAA) provides appealing clinical outcomes and is continually gaining popularity. The aim of this study was to evaluate the intermediate- to long-term clinical outcome including the survival rate of Salto Mobile Bearing TAA (Tonier SA, Saint Ismier, France).

MATERIAL AND METHODS

In this retrospective study intermediate- to long-term outcomes measures [Ankle Range of Motion (ROM), American Orthopaedic Foot and Ankle Score (AOFAS score) and survival rate] of 171 consecutive TAA were analysed and compared before and after surgery. Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle.

RESULTS

At a mean follow-up (FU) period of 7.2 ± 2.7 years (range 2.0 to 14.1 years) there was a significant improvement in ankle ROM (total ROM improved from 25.0° ± 15.0° to 28.7° ± 11.3°, p = 0.015; plantarflexion improved from 18.4° ± 11.7° to 20.6° ± 8.2°, p = 0.044; dorsiflexion improved from 6.6° ± 5.7° to 8.1° ± 4.9°, p = 0.011). AOFAS score increased significantly by 41 ± 15 points after surgery (43.3 ± 11.1 before and 84.3 ± 12.0 after surgery, p < 0.001). Overall survival rate within the FU was 81.3% (95% CI 75.3% to 87.3%) with any secondary surgery, 89.9% (95% CI 84.1% to 93.6%) with revision and 93.6% (95% CI 89.8% to 97.3%) with reoperation as endpoint.

CONCLUSION

This study endorses the previously reported appealing intermediate- to long-term outcomes of the Salto Mobile Bearing TAA. There was a significant increase in ROM and AOFAS score as well as decent implant survival at final FU.

Tibial pilon fractures treated with a periarticular external fixator: Retrospective study of 47 cases

INTRODUCTION

Tibial pilon fractures are a treatment challenge, since there is no true gold standard treatment, and because of potential skin complications. Periarticular external fixation (PAEF) appears to produce good results, but the outcomes with the TL-HEX Trauma™ (Orthofix®, Verona, Italy) have not yet been evaluated. We performed a study with the following objectives: 1) evaluate time to union and union rate; 2) determine clinical and radiological results; 3) detect complications.

HYPOTHESIS

PAEF will produce comparable fracture union to other external fixator techniques for tibial pilon fractures.

METHODS

A single center, retrospective study, was done between June 2016 and December 2018. Patients who had a tibial pilon fracture operated with a PAEF were included if they had a minimum of 12 months' follow-up. Forty-seven patients were included; the mean follow-up was 2.45 years (1.2-3.7). The primary endpoint was the time to union and union rate at the final assessment. The secondary endpoints were the joint range of motion, residual pain (VAS), functional scores (AOFAS and SF12) and complication rate.

RESULTS

The union rate was 70% (33/47) and the mean time to union was 201±79 days (89-369). The range of motion was significantly reduced relative to the contralateral side. Twenty patients had residual pain that averaged 2.9 (1-6) on the VAS. The mean AOFAS score was 74 points (51-95). Twenty patients (43%) suffered at least one complication.

DISCUSSION

While a PAEF helps to avoid skin complications, in our study, it was associated with a lower union rate and longer time to union than in other published studies. This difference is likely due to a higher rate of open fractures and high-energy trauma in our study, different protocol for return to weightbearing and a different external fixator than other studies. This is the first study reporting the results of the TL-HEX Trauma in this indication.

LEVEL OF EVIDENCE

IV, retrospective study.

Structural and Construct Validity of the Foot and Ankle Ability Measure (FAAM) With an Emphasis on Pain and Functionality After Foot Surgery: A Multicenter Study

The Foot and Ankle Ability Measure (FAAM) is a patient-reported outcome measure that is available in several languages. We aim to assess the structural and construct validity of the FAAM with an emphasis on pain and functionality after foot surgery. The activities of daily living (ADL) and Sports subscales of the Finnish version of the FAAM were completed by 182 patients who underwent operative treatment for disorders of the foot. Convergent validity was assessed by principal component analysis using Spearman's correlation coefficient between the FAAM subscales and the principal components (Function-PC and Pain-PC) derived from validated patient-reported outcome measures. Subscales were studied for floor and ceiling effects, internal consistency and unidimensionality. Internal consistency was examined with Cronbach's alpha and the subscale structure with exploratory factor analysis. FAAM-ADL had high correlation with the Function-PC (r = 0.87, 95% confidence interval [CI] 0.81-0.91) and the Pain-PC (r = 0.75, 95% CI 0.65-0.83). FAAM-Sports had moderate correlation (r = 0.64, 95% CI 0.50-0.74) with the Function-PC and high correlation (r = 0.74, 95% CI 0.64-0.82) with the Pain-PC. No floor or ceiling effects were observed. Cronbach's alpha was 0.97 (95% CI 0.96-0.98) for the ADL and 0.93 (95% CI 0.91-0.95) for the Sports subscales. The results supported the unidimensionality of the FAAM-Sports. Within the ADL subscale, 3 factors were identified, suggesting a 3-factor model for the FAAM overall. Results highlighted the inter-relationship of pain and physical function. Further research on longitudinal validity is needed.

Systematic Review of Patient-Reported Outcome Measures for Patients with Exercise-Induced Leg Pain

Background and Objectives: To determine the most commonly used patient-reported outcome measures (PROMs) in exercise-induced leg pain (EILP) and to identify specific PROMs for EILP in order to evaluate their psychometric properties and methodological quality. Materials and Methods: A strategic search was performed in different databases to identify and extract the characteristics of studies based on the use of PROMs in patients with EILP. Specific PROMs were evaluated according to the Terwee et al. and COSMIN criteria. Results: Fifty-six studies were included in the review. The Medial Tibial Stress Syndrome Score (MTSSS), Lower Extremity Functional Scale (LEFS) and Exercise-Induced Leg Pain Questionnaire (EILP-Q) were identified as specific PROMs for EILP. The Visual Analog Scale (VAS) was the most widely used instrument in the assessment of EILP. The methodological quality assessment showed six positive values for the LEFS, four for the MTSSS and three for the EILP-Q for the eight psychometric properties analyzed according to the COSMIN criteria. The evaluation of the nine psychometric properties according to Terwee showed five positive values for the LEFS and MTSSS, and three for the EILP-Q. Conclusions: The overall methodological quality of the PROMs used was low. The VAS was the most widely used instrument in the assessment of EILP, and the LEFS was the highest quality PROM available for EILP, followed by the MTSSS and EILP-Q, respectively.

OUTCOMES AFTER UNSTABLE FRACTURES OF THE ANKLE: WHAT'S NEW? A SYSTEMATIC REVIEW

BACKGROUND

Unstable ankle fractures are very frequent. Given the instability, they often require surgical treatment, but literature scarcely reports on the outcomes of their management.

QUESTIONS/PURPOSES

For this systematic review we asked: (1) What are the outcomes in treatment of unstable ankle fractures? (2) What about complications of treatment in unstable fractures? (3) What factors influence the outcomes? (4) What about the role of the posterior malleolus?

METHODS

The electronic databases PubMed, Scopus, and Embase were interrogated using the search terms "bimalleolar" or "trimalleolar" and "fracture". Studies were included if they reported on: (1) bimalleolar or trimalleolar fracture in adults; (2) treatment; (3) outcomes reported by scales; (4) follow-up. The final review included 33 studies. The quality of the studies was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.

RESULTS

All the outcomes of the thirty-three selected studies were analyzed.

DISCUSSION

Surgical fixation of unstable ankle fractures should always be performed within the first 48 hours from the trauma, preventing instability and post-traumatic osteoarthritis. Surgeon should consider factor may influence functional outcomes. Posterior malleolar fractures should be fixed regardless the size, considering some individual factors.

Association of Ankle Sprain Frequency With Body Mass and Self-Reported Function: A Pooled Multisite Analysis

CONTEXT

Ankle sprains result in pain and disability. While factors such as body mass and prior injury contribute to subsequent injury, the association of the number of ankle sprains on body anthropometrics and self-reported function are unclear in this population. Therefore, the purpose of this investigation was to assess differences in anthropometric measurements and self-reported function between the number of ankle sprains utilizing a large, pooled data set.

DESIGN

Cross-sectional.

METHODS

Data were pooled from 14 studies (total N = 412) collected by the Chronic Ankle Instability Outcomes Network. Participants were categorized by the number of self-reported sprains. Anthropometric data and self-reported function were compared between those who reported a single versus >1 ankle sprain as well as among groups of those who had 1, 2, 3, 4, and ≥5 ankle sprains, respectively.

RESULTS

Those who had >1 ankle sprain had higher mass (P = .001, d = 0.33) and body mass index (P = .002, d = 0.32) and lower Foot and Ankle Ability Measure-Activities of Daily Living (P < .001, r = .22), Foot and Ankle Ability Measure-Sport (P < .001, r = .33), and Cumberland Ankle Instability Tool (P < .001, r = .34) scores compared to the single ankle sprain group. Those who had a single ankle sprain weighed less than those who reported ≥5 sprains (P = .008, d = 0.42) and had a lower body mass index than those who reported 2 sprains (P = .031, d = 0.45).

CONCLUSIONS

Some individuals with a history of multiple ankle sprains had higher body mass and self-reported disability compared to those with a single sprain, factors that are likely interrelated. Due to the potential for long-term health concerns associated with ankle sprains, clinicians should incorporate patient education and interventions that promote physical activity, healthy dietary intake, and optimize function as part of comprehensive patient-centered care.

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.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

The French Ankle Ligament Reconstruction - Return to Sport after Injury (ALR-RSI-Fr) is a valid scale for the French population

PURPOSE

The aim of this study was to translate, adapt and validate in French the Ankle Ligament Reconstruction - Return to Sport after Injury (ALR-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction. Our hypothesis was that the French version of the ALR-RSI scale would be valid and adaptable to the French population.

METHODS

The procedure followed the guidelines for the intercultural adaptation of the self-administered questionnaires. A version of the ALR-RSI-Fr questionnaire was validated according to the international guidelines of COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments). A prospective study was conducted between March 2020 and June 2021. The study included two population groups, the first one being that of adult athletes of all levels who underwent arthroscopic ankle ligament reconstruction and the second being that of adult athletes who did not suffer from any ankle problems. After consent, patients completed three questionnaires, the ALR-RSI-Fr, the AOFAS and the Karlsson score.

RESULTS

The study included 30 patients and 30 controls who were all athletes. The mean age of the patients was 34.6 with 60% male and 40% female. The average time for patients to return to sport was 5.6 months. Twenty-nine patients (96.6%) underwent arthroscopic ankle reconstruction while only one was eligible for ligament reinsertion. The control group with demographic data matched to the patient group was included in this study. Correlations between ALRSI, the total Karlsson score and its different sub items and the AOFAS were estimated using Spearman coefficients. Discriminant validity was tested between the "patient" and "control" groups and sub-groups using the Wilcoxon tests. Reliability was evaluated on the ρ intraclass correlation coefficient (ICCC). A strong correlation was noted between the ALR-RSI-Fr , Karlsson and AOFAS with a Spearman score of 0.90 [0.76-0.96].A highly significant difference was found between the "patient" and "control" groups. The internal consistency of the questionnaire was excellent with a Cronbach's alfa of 0.94. Reproducibility was "excellent" with an interclass correlation coefficient of q = 0.97 [0.94-0.99].

CONCLUSION

This study showed that the cross-cultural adaptation of the English version of the ALR-RSI was successful and validated for the French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was also confirmed. This questionnaire will allow surgeons to better evaluate the psychological impact of returning to sports after ankle ligament reconstruction in French speaking patients LEVEL OF EVIDENCE: LEVEL II: Prospective cohort study (patients enrolled at different points in their disease) Control arm of randomized trial.

Anti-Glide Plate Fixation for Lateral Malleolus Fractures by Minimally Invasive Technique in Geriatric Patients

The objective was to evaluate the functional outcomes of anti-glide fixation by minimally invasive plate osteosynthesis (MIPPO) in lateral malleolus ankle fractures.

The study was a retrospective cohort study conducted at a single trauma center. We reviewed 39 patients >60 years old with either isolated or non-isolated lateral malleolus Weber B ankle fractures.

The main outcome measures were postoperative functional assessment performed with the American Orthopaedic Foot and Ankle Society (AOFAS) and Short Musculoskeletal Functional Assessment (SMFA) scores. Our results showed that the mean time to surgery was 1 day. Seventeen patients underwent surgery within 24 hours after sustaining the injury. The mean AOFAS and SMFA scores were 87.8 and 209.7, respectively. No patient developed implant failure or wound complications.

It was concluded that the anti-glide plating of the lateral malleolus had better functional outcomes compared to lateral plating by open reduction and internal fixation (ORIF), as shown by the higher AOFAS scores and fewer postoperative complications.

Percutaneous subtalar joint screw fixation of comminuted calcaneal fractures: a salvage procedure

INTRODUCTION

Malunited comminuted calcaneal fractures result in poor function due subtalar joint arthritis and altered biomechanics. We aimed to assess whether percutaneous subtalar joint screws after fracture reduction provide good outcomes for these difficult injuries.

METHODS

We retrospectively analysed 15 comminuted calcaneal fractures (in 14 patients) treated with percutaneous subtalar screw fixation. All patients had a minimum of 12 months' follow-up. Six patients had open injuries. On the preoperative and the latest postoperative radiograph, Bohlers angle, Gissane angle, calcaneal inclination, width and length, absolute foot height, and posterior facet height were measured. Preoperative computed tomography scans were used to classify the fractures by Sanders classification. Clinical outcome scores were recorded postoperatively.

RESULTS

Mean age was 34.2 ± 14.2 years. Minimum follow-up was 12 months (mean 17.2 ± 4.4 months). Nine patients had a Sanders 4, 3 had a Sanders 3AB, 2 had a Sanders 3BC, and 1 had a Sanders 3AC fracture. Eighty percent of patients had their angle of Gissane, absolute foot height, calcaneal length and inclination restored by this technique. Bohlers angle was restored back into the normal range in 54% of patients. Mean postoperative AOFAS score was 74 ± 11. AOFAS scores positively correlated with postoperative Bohlers angle (Pearson's correlation coefficient 0.85; p = 0.004). One patient (7%) had a wound breakdown postoperatively and three patients (20%) had heel pain from the screws, which improved after removal.

CONCLUSION

Percutaneous subtalar screws offer a reliable option to restore calcaneal anatomy in comminuted calcaneal fractures, with low complication rates. Over 80% of patients had their angle of Gissane, calcaneal length and inclination restored, and over 50% of patients had all radiological parameters restored by this technique. It offers the benefits of percutaneous reduction and fixation and this procedure may be considered an effective first stage prior to definitive subtalar fusion. Further work is needed to review the longer-term outcomes and the conversion rate to arthrodesis.

LEVEL OF EVIDENCE

IV (case series), Therapeutic.

Structural validity of the foot and ankle outcome score for orthopaedic pathologies with Rasch Measurement Theory

BACKGROUND

The Foot and Ankle Outcome Score (FAOS) is one of the most frequently used patient-reported outcome measures for foot and ankle conditions. The aim is to test the structural validity of the Finnish version of the FAOS using Rasch Measurement Theory.

METHODS

FAOS scores were obtained from 218 consecutive patients who received operative treatment for foot and ankle conditions. The FAOS data were fitted into the Rasch model and person separation index (PSI) calculated.

RESULTS

All the five subscales provided good coverage and targeting. Three subscales presented unidimensional structure. Thirty-eight of the 42 items had ordered response category thresholds. Three of the 42 items had differential item functioning towards gender. All subscales showed sufficient fit to the Rasch model. PSI ranged from 0.73 to 0.94 for the subscales.

CONCLUSIONS

The Finnish version of the FAOS shows acceptable structural validity for assessing complaints in orthopaedic foot and ankle patients.

Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures

Background

Ankle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time.

Methods

Fourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated.

Results

Statistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53–75%: p = 0.001) and patients after 26 weeks (58–70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15–40%: p < 0.001; 56,5–70%: p = 0.007; 82–88%: p = 0.033; 97–98,5%: p = 0.048) as well as patients after 26 weeks (62,5–65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0–17%: p < 0.001; 21–37%: p < 0.001; 41–54%: p < 0.001; 60–64%: p = 0.013) as well as patients after 26 weeks (0–1,5%: p = 0.046; 5–15%: p < 0.001; 27–33%: p = 0.001; 45–49%: p = 0.005; 57–59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks.

Conclusions

This study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients’ values tend to get closer to those of the control group.

Trial registration

This study is registered at the German Clinical Trials Register (DRKS00023379).

Minimal important change for Foot and Ankle Outcome Score (FAOS)

BACKGROUND

Although Foot and Ankle Outcome Score (FAOS) is a widely used patient-reported outcome measure (PROM) for foot and ankle conditions, research on its longitudinal validity is still needed. Minimal important change (MIC) values for the FAOS were determined using predictive modeling.

METHODS

Overall, 134 patients that underwent operative treatment for foot and ankle conditions were included. An anchor based predictive logistic modeling method was used for estimating the MIC values for the FAOS subscales after surgery.

RESULTS

Mean score changes in the improved and the unimproved groups were 17.7 and 0.43 points for Pain, 3.9 and -3.3 points for Symptoms, 21.3 and 1.8 points for Activities and daily living (ADL), 8.7 and -2.8 points for Sport, and 12.5 and -3.3 points for quality of life subscale, respectively. MIC was successfully determined to four out of five subgroups as follows: Pain 9.5 (94% CI -6.4 to 24.6); ADL 11.7 (95% CI -19.6 to 46.6); Sport (95% CI -10.4 to 15.4); QoL 5.0 (95% CI -2.6 to 12.9). The Symptoms subgroup presented with low MIC of 0.3 (95% CI -11.7 to 13.4) fitting to the measurement error.

CONCLUSION

ADL, Sports, Pain, and QoL subscales of the FAOS presented logical MIC values. The MIC can be further evaluated for specific conditions.

Open Reduction and Internal Fixation of a Calcaneal Anterior Process Fracture Using a Locking Plate

Fractures involving the anterior process of the calcaneus (APC) are rare, underdiagnosed, and carry a significant increase in morbidity if not identified acutely. Identifying patients with intra-articular fracture extension is crucial as they may benefit from surgical fixation to reduce the risk of morbidity and post-traumatic osteoarthritis. There are no specific guidelines in the United Kingdom regarding the management of these fractures, and there is little evidence regarding optimal management, mainly limited to case reports and small sample observational trials. Previous reports of surgical intervention have described excision of fragments or fixation using single cancellous screws.

A 55-year-old man fell from a height of 2 metres, sustaining an APC fracture extending into the calcaneocuboid joint. This was identified on plain radiographs following a virtual fracture clinic referral from the emergency department and further investigated with computed tomography scanning.

He underwent open reduction and internal fixation with a locking T-plate and screws three weeks post-injury to restore congruence of his articular surface. Following a period of non-weight-bearing and progressive physiotherapy, he reported an excellent functional outcome six months post-operatively, measured by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score of 90%.

In the absence of specific guidelines for these fractures, this case provides an example of good initial functional outcomes following surgical fixation using a locking plate and screws, the first such fixation of an APC fracture described in the literature. This case can also be seen as a useful reminder of the need for an index of clinical suspicion for these injuries, given that up to 40% may be missed in the emergency department. While now fairly widespread, not all hospitals will have a virtual fracture clinic system in place, meaning emergency department practitioners must be wary of these injuries before discharging patients with suspicious histories and examination findings with no follow-up. Examination techniques that may help differentiate APC fractures from ankle sprains are discussed to provide clinicians with evidence to support a suspicion of these injuries in the emergency department.

Influence of Foot Type on the Clinical Outcome of Minimally Invasive Surgery for Metatarsalgia. A Prospective Pilot Study

Background and aims: Surgical procedures for central metatarsalgia seek to harmonise the metatarsal parabola with osteotomies that can be performed by minimally invasive techniques. However, the possible relationship of the foot type and the mid-term postoperative outcome is poorly described. The objective of this prospective pilot study was therefore to determine whether the foot type (pronate, neutral, or supinate) conditions the postoperative mid-term functional outcome.

Methods: A series of 28 patients (6 men, 22 women) were treated for primary central metatarsalgia by means of minimally invasive distal metaphyseal osteotomy (DMMO).

Results: Their functional outcomes at 6 and 12 months were assessed by the self-reporting AOFAS scale. Pre-surgery, the patients' scores were 42.82 ± 15.60. Scores improved at 6 months to 86.50 ± 8.6 and to 92.93 ± 8.6 at 12 months (p < 0.001 in both cases). There were no differences either by sex or by foot type in these overall values, although there was only a slight limitation of interphalangeal mobility in the supinated feet (p = 0.03) at 6-month follow-up as compared to other foot types.

Conclusion: Hence, DMMO provides an optimal clinical and functional outcome for the surgical treatment of metatarsalgia, regardless of the patient's foot posture. The occurrence of adverse events was minimal and clinically irrelevant.

Trial registration: The study was authorised by the Research Ethics Committee of the Universidad Católica de Valencia San Vicente Mártir, with the registry UCV/2018-2019/019.

Cartilage Matrix Changes in Hindfoot Joints in Chronic Ankle Instability Patients After Anatomic Repair Using T2-Mapping: Initial Experience With 3-Year Follow-Up

BACKGROUND

Anatomic repair is widely accepted as the primary surgical treatment for chronic lateral ankle instability (CLAI). T2-mapping is a powerful tool for quantitative assessment of biochemical changes in cartilage matrix.

PURPOSE

To longitudinally evaluate cartilage matrix changes in the hindfoot joints of CLAI patients before and after anatomic repair by using T2-mapping with magnetic resonance imaging (MRI).

STUDY TYPE

Prospective.

SUBJECTS

Thirty-two CLAI patients (males/females = 20/12) and 21 healthy controls (males/females = 13/7).

FIELD STRENGTH/SEQUENCE

3 T; sagittal multi-echo spin-echo technique (T2-mapping), coronal, sagittal, and axial spin-echo PD-FS, and sagittal T1WI sequences.

ASSESSMENT

MRI examinations were performed in CLAI patients at baseline (prior to surgery) and 3 years after anatomic repair and in healthy controls. On T2-maps, the hindfoot joints were segmented into 16 cartilage subregions. The T2 value of each subregion was measured. All patients were evaluated with the American Orthopedic Foot and Ankle Society (AOFAS) scale at baseline and after surgery.

STATISTICAL TESTS

Analysis of variance (ANOVA) and Student's t-test were used. The differences corresponding to P < 0.05 were considered statistically significant.

RESULTS

At baseline, the T2 values in most cartilage subregions of talar dome and medial posterior subtalar joint (pSTJ) were higher in CLAI patients than in healthy controls. After surgery, only the T2 value of anteriomedial talar dome decreased from that at baseline (31.11 ± 3.88 msec vs. 34.27 ± 5.30 msec). The T2 values of other subregions with elevated T2 values remained higher than healthy controls. There were no significant differences in T2 values in the midtarsal joints between CLAI patients and healthy controls (P = 0.262, 0.104, 0.169, 0.103). Postoperatively, the patients' AOFAS scores improved significantly from 67.81 to 89.13.

DATA CONCLUSION

CLAI patients exhibited elevated T2 values in most subregions of talar dome and medial pSTJ. After anatomic repair, although the patients exhibited good clinical outcomes, the elevated T2 values could not be fully recovered.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 4.

Matrix-induced autologous chondrocyte implantation versus autologous matrix-induced chondrogenesis for chondral defects of the talus: a systematic review

INTRODUCTION

Chondral defects of the talus are common and their treatment is challenging.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

Membrane-induced Autologous Chondrocyte Implantation (mACI) and Autologous Matrix-Induced Chondrogenesis (AMIC) have been proposed as management for chondral defects of the talus.

AREAS OF CONTROVERSY

It is debated whether AMIC provides greater outcomes compared to mACI for chondral regeneration. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up.

AREAS TIMELY FOR DEVELOPING RESEARCH

AMIC exhibits similar clinical results to mACI. However, AMIC involves one single surgical procedure, no articular cartilage harvest and hence no morbidity from it, no need for chondrocyte expansion in a separate laboratory setting. For these reasons, AMIC may be preferred to mACI.

Timeline for maximal subjective outcome improvement following total ankle arthroplasty

BACKGROUND

Maximal medical improvement (MMI) establishes the timepoint when patients no longer experience clinically significant improvements following surgery. The purpose of this investigation is to establish when patients achieve MMI following total ankle arthroplasty (TAA) through the use of patient reported outcome measures (PROMs).

METHODS

A systematic review to identify studies on TAA which reported consecutive PROMs for two years postoperatively was performed. Pooled analysis was done at 6 months, 12 months, and 24 months. Clinically significant improvement was defined as improvement between time intervals exceeding the minimal clinically important difference.

RESULTS

Twelve studies and 1514 patients met inclusion criteria. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Score and Visual Analog Scale scoring systems. The Short Musculoskeletal Function Assessment Dysfunction and Bother subsections showed maximal clinically significant improvement by 1 year postoperatively.

CONCLUSION

Following TAA, MMI is seen by one year postoperatively. Physicians may allocate the majority of resources within the first year when most of the improvement is perceived. This data may help inform preoperative counseling as it establishes a timeline for MMI.

LEVEL OF EVIDENCE

IV.

Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide

BACKGROUND

We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides.

METHODS

A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses.

RESULTS

The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort.

CONCLUSION

Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Transcultural adaptation and validation of the Spanish-French versions of the Self-reported Foot and Ankle Score (SEFAS)

OBJECTIVE

The study aim was to cross-culturally adapt the Self-reported Foot and Ankle Score (SEFAS) into Spanish and French-language versions, to validate them and to evaluate their psychometric properties.

METHODS

The cross-cultural translation from the original SEFAS into French and Spanish was performed in accordance with the guidelines of the ISPOR. The participants were recruited from some private healthcare institutions in France and Sapin, from June to August 2019. The following inclusion criteria were applied: aged at least 18 years, with foot and/or ankle deformity, had a history of subtalar and/or ankle and/or talonavicular or hindfoot pain, did not make daily use of walking aids, and were able to achieve the normal range of motions in the ankle, subtalar and midtarsal joints. All patients gave signed informed consent and completed the SF-36 and SEFAS questionnaires in the Spanish or French version.

RESULTS

The analysis was based on 319 participants. Internal consistency was excellent (Cronbach's alpha values of 0.94 for the Spanish version and 0.88 for the French version). No floor/ceiling effect was observed in any item, in either version.

CONCLUSION

The Spanish and French versions of SEFAS are valid, reliable instruments for evaluating foot and ankle pain and function.IMPLICATIONS FOR REHABILITATIONSelf-report questionnaires specific to patients with rheumatoid arthritis are needed to assess the degree of pain, disability, and disability caused by foot problems.The Spanish and French versions of SEFAS show the necessary psychometric characteristics.Each version provides a valid, reliable tool ensuring the correct evaluation of pain, function and limitation of function in the foot and/or ankle in the target population.

Clinical and radiological outcomes after arthrodesis of the first metatarsophalangeal joint

PURPOSE

The main aim of this study was to investigate the correlation between radiographic findings and clinical outcomes following the first metatarsophalangeal (MTP) joint arthrodesis.

METHODS

In a comparative retrospective study, on 46 patients (48 ft), the correlation between post-operative radiographic findings including hallux valgus angle (HVA) and first MTP dorsiflexion angle (MTPDA) and clinical outcomes including VAS pain, modified AOFAS hallux score, and FFI questionnaire were evaluated. Moreover, clinical outcomes were compared between cases with pre-operative diagnosis of first MTP inflammatory arthritis, hallux valgus, hallux varus, and grade 3 and 4 of hallux rigidus. The effect of first MTP arthrodesis on Meary's angle and intermetatarsal angle (IMA) were found out.

RESULTS

The mean age of the patients was 56.3 ± 9.1 (range, 29-69) years, including 42 (91.3%) females and 4 (8.7%) males. We had fusion rate of 97.9%, one asymptomatic nonunion case (2.1%). Totally, mean scores of modified AOFAS hallux score, FFI percentage, and VAS pain were 88.9 ± 12.6, 9.4 ± 16.5, and 1.23 ± 2.24, respectively. Hallux varus was associated with the most favourable outcomes; whereas, patients with first MTP arthritis got the worst outcome. Regression analysis test between clinical outcomes and HVA > 15° and first MTPDA >15° showed correlation coefficient of almost zero. No statistically significant differences were found between the clinical outcomes of grade 3 and 4 of hallux rigidus (p value of modified AOFAS hallux score, FFI percentage, and VAS pain: 0.879, 0.906, and 0.298, respectively). Mean of HVA and IMA reduction in 15 hallux valgus underwent first MTP fusion were 34.4° and 8.4°, respectively. Meary's angle increased about 4° with statistically significant difference (p value 0.001).

CONCLUSION

Patients with first MTP fusion > 15° in coronal and transverse plans could have acceptable clinical outcomes. The clinical outcome of first MTP arthrodesis for grade 3 hallux rigidus is comparable with grade 4. First MTP fusion would have positive effect on IMA and Meary's angle.

Does the Method of Administration Affect Reliability of the Foot and Ankle Ability Measure?

BACKGROUND

Region-specific patient-reported outcomes (PROs) are commonly used in rehabilitation medicine. Digital versions of PROs may be implemented into electronic medical records and are also commonly used in research, but the validity of this method of administration (MOA) must be established.

PURPOSE

To determine the agreement between and compare the test-retest reliability of a paper version (FAAM-P) and digital version (FAAM-D) of the Foot and Ankle Ability Measure (FAAM).

STUDY DESIGN

Randomized, nonblinded, crossover observational study.

METHODS

A total of 90 adults were randomized to complete the FAAM-P or FAAM-D first, and then completed the second MOA (first day [D1]). The FAAM-D was a digital adaptation of both FAAM-P subscales on Qualtrics. Identical test procedures were completed 1 week later (D2). Data were removed if a participant scored 100% on both MOA, reported injury between D1 and D2, or did not complete both MOA. Agreement was assessed on 46 participants between the 2 MOA using intraclass correlation coefficients (ICC) at D1. There was good-to-excellent test-retest reliability for the FAAM activities of daily living.

RESULTS

The authors observed good agreement between the FAAM-P and FAAM-D for the activities of daily living (ICC = .88) and sport scales (ICC = .87). Test-retest reliability was good-to-excellent for the FAAM activities of daily living (FAAM-P: ICC = .87; FAAM-D: ICC = .89) and sport (FAAM-P: ICC = .71; FAAM-D: ICC = .91).

CONCLUSIONS

The MOA does not appear to affect the responses on the FAAM; however, the authors observed slightly higher reliability on the FAAM-D. The FAAM-D is sufficient to be used for generating practice-based evidence in rehabilitation medicine.