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

Atelocollagen-Induced Chondrogenesis Versus Microfracture Alone for Osteochondral Lesions of the Talus: Surgical Technique and a 1-Year Clinical Outcome Study

Osteochondral lesions of the talus (OLTs) are a common cause of post-traumatic ankle pain and disability. Atelocollagen-induced chondrogenesis (ACIC) aims to encourage the development of hyaline cartilage, which is biomechanically superior to fibrocartilage. This single-center, retrospective database study assessed patients who underwent arthroscopic microfracture with or without atelocollagen scaffold augmentation for OLT. Between 2010 and 2019, 87 patients underwent microfracture only and 31 patients underwent ACIC. Propensity score matching was used to match the ACIC group in a 1:2 ratio to a corresponding microfracture-only group using logistic regression. American Orthopaedic Foot & Ankle Society (AOFAS) scores, 100-mm Visual Analog Scale (VAS), Short Form-36 (SF-36), and satisfaction were assessed at preoperative, 3-, 6-, and 12-month intervals. There were no differences in baseline characteristics between groups after matching (P > .05). Both groups had similar improvements to VAS, AOFAS, and SF-36 scores up to 12 months (P > .05). Both groups had significant 1-year improvements to physical functioning, physical limitations in usual role activities, pain, and social functioning domains, but the ACIC group additionally had significant improvements to general health, vitality, and mental health. Patients in the ACIC group were also more satisfied than the microfracture group at all time points. Patients with OLTs who underwent ACIC reported superior satisfaction and improvements to quality of life, although clinical outcomes were similar to those who underwent microfracture alone at 1 year.Level of Evidence: Level III: Cohort study.

Kinetics of functional recovery after foot and ankle surgery. Comparison of EFAS and SF36 scores

INTRODUCTION

The EFAS score is a new recently validated European quality of life score for foot and ankle surgery, comprising 6 questions on activities of daily living (ADL) and 4 on sport. The aim of the present study was to assess the kinetics of functional recovery on the EFAS and SF36 scores, and to assess correlations between the two at 0 to 6 months then 6 months to 1 year in a population of foot and ankle surgery patients, globally and per pathology.

HYPOTHESIS

Hindfoot and ankle surgery requires at least 1 year's follow-up for assessment of recovery, whereas 6 months is sufficient to assess forefoot recovery.

MATERIAL AND METHODS

A multicenter prospective cohort study included all patients undergoing surgery for foot and ankle pathology between December 2015 and July 2016. Statistical analysis, global and per pathology, was performed preoperatively and at 6 months and 1 year.

RESULTS

In total, 98 patients were assessed at 1 year. In the global population, EFAS ADL score improved by 17.1±22.1 points (hindfoot, 16.9±24.6; forefoot, 19.7±21.4) and global SF36 score by 8.7±17.1 points (hindfoot, 10.2±19.1; forefoot, 9.6±15.9). Both scores progressed between 6 months and 1 year for hindfoot pathologies, whereas they remained constant after 6 months for the forefoot. The EFAS score showed weak correlation with SF36.

CONCLUSION

Recovery kinetics differs according to type of foot and ankle pathology. The EFAS score is more suitable than the SF36.

LEVEL OF EVIDENCE

II.

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.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures

BACKGROUND

Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context.

METHODS

A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review.

RESULTS

Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study.

CONCLUSION

Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

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.

The effect of hallux valgus open and percutaneous surgery on AOFAS scale: a systematic review and meta-analysis

PURPOSE

To estimate the comparative effect of open and percutaneous hallux valgus (HV) surgery on patients' quality of life (QoL) using the American Orthopedic Foot and Ankle Society (AOFAS) scale including total score and individual domains (pain, function, and alignment).

METHODS

MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to March 2020 for studies on the effect of HV surgery on patients' QoL using the AOFAS score. A standardized mean difference score was calculated on the total AOFAS score and on each AOFAS domain (pain, function, and alignment) using Cohen's d index.

RESULTS

Considering the 53 published studies included, the pooled effect size (ES) estimates for the AOFAS total score were 3.69 (95% CI 3.37-4.01; I² = 95.5%) for open surgery and 3.40 (95% CI 2.99-3.80, I² = 88.2%) for percutaneous surgery. The total pooled ES estimate was 3.61 (95% CI 3.35-3.87, I² = 94.5%). Considering the pain domain, the pooled ES estimates were 2.21 (95% CI 1.98-2.43, I² = 64%) for open surgery and 2.52 (95% CI 1.83-3.20, I² = 92.6%) for percutaneous surgery. For the function domain, the pooled ES estimates were 1.37 (95% CI 0.93-1.81, I² = 91%) for open surgery and 2.28 (95% CI 1.10-3.47, I² = 96.8%) for percutaneous surgery. Finally, the pooled ES estimates for the alignment domain were 3.99 (95% CI 3.51-4.47, I² = 85.7%) for open surgery and 2.66 (95% CI 2.23-3.09, I² = 78.5%) for percutaneous surgery.

CONCLUSION

Our data support that HV surgery increases the total AOFAS score as well as the AOFAS scores by domain (pain, function, and alignment). Furthermore, our data show that HV surgery increases patients' QoL, after both open and percutaneous surgery, without differences between them.

Primary outcome measures used in interventional trials for ankle fractures: a systematic review

Background

Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture.

Methods

We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type.

Results

The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s.

Conclusion

This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.

Patient-Reported Outcomes in Foot and Ankle Orthopedics

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

Level of Evidence

Level V, expert opinion.

Outcomes Following Interposition Arthroplasty of the First Metatarsophalangeal Joint for the Treatment of Hallux Rigidus: A Systematic Review

Background:

Interposition arthroplasty of the first MTP joint has recently experienced renewed interest as a treatment for hallux rigidus. The purpose of this study was to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint.

Methods:

PubMed Central, Embase, and the Cochrane Central Register for Controlled Trials (CENTRAL) were searched. Inclusion criteria included length of time to follow-up, number of patients, outcome measure, and use of allogeneic or autogenous soft tissue or a synthetic matrix as interposition.

Results:

20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0%) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6% were of a retrospective nature. Progression to further surgery was observed in 3.8% of toes. The most common complication reported was transfer metatarsalgia of 1 or more lesser toes, observed in up to 57.9% of patients in one study.

Conclusion:

Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic, and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited.

Level of Evidence:

Level IV, systematic review of Level III-IV studies

The Effectiveness of Surgical Interventions in the Management of Malunited Calcaneal Fractures: A Systematic Review

Nonoperative management may result in calcaneal malunion with consequences of pain, deformity, and functional limitation. The aim of this review was to proffer an evidence-based scientific account of the effectiveness of contemporary surgical procedures in the management of malunited calcaneal fractures after initial conservative management. This systematic review included studies that evaluated the surgical procedures in the management of calcaneal malunion and systematically searched studies published between January 2005 and June 2016. The search was conducted using the following search engines: the Cochrane Library, Web of Science, PubMed/ MEDLINE, EMBASE, CINAHL, Academic Search Premier, and Open Grey. Methodologic assessment was conducted using the Cochrane Risk of Bias In nonrandomized Studies- of Interventions assessment tool version 7. Ten observational studies (212 patients) were included in this review. Five articles explored various means of achieving subtalar arthrodesis, 2 articles evaluated joint-sparing osteotomies, 1 examined corrective osteotomy for extra-articular os calcis malunion, and 2 articles explored combined procedures based on the Stephen and Sanders calcaneal malunion classification. Clinical and methodologic heterogeneity did not allow quantitative pooling of results. The overall risk of bias was considered moderate in 7 studies and 3 were considered at high risk of bias. The inability for any study to be considered at low risk of bias in this review might be mainly attributed to the lack of a valid and reliable outcome measure for the assessment of foot and ankle conditions. There is clear evidence that appropriately indicated procedures are effective in terms of pain alleviation, correction of deformity, and improved function. However, long-term outcomes may improve the acceptability to joint-preserving osteotomies, subtalar arthrodesis with the VIRA implant and subtalar distraction osteogenesis.

Patient-Reported Outcomes in Foot and Ankle Surgery

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

Correlation of MRI Appearance of Autologous Chondrocyte Implantation in the Ankle with Clinical Outcome

The objective of this study was to characterize magnetic resonance imaging (MRI) findings and correlate with clinical results in patients who underwent autologous chondrocyte implantation (ACI) of osteochondral lesions of the talus (OLT).

METHODS

Twenty-four grafts were evaluated at a mean 65.8 months after ACI for OLT. MRI was performed on a 1.5-T GE scanner using multiple sequences. Graft appearance was compared with preoperative MRI and evaluated for 6 criteria: defect fill, surface regularity, signal pattern, bone marrow edema, subchondral plate irregularity, and presence of cystic lesions. Clinical outcome was measured with the American Orthopaedic Foot and Ankle Society (AOFAS) clinical outcome score.

RESULTS

Of 24 grafts, 22 (92%) demonstrated >75% defect fill. Eighteen (75%) had a mildly irregular and 6 (25%) had a moderately irregular articular surface. The signal pattern of the repair tissue was heterogenous in 23 (96%); 14 (58%) layered and 9 (38%) mottled. Fourteen grafts (58%) showed decreased amount of bone marrow edema while 4 (17%) had no change and 5 (21%) had an increase in the amount of bone marrow edema. The subchondral bone plate was abnormal in most grafts, with focal defects seen in 10, slight depression in 7, and both in 5. Seven had an increase in cystic lesions while the others had no change, decrease or no cysts seen. Mean postoperative AOFAS score was 87.5 with mean improvement of 39.4.

CONCLUSIONS

At 66-month mean follow-up, MRI appearance of the ACI grafts show imaging abnormalities but demonstrate good clinical results. While MRI is an important tool in the postoperative assessment of ACI grafts, the various variations from a normal/nonoperative ankle must be interpreted with caution.

Arthroscopic treatment of focal osteochondral lesions of the first metatarsophalangeal joint

Background

Although arthroscopic surgical treatment of the first metatarsophalangeal (MTP) joint involves painful sesamoid excision, synovectomy, debridement, and partial cheilectomy, no gold standard treatment technique has been defined in the literature for hallux rigidus and focal osteochondral lesions. This study aimed to assess the arthroscopic treatment for early-grade focal osteochondral lesions of the first MTP joint and to determine the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in a group of patients who failed conservative treatment.

Methods

This prospective study included 14 patients with hallux rigidus and focal osteochondral lesions of the first MTP joint who underwent surgery in 2014 and were followed on a regular basis thereafter.

Results

The patients had mean preoperative VPS (visual pain scale) and AOFAS (American Orthopedic Foot and Ankle Society)-Hallux scores of 8.14 ± 0.86 SD and 48.64 ± 4.27, respectively; the corresponding postoperative values of both scores were 1.86 ± 0.66 SD and 87.00 ± 3.70, respectively. Both VPS and AOFAS-Hallux scores changed significantly.

Discussion

In this prospective study, we explored the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in patients with focal osteochondral lesions of the first MTP joint. Our results showed significant improvements in VPS and AOFAS scores with this treatment.

Conclusions

An arthroscopic microhole drill technique can be used with impressive functional scores and without any complications in patients who failed conservative therapy for hallux rigidus with focal chondral injury.

Therapeutic Ultrasound in Navicular Stress Injuries in Elite Track and Field Athletes

OBJECTIVE

To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries.

DESIGN

This is a prospective, clinical case series. Level of evidence IV.

SETTING

All participants were examined and followed up in a private Sports Injury Clinic.

PARTICIPANTS

Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study.

INTERVENTIONS

All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks.

MAIN OUTCOME MEASURES

Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded.

RESULTS

The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period.

CONCLUSIONS

The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.

Arthroscopic treatment of focal osteochondral lesions of the first metatarsophalangeal joint

Background

Although arthroscopic surgical treatment of the first metatarsophalangeal (MTP) joint involves painful sesamoid excision, synovectomy, debridement, and partial cheilectomy, no gold standard treatment technique has been defined in the literature for hallux rigidus and focal osteochondral lesions. This study aimed to assess the arthroscopic treatment for early grade focal osteochondral lesions of the first MTP joint and to determine the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in a group of patients who failed conservative treatment.

Methods

This prospective study included 14 patients with hallux rigidus and focal osteochondral lesions of the first MTP joint who underwent surgery in 2014 and were followed on a regular basis thereafter.

Results

The patients had mean preoperative VPS (visual pain score) and AOFAS (American Orthopedic Foot and ankle Society)-Hallux scores of 8.14 ± 0.86 SD and 48.64 ± 4.27, respectively; the corresponding postoperative values of both scores were 1.86 ± 0.66 SD and 87.00 ± 3.70. Both VPS and AOFAS-Hallux scores changed significantly.

Discussion

In this prospective study, we explored the impact of arthroscopic microhole drill surgery on foot function and activities of daily living in patients with focal osteochondral lesions of the first MTP joint. Our results showed significant improvements in VPS and AOFAS scores with this treatment.

Conclusions

An arthroscopic microhole drill technique can be used with impressive functional scores and without any complications in patients who failed conservative therapy for hallux rigidus with focal chondral injury.

Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: A meta-analysis

BACKGROUND

Acute Achilles tendon rupture (AATR) is a frequent injury occurring dominantly in young to middle-aged males. Outcomes and complications between percutaneous and open repair are still controversial. Thus, the purpose of this meta-analysis is to evaluate the outcomes and complications of these two operative methods.

MATERIALS AND METHODS

We searched multiple databases: PubMed, Web of Science, EMBASE and the Cochrane Library up to October 2016. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted data from eligible studies, with confirmation by cross-checking. The major results and conclusions were concluded, and the different complication rates and functional outcomes were compared. Meta-analysis was processed by Rev Man 5.3 software.

RESULTS

Five randomized controlled trials (RCTs) and seven retrospective cohort studies involving 815 patients met the inclusion criteria. The sural nerve injury rate in the percutaneous group was significantly higher (RR = 3.52, 95%CI 1.45 to 8.57, P = 0.006). However, deep infection rate in the open group was higher (RR = 0.33, 95%CI 0.11 to 0.96, P = 0.04) and subgroup analysis of five RCTs showed no significant difference (RR = 0.42, 95%CI 0.09 to 2.10, P = 0.29). No significant difference was seen regarding the rate of re-rupture. The time of operation in the percutaneous group was shorter (RR = -1.99, 95%CI -3.81 to -0.80, P = 0.001). American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score showed statistically different in the two groups. Other functional outcomes were similar in the two groups.

CONCLUSIONS

Percutaneous repair has the advantages of operation time, deep infection and AOFAS score. The functional outcomes were similar in two treatment groups except AOFAS score. Despite the higher incidence of sural nerve injury, we still believe that percutaneous repair is superior to open repair for treating AATR.

Outcome following first metatarsophalangeal joint replacement using TOEFIT-PLUS™: A mid term alert

BACKGROUND

We aim to evaluate the mid-term results of first metatarsophalangeal joint replacement for hallux rigidus using Toefit-Plus™ in a single surgeon series.

METHODS

We prospectively studied the outcomes of 86 toes in 73 patients using the AOFAS-HMI score and radiological follow up. The mean follow up was 33 months (2-72). Ten patients have been lost to follow up.

RESULTS

Eight patients sustained intraoperative fractures or impending fractures requiring circlage wiring. Eighteen joints have either been revised or listed for revision giving a revision rate of 24%; this occurred at a mean of 33 months post-surgery.

CONCLUSIONS

First MTPJ replacement is an option in hallux rigidus and patients who are not revised experience significant improvement in AOFAS scores in the medium term. We have previously published satisfactory results with this prosthesis. However the revision rate is unacceptably high and we have discontinued its use completely. Future design evolutions should address the issue of osteointegration on the phalangeal side.

Mid-term results of ankle fractures with and without syndesmotic rupture

BACKGROUNDS

This study investigated the effect of short term removal of syndesmotic screws on the ankle function after 6 years, as there still exists controversy on the duration of screw stabilization.

METHODS

Patients with an ankle fracture who received surgery between 1998 and 2004 were reviewed. One group was composed of patients with an ankle fracture needing a syndesmotic repair with screws. The second was composed of operated patients that did not need syndesmotic repair. The primary scoring used was the Olerud-Molander Ankle Score (OMAS).

RESULTS

A total of 59 patients were studied with comparable characteristics, with no significant difference on the OMAS after 6 years between the repair group (81.9) and the non-repair group (90.4). On additional clinical scoring groups remained the same. Joint degeneration was seen in both groups (86.7% vs. 55.5%).

CONCLUSIONS

Patients with ankle fractures using syndesmotic repair and screw removal after 8 weeks and operated patients without syndesmotic injury have comparable results after 6 years.

The impact of ankle osteoarthritis. The difference of opinion between patient and orthopedic surgeon

BACKGROUND

Outcome measures for ankle osteoarthritis (OA) are created by physicians with little input of the target patient group. The aim of this study was to determine the difference in opinion between patients and orthopedic surgeons concerning the importance of specific symptoms of ankle OA and its impact on daily life and function.

METHODS

A modified Delphi method was applied, consisting of structured interviews with patient focus groups and experts, followed by a poll using 32 statements. The difference in opinion between patients and orthopedic surgeons was evaluated.

RESULTS

Forty patients and forty orthopedic surgeons responded to the 32 statements. Statistically significant differences in opinion on symptoms, function and the impact of ankle OA on daily life were found.

CONCLUSIONS

This study demonstrates a significant difference in opinion between patients and orthopedic surgeons concerning specific symptoms of ankle OA. These results advocate incorporating the needs and demands of the individual patient for new outcome measures.

Comparison of the Self-reported Foot and Ankle Score (SEFAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS)

BACKGROUND

The Self-reported Foot and Ankle Score (SEFAS) is a patient-reported outcome measure, while the American Orthopedic Foot and Ankle Society Score (AOFAS) is a clinician-based score, both used for evaluation of foot and ankle disorders. The purpose of this study was to compare the psychometric properties of these 2 scoring systems.

METHODS

A total of 95 patients with great toe disorders and 111 patients with ankle or hindfoot disorders completed the 2 scores before and after surgery. We evaluated time to complete the scores in seconds, correlations between scores with Spearman's correlation coefficient (r s), floor and ceiling effects by proportion of individuals who reached the minimum or maximum values, test-retest reliability and interobserver reliability by intraclass correlation coefficient (ICC), internal consistency by Cronbach's coefficient alpha (CA), and responsiveness by effect size (ES). Data are provided as correlation coefficients, means, and standard deviations.

RESULTS

SEFAS was completed 3 times faster than AOFAS. The scores correlated with an r s of .49 for great toe disorders and .67 for ankle/hindfoot disorders (both P < .001). None of the scores had any floor or ceiling effect. SEFAS test-retest ICC values measured 1 week apart were .89 for great toe and .92 for ankle/hindfoot disorders, while the corresponding ICC values for AOFAS were .57 and .75. AOFAS interobserver reliability ICC values were .70 for great toe and .81 for ankle/hindfoot disorders. SEFAS CA values were .85 for great toe and .86 for ankle/hindfoot disorders, while the corresponding CA values for AOFAS were .15 and .42. SEFAS ES values were 1.15 for great toe and 1.39 for ankle/hindfoot disorders, while the corresponding ES values for AOFAS were 1.05 and 1.73.

CONCLUSION

As SEFAS showed similar or better outcome in our tests and was completed 3 times faster than AOFAS, we recommend SEFAS for evaluation of patients with foot and ankle disorders.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Is there a relation between AOFAS ankle-hindfoot score and SF-36 in evaluation of Achilles ruptures treated by percutaneous technique?

The percutaneous technique of Achilles tendon repair seems to offer satisfactory clinical and functional results, although these results have been evaluated mainly using objective rating scales. Recently, some "subjective" rating scales have been combined to evaluate the results of various surgical treatments. The purpose of the present study was to compare the results of a percutaneous Achilles tendon repair evaluated objectively using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and subjectively using the Medical Outcomes Study, short-form, 36-item questionnaire (SF-36) questionnaire. A total of 17 consecutive patients were treated for acute Achilles tendon rupture using the modified percutaneous Ma and Griffith technique. We reviewed all patients with a follow-up of 24 to 64 months (mean 45.5). At the final follow-up visit, the AOFAS ankle-hindfoot score of each patient was compared with each 1 of the 8 domains of the SF-36 questionnaire, using the parametric Pearson correlation coefficient and the equivalent nonparametric Spearman rho correlation coefficient. The relation between the objective (AOFAS) and subjective (SF-36) results showed a significant correlation (Pearson's correlation coefficient) between the physical functioning (r = 0.597, p = .011) and bodily pain (r = 0.663, p = .004) SF-36 domains, and a nonstatistically significant correlation with the other SF-36 domains. Very similar results were found using the nonparametric Spearman rho correlation coefficient. These results suggest that regarding pain and function, the AOFAS ankle-hindfoot score and SF-36 provide complementary information; therefore, we believe that the SF-36 questionnaire should be used with the AOFAS ankle-hindfoot score for a more complete evaluation of the outcome.

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery

Outcome measures may be simple questions or complex measures that assess multiple interrelated domains affecting treatment outcomes. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. Joint and disease-specific outcome measures have been developed for the hip, knee, and foot and ankle. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability. General health measures and activity level scores should be included in outcome assessments after treatment for orthopaedic conditions.

The arthroscopic Lapidus procedure

BACKGROUND

Hypermobility of the first metatarsocuneiform (MC) joint is one of the causes believed to contribute to symptomatic hallux valgus. An arthrodesis of the first MC joint offers definitive correction of the intermetatarsal angle. This procedure can be associated with pseudoarthrosis and shortening of the first ray. This study presents our experience and results with an arthroscopic technique for performing this arthrodesis.

MATERIALS AND METHODS

Five patients with severe hallux valgus associated with hypermobility of the first MC joint were treated with this operation.

RESULTS

The functional assessment scales revealed very good results. Radiographic evaluation confirmed fusion in all the patients. The hallux valgus angle improved by 25.6°, the intermetatarsal angle improved by 10.6°. The shortening of the first ray was limited to 2.7 mm.

CONCLUSION

This new technique is a valid option for performing an arthrodesis of the MC joint.

Measuring foot and ankle injury outcomes: common scales and checklists

Functional health outcome measures are increasingly being used in both clinica trials and practice as measures of patient health. Whilst outcome measures can be generic, there are a number of foot and ankle specific measures available and in use. These are being used as not only region specific but also disease specific measures of patient function. Unfortunately not all of these outcome measures have been completely validated which leads to challenges in applying the results of outcomes research to specific patients. Continued work however is being done in this area and these challenges provide opportunities for further investigation into the role of functional outcome scores specific to the foot and ankle.

A pilot study to explore if the age that women undergo hallux valgus surgery influences the post-operative range of motion and level of satisfaction

BACKGROUND

Scarf and Akin osteotomies are commonly used to treat hallux valgus. One post-operative complication is a reduction in the range of motion at the first metatarsophalangeal joint. This can cause pain and restrict the heel height of footwear. This pilot study aims to examine if women's age has an effect on the post-operative outcome following Scarf and Akin osteotomies.

METHODS

A pilot study using a convenience sample compared the outcomes of two groups of female patients, those aged under 50 and those aged over 50. The range of motion at the first metatarsophalangeal joint was measured using a goniometer, the American Orthopaedic Foot and Ankle Society (AOFAS) scale and satisfaction levels were collected 2 years post-operatively.

RESULTS

There were no significant statistical differences between the two age groups for the outcomes measured. Similar AOFAS scores and ranges of motion were found for both age groups. Satisfaction levels were high but the under 50-year group were slightly less satisfied.

CONCLUSIONS

The outcome of this pilot study suggests that age does not have an effect on the range of motion of the first metatarsophalangeal joint, the AOFAS score or the level of patient satisfaction 2 years following Scarf and Akin osteotomies.

Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature

As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase from pre- to postoperative scores in both procedures. The median postoperative score for joint replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for arthrodesis. The median revision rate in joint replacements was 7% (range 0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be functionally superior to an arthrodesis.

Which are the most frequently used outcome instruments in studies on total ankle arthroplasty?

The number of studies reporting on outcomes after total ankle arthroplasty is continuously increasing. As the use of valid outcome measures represents the cornerstone for successful clinical research, we aimed to identify the most frequently used outcome instruments in ankle arthroplasty studies and to analyze the evidence to support their use in terms of different quality criteria. A systematic review of the literature identified 15 outcome instruments reported in 79 original studies. The most commonly used measures were the American Orthopaedic Foot and Ankle Society hindfoot score (n = 41), the Kofoed ankle score (n = 21), a visual analog scale assessing pain (n = 15), and the generic SF-36 (n = 6). Eight additional instruments were used only once or twice. The American Orthopaedic Foot and Ankle Society and Kofoed instruments include a clinical examination and score up to 100 points. Evidence to support their use in terms of validity, reliability, responsiveness, and interpretability is limited, raising the question whether their use is justified. Self-reported questionnaires related to ankle osteoarthritis or arthroplasty are rather disregarded in the current literature, and only the Foot Function Index is associated with evidence in terms of the above-mentioned quality criteria. Future research is warranted to improve the outcome assessment after total ankle arthroplasty.

Moje first metatarsophalangeal replacement--a case series with functional outcomes using the AOFAS-HMI score

We report the functional results of a case series of Moje first metatarsophalangeal total joint replacements carried out between February 2001 and November 2006. All patients who underwent Moje arthroplasty under the care of a single surgeon were included; outcome scores and complications were recorded annually. A total of 32 joints in 29 consecutive patients were followed for a mean duration of 34 (range 6 to 74) months, and the mean patient age at the time of operation was 56 (range 38 to 79) years. Hallux rigidus was the primary diagnosis in 28 (87.5%) of the cases. The mean American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal score at final follow-up was 74/100 (range 9 to 100), with 13 (40.63%) joints rated good to excellent. Two (6.25%) joints were revised to arthrodesis at a mean of 52 (range 41 to 63) months following the arthroplasty procedure, and the overall prevalence of postoperative complications was 6 (18.75%). Based on these results, we concluded that first MTPJ total joint replacement with the Moje device remains promising, but still has room for improvement before the results match those obtained with larger joint (knee, hip) arthroplasty.

Percutaneous and minimum incision metatarsal osteotomies: a systematic review

Percutaneous and minimum incision metatarsal osteotomies have received increasing recognition because of the perceived efficacy comparable to traditional open approaches but with purported less cost, fewer complications, and higher patient satisfaction. The use of these treatments has also been proposed for medically compromised patients who are not expected to recover well from traditional open approaches, a patient population that comprises a substantial proportion of the author's practice. Therefore, the author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the use of percutaneous and minimum incision metatarsal osteotomies. Information from peer-reviewed journals, as well as that from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they were prospective, involved consecutively enrolled patients undergoing the same percutaneous or minimum incision surgical treatment, evaluated patients at a mean follow-up of 12 months or longer duration, and included outcome measurements consisting of subjective patient satisfaction, radiographic measurements, and details of complications. Three studies involving percutaneous surgical treatment specific to hallux valgus were identified that met the inclusion criteria, all of which were case series of relatively poor methodological quality. Rather than providing strong evidence for or against the use of percutaneous minimum incision metatarsal osteotomies, the results of this review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.

LEVEL OF EVIDENCE

1.