Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints

Translation, cross-cultural adaptation and validation of psychometric properties of foot function index in Urdu-speaking population with ankle and foot disorders

BACKGROUND

Foot and ankle problems are frequently prevalent, especially among the elderly, ranging from 70 to 80%. In primary care, foot, and ankle complaints stand out as one of the most frequent reasons for orthopedic consultations. Patient-reported outcome measures are significant in the assessment burden of any condition on the effects of intervention as well as research. The Foot Function Index (FFI) is a region-specific tool that was identified as one of the most commonly used evaluation tools for foot complaints. This study aimed to translate, cross-cultural adapt, and test the psychometric properties of FFI in the Urdu language.

METHODOLOGY

The FFI was translated into Urdu language (FFI-U) following Beaton et al. translation guidelines. The data were collected from 230 Urdu-speaking participants with different foot and ankle pathologies. Data collection started after the written informed consent from the participants. All participants completed the FFI-U, Visual Analogue Scale (VAS), SF-36, and the Foot and Ankle Outcome Score (FAOS) at baseline while only 30 participants completed ULFI-U after one week for test-retest reliability. The psychometric properties involved reliability and validity testing. Reliability was assessed where internal consistency was measured using Cronbach's alpha and test-retest reliability through the intra-class correlation coefficient (ICC). FFI-U was tested for face validity and construct validity (convergent and discriminant). Psychometric criteria were examined against priori hypotheses, and alpha level (p-value < 0.05) was considered statistically significant.

RESULTS

FFI-U demonstrated good reliability with internal consistency (α = 0.86) and test-retest reliability with intra-class correlation coefficient = 0.845 (0.78-0.89). A moderate correlation was found using Pearson correlation between FFI-U total score and physical components of SF-36, VAS (pain, disability), and FAOS (γ= -0.65, 0.72, 0.71, -0.68) respectively, indicating convergent validity however, a weak correlation was found with mental components of SF-36 (γ=-0.25) demonstrating discriminant validity. Face validity was assessed at the pre-final testing stage by interviewing patients. There were no floor and ceiling effects found for FFI-U.

CONCLUSION

The FFI-U has been found reliable, valid, and feasible tool to be used as a patient-reported outcome measure to assess functional levels with different foot and ankle disorders in Urdu speaking population.

Update of Modified Version of the Foot Function Index Tool Spanish Version (FFI-Sp), in Patients with Rheumatoid Arthritis: Cross Sectional Study

Background and Objectives: The Foot Function Index (FFI) is a widely recognized patient-reported outcome measure (PROM) for assessing foot functionality and its impact on quality of life in individuals with rheumatoid arthritis (RA). This study aimed to observe the behavior of the tool in the Spanish population with RA, optimize the tool, and check its functionality. Materials and Methods: A total of 549 RA patients, with a predominant female participation (75.6%). This study involved a comprehensive statistical analysis, leading to a refined version of the FFI for a Spanish-speaking population. Results: The original 23-item FFI was revised, resulting in a 15-item version by excluding items that caused confusion or were considered redundant. This modified version maintained the original's subscales of pain, disability, and activity limitation, but with an adjusted item distribution. The construct validity was confirmed through exploratory factor analysis, demonstrating excellent fit indices (Kaiser-Meyer-Olkin test = 0.926, Bartlett's test of sphericity = 4123.48, p < 0.001). The revised FFI demonstrated good internal consistency (Cronbach's alpha = 0.96) and test-retest reliability (ICC = 0.89). Conclusions: This study highlights the applicability of the FFI in Spanish-speaking RA populations, offering a valid and reliable tool for clinicians and researchers. The modifications enhance the FFI's relevance for RA patients, facilitating better assessment and management of foot-related functional impairments.

Ankle Muscle Strength and Gait Function After Dorsal Closing Wedge Calcaneal Osteotomy for Haglund Exostosis-Related Heel Pain

BACKGROUND

Haglund exostosis-related heel pain may be surgically treated with dorsal closing wedge calcaneal osteotomy (DCWCO). Recent reports on this technique show good clinical and self-reported outcomes. However, uncertainty about functional consequences related to ankle muscle strength and gait function due to a shortened Achilles tendon lever arm exists.

METHODS

Fifteen patients (15 feet) with Haglund exostosis-related heel pain were surgically treated with DCWCO and evaluated before and 1 year after surgery. Isometric plantar flexion and dorsiflexion strength was quantified for both the involved and the uninvolved limb. Gait analysis was performed at a self-selected walking speed using a 3D motion capture system including force plates. Self-reported outcomes (Foot Function Index and Global Treatment Outcome) were also assessed.

RESULTS

Before surgery, as well as after surgery, plantar flexion strength of the involved limb was significantly lower compared to the uninvolved limb while dorsiflexion strength did not differ between limbs at both time points. Step length and time, ankle flexion angles, power generation, and propulsive impulses during gait did not differ between limbs both before and after surgery. Propulsive impulse and step length of the involved limb increased from pre- to postsurgery with an effect size of 1.04 and 0.48, respectively, revealing a general improvement in gait dynamics. Total Foot Function Index improved by 48% after surgery, and 80% of patients rated their surgery as "helped" or "helped a lot" (Global Treatment Outcome).

CONCLUSION

In this relatively small cohort, we found that patients treated for Haglund exostosis-related heel pain with DCWCO surgery had minor interlimb differences in gait kinematics and kinetics and generally improved gait dynamics and self-reported function at 1-year follow-up.

LEVEL OF EVIDENCE

Level II, observational prospective cohort study.

Measurement properties of the Foot Function Index (FFI) questionnaire: A systematic review

OBJECTIVE

Large numbers of people are subject to alterations and pathologies in the foot. To quantify how these problems of foot function affect the quality of life, clinicians and researchers have developed measures such as the Foot Function Index (FFI). Our aim is to determine the methodological quality of the FFI including adaptations to other languages.

DATA SOURCES

The studies considered in this review were extracted from the PubMed, Embase and CINAHL databases. The inclusion criteria were followed: (1) studies of patients with no previous foot or ankle pathology and aged over 18 years; (2) based on English-language patient-reported outcome measures that assess foot function; (3) the patient-reported outcome measures should present measurement properties based on COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria.

REVIEW METHODS

The systematic review was conducted following the COSMIN criteria to establish the methodological quality of the original FFI, together with its variants and adaptations. The last search was carried out in May 2024.

RESULTS

Of the 1994 studies obtained in the preliminary search, 20 were eligible for inclusion in the final analysis. These results are the validations and cross-cultural adaptations to the following languages: the original FFI has cross-cultural adaptation in 13 languages and the FFI-Revised Short Form has been adapted and validated for use in 2 languages.

CONCLUSION

In terms of methodological quality, the FFI-Revised Short Form questionnaire is a valuable instrument for evaluating ankle and foot function and could usefully be expanded to be available in more languages.

Ten-Year Minimum Follow-up Study of First Metatarsophalangeal Joint Fusion in Young vs Old Patients

BACKGROUND

Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort.

METHODS

All patients aged <50 years who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI).

RESULTS

Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group.

CONCLUSION

In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage hallux rigidus.

LEVEL OF EVIDENCE

Level III, a case-control study.

Increased ankle pain after total knee arthroplasty is associated with a preoperative lateralized gait and talar tilt, but not with ankle laxity or the range of motion of the subtalar joint

Aims

Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity.

Methods

Patients who underwent TKA from September 2020 to September 2021 were prospectively included. Inclusion criteria were primary end-stage osteoarthritis (Kellgren-Lawrence stage IV) of the knee. Exclusion criteria were missed follow-up visit, post-traumatic pathologies of the foot, and neurological disorders. Radiological angles measured included the mTFA, hindfoot alignment view angle, and TT. The Foot Function Index (FFI) score was assessed. Gait analyses were conducted to measure mediolateral changes of the gait line and ankle laxity was tested using an ankle arthrometer. All parameters were acquired one week pre- and three months postoperatively.

Results

A total of 69 patients (varus n = 45; valgus n = 24) underwent TKA and completed the postoperative follow-up visit. Of these, 16 patients (23.2%) reported the onset or progression of ankle symptoms. Varus patients with increased ankle symptoms after TKA had a significantly higher pre- and postoperative TT. Valgus patients with ankle symptoms after TKA showed a pathologically lateralized gait line which could not be corrected through TKA. Patients who reported increased ankle pain neither had a decreased ROM of the subtalar joint nor increased ankle laxity following TKA. The preoperative mTFA did not correlate with the postoperative FFI (r = 0.037; p = 0.759).

Conclusion

Approximately one-quarter of the patients developed ankle pain after TKA. If patients complain about ankle symptoms after TKA, standing radiographs of the ankle and a gait analysis could help in detecting a malaligned TT or a pathological gait.

[The German Association for Foot and Ankle (D.A.F.) registry on treatment of end-stage total ankle arthritis-what is its clinical impact?]

Initially established as a voluntary prosthesis register for total ankle replacement, the registry now enables analysis of revisions, complications, and clinical and functional outcomes-including patient-reported outcome measures-based on a period spanning more than 10 years. To allow analyses of the outcomes of ankle arthrodesis and supramalleolar osteotomies for treatment of end-stage arthritis in the future, the registry was extended by structured capturing of these procedures in 2018. While descriptive and analytical statistical evaluations of total ankle replacement are already possible today, the number of datasets on arthrodesis and supramalleolar osteotomies is still too small to support these analyses or comparative evaluations.

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

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

Clinical, Radiographic and Gait Parameters Associated with Medial Arch Pain in the Flexible Pediatric Flatfoot

Pain in the flexible flatfoot is a common complaint, if present it is important to find its exact location and causes Therefore, the study aimed to find differences between children with and without medial arch pain and relate them to the reduction of pain following surgical treatment. Children with idiopathic flexible flatfeet were retrospectively included in the study. All children underwent a clinical, radiographic, and gait examination. The feet were subdivided into 2 groups: asymptomatic and those with medial arch pain. Factors associated with medial arch pain were identified via t test. Significant radiological and gait parameters were correlated to the change in medial arch pain score following surgery. Included were 322 feet belonging to 177 children, with the mean age of 11.8 (SD = 2.2) years. The pain was perceived in 52% of the feet, of these, 74% in the medial arch. In the group with pain, 31 feet received a gait analysis following surgery. The radiological parameters, talus-1 and -2 metatarsal angles and the gait parameter, calcaneal lateral shift during walking showed a significant difference (p ≤ .004) between the no pain and pain groups and were associated (R² ≥0.14, p ≤ .04) with the reduction in pain following surgery. The increased talus-1 and -2 metatarsal angles and the calcaneal lateral shift may cause increased tension on the soft-tissues along the medial side of the foot and may produce pain. Therapies aiming at improving the medial arch pain should be directed to normalize the talus-1 or -2 metatarsal angles and the calcaneal lateral shift.

Chopart Joint Injuries: Assessment, Treatment, and 10-Year Results

OBJECTIVES

To investigate injury patterns and long-term outcomes of midtarsal (Chopart) injuries in a sizeable number of patients.

DESIGN

Prospective study.

SETTING

Level 1 trauma center.

PATIENTS

One hundred twenty-two patients (average age 37.6 years) with 128 Chopart injuries over a 15-year period, 27% of who were polytraumatized. In 47%, more than 1 of the 4 bones of the midtarsal joint was fractured. The navicular and cuboid were fractured most often. Purely ligamentous dislocations occurred in 4%.

INTERVENTIONS

Operative treatment tailored to the individual fracture pattern was performed in 91.4%.

MAIN OUTCOME MEASUREMENTS

Foot Function Index, American Orthopaedic Foot and Ankle Society score, SF-36 physical (PCS) and mental component summary (MCS).

RESULTS

Seventy-three patients with 75 Chopart injuries were available for follow-up at an average of 10.1 years. The Foot Function Index averaged 26.9, the American Orthopaedic Foot and Ankle Society score averaged 71.5, and the SF-36 PCS and MCS averaged 43.5 and 51.2, respectively. Negative prognostic factors were a high injury severity score, work-related accidents, open and multiple fractures, purely ligamentous dislocations, staged surgery, delay of treatment >4 weeks, postoperative infection, and primary or secondary fusion. Open reduction and internal fixation led to significantly better results than attempted closed reduction and percutaneous fixation. Radiographic signs of posttraumatic arthritis were observed in 93%, but only 4.7% of cases required a late fusion at the Chopart joint.

CONCLUSIONS

Chopart joint injuries lead to functional restrictions in the long term. Purely ligamentous dislocations have the worst prognosis, whereas fractures of a single bone have a favorable outcome after anatomic reduction and internal fixation.

LEVEL OF EVIDENCE

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

Callus distraction for brachymetatarsia - A comparison between an internal device and the external fixator

BACKGROUND

Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters.

METHODS

Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail).

RESULTS

Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001).

CONCLUSION

CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

Many-faceted rasch calibration of the foot function index-revised short form

Background

The Foot Function Index Revised Short version (FFI-RS) is a foot- and ankle- patient-reported outcome measure (PROM), developed from the Foot Function Index (FFI). Previous studies, estimating item parameters and multidimensional properties, have limitations properly establishing the measurement properties of the FFI-RS. A multi-faceted Rasch analysis with a larger sample would allow for a more robust validation approach to improve the clinical interpretation of the FFI-RS using a multidimensional perspective. Therefore, the purpose of this study was to assess the psychometric properties of the FFI-RS as a PROM of foot function.

Method

A total of 2184 patients with foot pathology who completed the FFI-RS were included in the data. Data were extracted from the cloud-based orthopedic and sports medicine global registry Surgical Outcome System (SOS). The psychometric properties of the FFI-RS were assessed using a many-faceted Rasch analysis that included model-data fit, rating scale function, item-person map (distribution of item difficulty and person ability), and item difficulty of the subscale.

Results

Two misfit items were discovered and deleted; 32-items from the original FFI-RS were retained. The 4-item Likert scale functioned effectively and item difficulty (-0.58 to 1.48), subscale difficulty (-0.58 to 1.15), and person’s foot function (-6.62 to 6.24) had wide distributions.

Conclusions

Many-faceted Rasch analysis revealed the FFI-RS had sound psychometric properties using the many-faceted Ranch analysis and retained 32 of the original items. Clinicians and researchers should consider weaknesses identified with items in the ‘Difficulty” subscale and future work should be conducted to modify or develop items that will more accurately evaluate a wide range of foot function levels.

Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis

AIM OF THE WORK

We aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients.

PATIENTS AND METHODS

This was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0-10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI.

RESULTS

Fifty RA patients with an average age of 59.3 ± 9.9 years [39-79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0-92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001).

CONCLUSION

Due to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one's quality of life can be important.

LEVEL OF CLINICAL EVIDENCE

4 (cohort studies, non experimental, observational studies).

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months

BACKGROUND

This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence.

METHODS

32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration.

RESULTS

After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction.

CONCLUSIONS

Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.

Clinical and Radiologic Results of a Human Bone Graft Screw in Tarsometatarsal II/+III Arthrodesis

BACKGROUND

For arthrodesis of the tarsometatarsal joints, there is the possibility of using a transplant screw made of allogenic human bone material (Shark Screw). This article investigates the clinical outcome and radiologic integration of the allogenic bone screw for arthrodesis of the tarsometatarsal joints II/+III.

METHODS

This is a prospective study involving 20 feet of 17 patients who received TMT II/+III arthrodesis with an allogenic bone screw. A visual analog scale (VAS pain and function), Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score, and Foot and Ankle Outcome Score (FAOS) were used as measures to compare preoperative with postoperative results. Radiologic integration in the recipient bone was also evaluated.

RESULTS

A significant mean pre- to postoperative improvement of all evaluated scores has been observed (P < .05) after a mean follow-up of 15.87 months (minimum 12 months, maximum 33 months). VAS score (pain) decreased from 7.6 to 1.4 points as well as a decrease of the VAS (function) from 7.25 to 1.8 points. Further, a reduction of the FFI from 62.3% to 16.7% and an increase from 29.7 to 79.9 points of the AOFAS was detected. Analyzing the FAOS score, in all surveyed subscales, there was an increase in the score (Symptoms: 55.2 to 85.6 points; Pain: 30.5 to 86.9 points; Function: 33.1 to 88.3 points; Quality of life: 27.8 to 79.7 points). Moreover, in all cases, a complete radiologic integration into the receiving bone was appreciated, and after a minimum follow-up time from 12 months, the screw in 19 feet (95%) was no longer distinguishable from the original bone.

CONCLUSION

With these first results of the allogenic bone screw in TMT II/+III arthrodesis, a significant improvement from preoperative to postoperative was confirmed in the collected scores, and a full radiographic integration was demonstrated in all feet.

Increasing grades of frontal deformities in knee osteoarthritis are not associated with ligamentous ankle instabilities

PURPOSE

Varus or valgus deformities in knee osteoarthritis may have a crucial impact on ankle subtalar range of motion (ROM) and ligamentous stability. The purpose of this study was to assess whether the grade of ankle eversion and inversion rotation stability was influenced by frontal deformities of the knee joint.

METHODS

Patients who were planned to undergo total knee arthroplasty (TKA) were prospectively included in this study. Patients were examined radiologically (mechanical tibiofemoral angle (mTFA), hindfoot alignment view angle (HAVA), anterior distal tibia angle (ADTA)) and clinically (ROM of the knee and ankle joint, foot function index, knee osteoarthritis outcome score). Ankle stability was assessed using an ankle arthrometer (AA) to test inversion/eversion (ie) rotation and anterior/posterior (ap) displacement stability of the ankle joint. Correlations were calculated using Pearson's coefficient, and differences between two independent groups of nonparametric data were calculated using a two-sided Wilcoxon signed rank test.

RESULTS

Eighty-two (varus n = 52, valgus n = 30) patients were included. The preoperative mTFA significantly correlated with the HAVA (Pearson's correlation = - 0.72, p < 0.001). Laxity testing of the ankle demonstrated that in both varus and valgus knee osteoarthritis, higher grades of mTFA did not correlate with the inversion or eversion capacity of the ankle joint. The ADTA significantly correlated with the posterior displacement of the ankle joint (cor = 0.24, p = 0.049).

CONCLUSIONS

This study could not confirm that higher degrees of frontal knee deformities in osteoarthritis were associated with increasing grades of ligamentous ankle instabilities or a reduced ROM of the subtalar joint.

LEVEL OF EVIDENCE

II.

Foot Function Index for Arabic-speaking patients (FFI-Ar): translation, cross-cultural adaptation and validation study

BACKGROUND

Foot Function Index (FFI) is a valid and reliable outcome measure, which is widely used to measure the foot and ankle functional level and disorders. Until now, no validated Arabic version of the FFI is available. This study was conducted at a tertiary care hospital in Riyadh, Saudi Arabia. The purpose of this project was to translate and adapt the FFI into Arabic and to evaluate its psychometric properties of validity and reliability.

METHODS

The study consisted of two phases. The first phase was the translation and cultural adaptation of the FFI to Arabic. The next phase involved, testing the psychometric properties of the Arabic version of the FFI on a sample of 50 consecutive participants which included internal consistency, test-retest reliability, floor and ceiling effects and construct validity.

RESULTS

The mean age of the study participants was 38 ± 12.94 years. Both the genders were evenly enrolled with 50% of the participants as male and 50% as female. Majority of them complained of plantar fasciopathy (32%) followed by pes planus (22%) and ankle sprain (18%). The scores of FFI-Ar were normally distributed, confirmed by a significant Shapiro-Wilk test. The mean value of FFI-Ar total score was 47.73 ± 19.85. There were no floor or ceiling effects seen in any of the subscales and total score. The internal consistency was good with the Cronbach's alpha value of 0.882, 0.936 and 0.850 for the pain, disability and activity limitation subscales, respectively. The reproducibility of the FFI-Ar was analysed by intra-class correlation coefficient which revealed good to excellent test-retest reliability. A significant correlation was found between FFI-Ar and SF-36 and numeric rating scale (NRS) confirming its construct validity.

CONCLUSION

The FFI-Arabic version showed good validity and reliability in patients with foot and ankle problems. This tool can be used in usual practice and research for analysing foot and ankle disorders in Arabic-speaking people.

Cross-cultural adaptation and validation of the Arabic version of the foot function index in patients with chronic lateral ankle instability

Background

The English version of the Foot Function Index (FFI) is a reliable and valid tool for measuring pain and functional instability due to chronic lateral ankle instability (CLAI). However, its use among Arabic speakers with CLAI is limited because of the unavailability of the Arabic version of the FFI (FFI-Arb). This study aimed to translate, cross-culturally adapt and validate the FFI from the original English version into Arabic.

Methods

The FFI questionnaire was translated using the Beaton guidelines. Two-hundred-and-thirty native Arabic-speaking participants with CLAI were recruited from different physiotherapy clinics in Saudi Arabia. The convergent validity of the FFI-Arb was tested using the Spearman correlation with the Arabic version Cumberland ankle instability tool (CAIT-Arab). Test-retest reliability was tested among 92 participants who completed the form again after seven days.

Results

Two-hundred-and-thirty participants were enrolled (mean age = 32.09, Standard deviation (SD) = 8.64 years old). There was excellent internal consistency for the three subscales of FFI: pain (0.95), disability (0.97), and activity limitation (0.86), as for the total score (0.98). Convergent validity was analyzed by Spearman rank correlation between the new translated versions of FFI-Arb and CAIT-Arab. The total FFI-Arb and CAIT-Arab scores were moderately correlated (rho = − 0.569; p < 0.001). Subscales of FFI-Arb, such as pain, disability, and activity limitation, were also moderately correlated with CAIT-Arab (rho = − 0.565, rho = − 0.561, rho = − 0.512; p < 0.001). The construct validity was confirmed by principal component analysis (factor analysis) showing a three-factor structure (eigenvalue 1) of FFI-Arb with a total variance of 77.3%. Test-retest reliability was excellent for the total score of the FFI-Arb and all its subscales (interclass correlation coefficient = 0.984–0.999).

Conclusions

The FFI-Arb is a reliable and valid tool for Arabic-speaking patients with CLAI. The FFI-Arb can be utilized in hospitals and clinics in Arabic speaking countries.

Adult-Acquired Flatfoot Deformity: Combined Talonavicular Arthrodesis and Calcaneal Displacement Osteotomy versus Double Arthrodesis

Background: Adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction (PTTD) is one of the most common foot deformities among adults. Hypothesis: Our study aimed to confirm that the combined procedures of calcaneal displacement osteotomy and talonavicular arthrodesis are equivalent to double arthrodesis. Methods: Between 2016 and 2020, 41 patients (13 male and 28 females, mean age of 63 years) were retrospectively enrolled in the comparative study. All deformities were classified into Stages II and III of PTTD, according to Johnson and Strom. All patients underwent isolated bony realignment of the deformity: group A (n = 19) underwent calcaneal displacement osteotomy and talonavicular arthrodesis, and group B (n = 23) underwent double arthrodesis. Measurements from the Foot Function Index-D (FFI-D) and the SF-12 questionnaire were collected, with a comparison of pre- and post-operative radiographs conducted. The mean follow-up period for patients was 3.4 years. Results: The mean FFI-D was 33.9 (group A: 34.5; group B: 33.5), the mean SF-12 physical component summary was 43.13 (group A: 40.9; group B: 44.9), and the mean SF-12 mental component summary was 43.13 (group A: 40.9; group B: 44.9). The clinical data and corrected angles showed no significant intergroup differences. Conclusion: Based on the available data, our study confirmed that the combined procedures of talonavicular arthrodesis and calcaneal shift, with preservation of the subtalar joint, can be considered equivalent to the established double arthrodesis, with no significant differences in terms of clinical and radiological outcomes.

Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms

PURPOSE

The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis.

METHODS

In this case-control study, n = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]).

RESULTS

The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI (R = 0.95, p < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85-0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10-127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI (R = 0.74, p < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint.

CONCLUSIONS

In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint.

LEVEL OF EVIDENCE

III.

Retrospective analysis of treatment strategies and clinical outcome of isolated talar dislocations

Talar dislocations are rare injuries of the foot and ankle and require quick and decisive diagnostic and therapeutic decisions. Evidence concerning the treatment and outcome of these injuries is sparse. The aim of this study was to analyze all talar dislocations of the last ten years treated in a large German level I trauma center in an effort to add to the experience on these injuries.

METHODS

All patients with a talar dislocation injury were retrospectively included. Medical reports, x-ray and computertomography scans were analyzed for the sex, age, trauma mechanism, and injury classifications as well as for the clinical outcome as measured by the Foot Function Index (FFI).

RESULTS

A total of 18 patients were included in this study: Luxatio pedis cum talo (n = 1), Luxatio tali totalis (n = 3), Luxatio pedis sub talo (n = 14). Analysis of the therapeutic algorithms revealed that only one patient was treated conservatively, the other 17 patients underwent operation. In most cases, stabilization was achieved using an external fixator and if necessary, the subtalar and talonavicular joints were temporarily stabilized using K-wires. The mean follow-up time was 4.25 years (2.05 SD) and the mean FFI-sum score 45.00 (42.26 SD). Two patients required subtalar fusion two years after the injury.

CONCLUSION

Isolated talar dislocations can have a good outcome and be effectively treated in the emergency setting by basic techniqes if neurovasular structures are not injured. Often, these injuries are associated with fractures of adjacent bones which then need complex reconstruction.

Retrospective analysis of treatment decisions and clinical outcome of Lisfranc injuries: operative vs. conservative treatment

Purpose

Lisfranc injuries are rare and often pose a challenge for surgeons, particularly in initially missed or neglected cases. The evidence on which subtypes of Lisfranc injuries are suitable for conservative treatment or should undergo surgery is low. The aim of this study was to retrospectively analyze treatment decisions of Lisfranc injuries and the clinical outcome of these patients within the last ten years.

Methods

All patients treated due to a Lisfranc injury in a German level I trauma centre from January 2011 until December 2020 were included in this study. Radiologic images and medical data from the patient files were analyzed concerning the classification of injury, specific radiologic variables, such as the Buehren criteria, patient baseline characteristics, and patient outcome reported with the Foot Function Index (FFI).

Results

Ninety-nine patients were included in this study (conservative = 20, operative = 79). The overall clinical outcome assessed by the FFI was good (FFI sum 23.93, SD 24.93); patients that were identified as suitable for conservative treatment did not show inferior functional results. Qualitative radiological factors like the grade of displacement and the trauma mechanism were more strongly associated with the decision for surgical treatment than quantitative radiologic factors such as the distance from the first to the second metatarsal bone.

Conclusion

If the indication for conservative or operative treatment of Lisfranc injuries is determined correctly, the clinical outcome can be comparable. These decisions should be based on several factors including quantitative and qualitative radiologic criteria, as well as the trauma mechanism.

Clinical and Functional Outcomes of Peroneus Longus to Brevis Tendon Transfer

BACKGROUND

Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet.

METHODS

Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests.

RESULTS

Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees).

CONCLUSION

Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function

PURPOSE

The aim of this study was to demonstrate, whether the degree of limb alignment correction in varus knee osteoarthritis correlated with an increase in ankle symptoms and to define a cut-off value concerning the degree of correction above which to expect ankle problems.

METHODS

Ninety-nine consecutive patients with preoperative intraarticular varus knee deformities who underwent total knee arthroplasty were retrospectively analyzed. Patients were examined clinically (Knee Society Score, Forgotten Joint Score, Foot Function Index, Range of Motion of the knee and ankle joint, pain scales) as well as radiologically. The mean follow-up time was 57 months.

RESULTS

The degree of operative limb alignment correction strongly correlated with the Foot Function Index (R = 0.91, p < 0.05). Given this, higher degrees of knee malalignment corrections were associated with worse postoperative outcomes in the knee and ankle joint-despite postoperative improved joint line orientations. Subsequently, a cut-off value for arthritic varus deformities (14.5°) could be calculated, above which the prevalence of ankle symptoms increased manifold [OR = 15.6 (3.2-77.2 95% CI p < 0.05)]. Furthermore, ROM restrictions in the subtalar joint were associated with a worse outcome in the ankle joint.

CONCLUSIONS

When correcting excessive intraarticular varus knee osteoarthritis, surgeons have to be aware of possible postoperative ankle symptoms and should consider ankle deformities or decreased subtalar ROM before operative procedures.

LEVEL OF EVIDENCE

III.

Shear wave elastography for treatment monitoring of plantar fasciitis

BACKGROUND

Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development.

METHODS

Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe.

RESULTS

A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002).

CONCLUSIONS

A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.

Thai version of the foot function index: a cross-cultural adaptation with reliability and validity evaluation

Background

The study aimed to translate the foot function index (FFI) questionnaire to Thai and to determine psychometric properties of the questionnaire among individuals with plantar foot complaints.

Methods

The Thai version of the FFI (FFI-Th) was adapted according to a forward and backward translation protocol by two independent translators and analyzed by a linguist and a committee. The FFI-Th was administered among 49 individuals with plantar foot complaints to determine internal consistency, reliability, and validity. Cronbach’s alpha and the Intraclass Correlation Coefficient (ICC_3,1) were used to test the internal consistency and test-retest reliability. The Principal Component Analysis with varimax rotation method was used to test the factor structure and construct validity. Furthermore, the criterion validity was tested using Pearson’s correlation coefficient (r_p) between the FFI-Th and the visual analogue pain scale (pain-VAS) as well as the EuroQol five-dimensional questionnaire (EQ-5D-5L).

Results

The FFI-Th showed good to excellent internal consistency and test-retest reliability in the total score, pain, disability, and activity limitation subscales. The Principal Component Analysis produced 4 principal factors from the FFI-Th items. Criterion validity of the FFI-Th total score showed moderate to strong correlations with pain-VAS and EQ-5D-5L, and EQ-VAS scores.

Conclusion

The FFI-Th was a reliable and valid questionnaire to assess the foot function in a Thai population.

Trial registration

NCT03161314 (08/05/2017).

Talus Secundarius: Case Series

BACKGROUND

Talus secundarius is a very rare accessory bone at the lateral border of the foot. It is attached via a synchondrosis or small synostosis to the lateral aspect of the talar body and has additional facets to the tip of the lateral malleolus and the superior aspect of the calcaneus.

METHODS

Over a period of 8 years, we have seen 5 patients with 6 cases of talus secundarius with an average age of 17 years at first presentation to the senior author. One ossicle was an incidental finding and completely asymptomatic. In the other 5 cases, the average duration of symptoms was 21 months at that time. In 3 cases, additional accessory bones were seen around the talus.

RESULTS

The average size of the ossicles was 18 × 12 × 8 mm. Complete removal resulted in considerable pain reduction without further functional restriction in 4 cases. Two cases (1 asymptomatic, 1 with mild intermittent symptoms) were treated nonoperatively. The average Foot Function Index improved from 22.6 to 4.8 in all patients and from 31.0 to 4.5 in the patients treated with excision for symptomatic talus secundarius (P < .01).

CONCLUSION

The knowledge of accessory bones at the foot is important, as missed diagnosis may lead to prolonged course of pain and unnecessary protection in the affected patients. Resection of symptomatic ossicles substantially reduces pain, but patients have to be counseled that some symptoms may prevail in a congenital deformity.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Functional limitations after lateral column lengthening osteotomy of the calcaneus are associated with lower quality of life

PURPOSE

The purpose of this study was to quantify limitations in sagittal ankle range of motion (ROM) at least two years after lateral column lengthening osteotomy of the calcaneus (LLC) and their implications regarding quality of life.

METHODS

Fifteen patients with a mean follow-up of 80 ± 27 months after LLC and 15 age-matched healthy persons participated in this study. Ankle joint complex ROM in plantarflexion and dorsiflexion was measured bilaterally using a goniometer and fluoroscopy (patients only). Quality of life was assessed using the short-form health questionnaire (SF36). Differences in ROM parameters (for the tibiotalar and subtalar joint) between sides (affected vs. unaffected) and between groups (patient vs. controls) and the relationship between ROM parameters and quality of life scores were assessed.

RESULTS

ROM of the ankle joint complex on the affected side in patients was smaller than on the contralateral side (goniometer and fluoroscopy) and in healthy persons (goniometer; all P < .05). Among patients, SF36 total and pain scores, respectively, correlated with ROM of the subtalar joint (fluoroscopy; R = 0.379, P = 0.039 and R = 0.537, P = 0.001). Among patients and healthy persons, those with smaller dorsiflexion (goniometer) had lower quality of life scores.

CONCLUSIONS

The smaller sagittal ROM of the affected ankle joint complex compared with the contralateral foot and healthy controls was mainly explained by limitations in the tibiotalar joint. Because of its association with quality of life, ROM should be considered in the treatment and rehabilitation planning in patients who are candidates for LLC.

Self-perceived foot function and pain in children and adolescents with flexible flatfeet - Relationship between dynamic pedobarography and the foot function index

BACKGROUND

There is considerable debate as to which parameters to include in the assessment of paediatric flatfeet. Dynamic pedobarography is an objective, dynamic method to measure foot function. Information about its associations to patient-reported measures may help to focus on the most relevant parameters.

RESEARCH QUESTION

What is the association between the Foot Function Index and pedobarographic assessments in flatfeet of children and adolescents?

METHODS

A consecutive clinical case series of 51 participants with idiopathic flexible flatfeet aged 7-17 years underwent barefooted pedobarography during gait and completed the Foot Function Index Questionnaire. Pedobarographic data categorized into values related to area, peak pressure and force with respect to the hind-, mid- and forefoot were extracted. To test the associations between the Foot Function Index and pedobarographic assessments, bivariate partial correlations were tested and contact times served as co-variate.

RESULTS

Several significant associations between peak pressure or forces beneath the hindfoot, midfoot and hallux to self-perceived function were found (|rho| = 0.28-.46, P < 0.05). In particular, reduced peak forces and pressures underneath the hindfoot and hallux, a lateral shift (smaller medio-lateral ratios) of hindfoot pressure and force and a medial shift (larger medio-lateral ratios) of midfoot pressure seem to be negatively associated with foot-related disability. Overall, less evidence was noted for associations to pain scores. Area related outcomes (including the arch index) contained no information for function while a larger BMI was the strongest thread for disability (rho = 0.42, P = 0.002) and pain (rho = 0.31, P = 0.027).

SIGNIFICANCE

When using pedobarography for the assessment of flexible flatfeet of children and adolescents, less attention should be paid to area related measurements which do not provide information about self-perceived function or disability. Instead, peak pressures or forces in the hind- or midfoot or beneath the hallux may be focussed. Weight reductions are potentially an effective strategy to reduce or prevent symptoms.

Shear Wave Elastography (SWE) for the Evaluation of Patients with Plantar Fasciitis

RATIONALE AND OBJECTIVES

The current imaging standard for diagnosing plantar fasciitis is B-Mode ultrasound (B-US). The aim of this study was to determine the diagnostic potential of Shear Wave Elastography (SWE) and the correlation of clinical scores to elastographic parameters.

MATERIALS AND METHODS

Diagnostic case-control study with n = 82 plantar fascia (PF). PF were divided into three subgroups: (1) symptomatic PF (n = 39); (2) control group of unilateral asymptomatic PF (n = 23); (3) bilateral asymptomatic PF (n = 20). Reference standard for positive findings in B-US was a PF thickness greater than 4 mm. For SWE tissue elasticity (Young's modulus kPa; shear wave speed m/s) was measured at Location 1: directly at the calcaneus; Location 2: +1 cm distal of the calcaneus and Location 3: central part of the calcaneus. Sensitivity, specificity, and diagnostic accuracy as well as correlation to American Orthopaedic Foot and Ankle Score (AOFAS) and Food Functional Index (FFI) were determined.

RESULTS

Symptomatic PF are thicker (4.2 mm, n = 39) than asymptomatic (3.0 mm, n = 43) (p < 0.001). Thickness of the PF (n = 82) correlated poorly to clinical scores (p = 0.001): FFI-pain (r = 0.349); FFI-function (r = 0.381); AOFAS (r = -0.387). Cut-off point for positive SWE finding was 51.5 kPa (4.14 m/s). Symptomatic PF (31.9 kPa, 3.26 m/s, n = 39) differ significantly from asymptomatic PF (93.3 kPa, 5.58 m/s, n = 43) with significant differences at L1 between all groups (p < 0.001). Correlation between Young's modulus (n = 82) and clinical scores was strong (p < 0.001): FFI-pain (r = -0.595); FFI-function (r = -0.567); AOFAS (r = 0.623,). B-US: sensitivity (61%), specificity (95%); SWE sensitivity (85%), specificity (83%). The combination of SWE and B-US increases the sensitivity (100%) with a diagnostic accuracy of 90%.

CONCLUSION

Based on our results, we could show that SWE can improve the diagnostic accuracy in patients with plantar fasciitis compared to B-US.

LEVEL OF EVIDENCE

II.

Nerve decompression according to A.L. Dellon in Morton's neuroma - A retrospective analysis

BACKGROUND

First reported by Dellon et al. in 1992, nerve decompression by dissecting the deep transversal intermetatarsal ligament through a dorsal incision appears to be a reliable method for treating Morton's neuroma by addressing its underlying pathomechanism, since it should rather be considered as Morton's entrapment. As there are no current studies dealing with Dellon's surgical technique, we carried out a retrospective analysis with the aim of showing that nerve decompression is an effective method to treat Morton's neuroma, and one that considers its true pathology.

MATERIALS AND METHODS

All patients with a clinical diagnosis of Morton's neuroma, verified by MRI and treated by nerve decompression were included in this study in the years from 2010 to 2018 at our department. Follow-up was performed at least six months post-intervention; pain and function history were ascertained using the VAS (visual analogue scale) score and the German foot function index. Skin sensitivity testing was performed using Semmes-Weinstein monofilaments.

RESULTS

A total of 12 patients were treated and followed-up during the study period. Postoperatively, there was significant improvement in the values of the VAS score both under strain (p-value: 0.0021) and at rest (p-value: 0.0062), as well as in the foot function index (p-value: 0.0022). There was no significant difference in skin sensitivity of the innervation areas of the interdigital nerves of the affected foot compared with the healthy reference foot (p-value: 0.0968).

CONCLUSION

Dellon's decompression method yielded a highly positive outcome, and based on our findings, we consider it a reliable, technically simple and promising approach to treat Morton's neuroma. It is a minimally invasive technique that addresses the pathomechanism of peripheral nerve entrapment and has a low rate of complication as well as rapid patient recovery.

Surgical Treatment of Talar Neck and Body Fractures: Mid-Term Results of 24 Cases

BACKGROUND

Talar neck and body fractures are rare. Major posttraumatic complications with a potential reduction in the quality of life are arthrosis and necrosis due to the specific vascular supply. The aim of the study was to evaluate mid-term results of surgery for talar fractures of neck and body. Parameters that potentially affected/influenced treatment outcomes were analysed exploratively.

METHODS

24 patients with 24 talar neck and body fractures (Marti type II n = 9, type III n = 12, type IV n = 3) were retrospectively examined for radiological and clinical functional outcomes. The independent parameters evaluated included age (< 40, ≥ 40 years), sex (male, female), general overall extent of injury (polytrauma/multiple injuries/multiple fractures of the extremities, additional injuries to the same foot, isolated talus fracture), soft tissue damage (open, closed), surgical latency (< 6, ≥ 6 h), fracture classification/displacement (undisplaced [= Marti II], displaced [= Marti III, IV]) and fracture type (talar body, neck fracture). The potential influencing parameters were analysed by univariate analyses.

RESULTS

With an average follow-up of 8.7 years (1,25 - 16 years) the AOFAS score was 71.4 ± 22.9 points, the Foot Function Index score 35.9 ± 28.3 points; the physical and mental component summary scores of the Short Form 36, version 2, was 43.8 ± 10.9 and 47.4 ± 13.6 points (mean ± standard deviation), respectively. Thus, the patient reported physical health of the patients was slightly reduced compared to the German population, while the mental health remained largely unaffected. Two patients developed partial avascular necrosis (8%), 10 patients developed osteoarthritis (42%). Of the independent parameters, only the general overall extent of injury showed a significant influence on osteoarthritis (p = 0.002). In the evaluation of undisplaced (n = 9) and displaced (n = 15) fractures, surgical treatment after more than 6 hours did not result in a worse outcome.

CONCLUSION

The clinical outcome of internal fixation of talar neck and body fractures can be classified as good. In the study group, there was no correlation between the occurrence of arthrosis and the Marti fracture classification.

Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years

BACKGROUND

We retrospectively evaluated the mid-term results of surgery for talar process fractures (lateral and posterior processes) and exploratively analyzed parameters that potentially impact treatment outcomes.

METHODS

Fifteen patients who underwent internal fixation (January 2000 to December 2015) were examined for radiological and clinical functional outcomes. The independent parameters evaluated were age, sex, extent of general injury, soft-tissue damage, surgical latency, and fracture type.

RESULTS

All fractures healed completely. Three patients developed osteoarthritis. The American Orthopaedic Foot and Ankle Society Ankle/Hindfoot Scale score was 79.5±18.6, the Functional Foot Index score was 31.1±31.4, and the physical and mental component summary scores of the Short Form 36, version 2, were 46.6±11.8 and 50.3±9.1, respectively. No influence on the above scores was determined.

CONCLUSIONS

The clinical outcomes of internal fixation of talar process fractures were good. Delayed surgical treatment (≥14days) did not significantly lead to poorer outcomes in our patients.

The circular arc shaped nail for fixing the tibiotalocalcaneal arthrodesis. After clinical results

BACKGROUND

Tibiotalocalcaneal arthrodesis is commonly considered a salvage option for a variety of hindfoot disorders involving the ankle and subtalar joint mostly with concomitant deformity. Retrograde interlocking nailing represents one of the biomechanically most stable fixation modes after reduction of hindfoot geometry. The considerable complications, non-union and revision rates at a moderate outcome reported even with modern retrograde nails underscore the idea that the development of an optimized retrograde nail may be warranted.

METHODS

A novel circular shaped nail was designed with a perfect fit to the reamed canal and the implant geometry which respects physiologic hindfoot anatomy and alignment. The present clinical series reports the experience and the clinical and radiographic outcomes after application of the implant in the first 30 consecutive patients. Assessments included validated versions of the AOFAS Ankle/Hindfoot Score and the Foot Function Index.

RESULTS

Anatomical alignment was achieved and maintained in 29/30 cases with a single case of later loss of reduction due to a technical error which led to surgical reintervention two months after the index procedure. The overall union rate reached 93%. Two non-unions (one ankle, one subtalar joint) were observed without necessitating further surgery. Three superficial surgical site infections were registered which made a local flap coverage necessary in two patients due to local skin break-down. No deep infection occurred. There were 2 implant removals, one was not related to hindfoot nailing. At the time of follow-up, the AOFAS Ankle/Hindfoot Score was 57 (median) from a maximum of 86 points. The self-assessment via the Foot Function Index improved from preoperative 155 points to 62.5 postoperatively (median values, p<0.001, Wilcoxon test).

CONCLUSION

On the basis of our results, which saw a high rate of successful fusion and patient satisfaction and where the hindfoot reduction was maintained until definite healing in the vast majority of cases, the novel circular arc nail represents a viable and safe option for tibiotalocalcaneal arthrodesis with a low complication rate.

Systematic review of the psychometric properties of patient-reported outcome measures for rheumatoid arthritis in the foot and ankle

OBJECTIVE

To identify self-reported outcome measures specific to the foot and ankle in patients with rheumatoid arthritis and to investigate the methodological quality and psychometric properties of these measures.

METHOD

A systematic review focusing on patients with rheumatoid arthritis.

SETTING

The search was conducted in the PubMed, SCOPUS, CINAHL, PEDro and Google Scholar databases, based on the following inclusion criteria: population (with rheumatoid arthritis) > 18 years; psychometric or clinimetric validation studies of patient-reported outcomes specific to the foot and ankle, in different languages, with no time limit. Two of the present authors independently assessed the quality of the studies located and extracted the relevant data. Terwee's criteria and the COSMIN checklist were employed to ensure adequate methodological quality.

RESULTS

Of the initial 431 studies considered, 14 met the inclusion criteria, representing 7,793 patients (56.8 years). These instruments were grouped into three dimensions (pain, perceived health status and quality of life and disability). The time to complete any of the PROMs varies around 15 minutes. PROMs criterias with the worst scores by COSMIN, 92.85% and 85.71% were criterion validity, measurement error, internal consistency and responsiveness. 28.57% of PROMs were compared with the measurement properties.

CONCLUSION

the Self-Reported Foot and Ankle Score achieved the highest number of positive criteria (according to Terwee and COSMIN), and is currently the most appropriate for patients with Rheumatoid arthritis.

Measurement properties of PROMIS short forms for pain and function in orthopedic foot and ankle surgery patients

PURPOSE

To examine the measurement properties of the German PROMIS short forms for pain intensity (PAIN), pain interference (PI) and physical function (PF) in orthopedic foot and ankle surgery patients.

METHODS

Patient-rated outcomes were collected from consecutive patients of our foot and ankle registry before and 6 months after surgery. Measurement properties were tested according to the COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN). The German Foot Function Index (FFI-D) served as a legacy measure.

RESULTS

748 patients were included in our cross-sectional sample. Longitudinal and test-retest data were available for 202 and 65 patients, respectively. Construct validity of all short forms was good. All Cronbach's α and intraclass correlation coefficients were > 0.7. The smallest detectable change (SDC) was highest for PF (8.9) and lowest for PI (6.5). Minimal important change was 4 to 5 points and thus smaller than SDC for all instruments. We observed a baseline ceiling effect for PF. PI showed insufficiently correlated change scores with FFI-D disability change scores, and therefore failed the responsiveness testing.

CONCLUSION

Our study showed some adequate psychometric properties, but also certain aspects regarding interpretability and responsiveness that researchers must be aware of when using PROMIS short forms of pain and function in foot and ankle surgery patients.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength and improved dorsal extension in forefoot overload syndrome

BACKGROUND

Gastrocnemius recession (GR) has been introduced for treatment of forefoot overload syndrome (FOS). We questioned if GR leads to an altered forefoot load and weakness of plantarflexors in those patients.

METHODS

26 patients suffering from FOS and gastrocnemius tightness underwent GR. A strength power analysis of plantar flexors and a pedobarography was performed. Clinical outcome was measured by Foot Function Index (FFI).

RESULTS

Plantarflexors are impaired about 40% six weeks and around 10% 24 weeks following GR compared to the contralateral side. Patients experienced a pain relief and an improvement of ankle dorsiflexion from 2° to 15°. An increased contact time of the heel (15%) and a shift of metatarsal plantar pressure from lateral to medial could be demonstrated.

CONCLUSIONS

This study suggests that GR leads to pain reduction by an increase in heel contact time and a shift of gait line to medial in patients with a FOS. Despite, a temporary impairment of muscle strength has to be considered.

Measurement properties of the most commonly used Foot- and Ankle-Specific Questionnaires: the FFI, FAOS and FAAM. A systematic review

PURPOSE

In the foot and ankle literature, a wide range of patient-reported outcome measures (PROMs) is used, however, consensus as to which PROMs are preferred is lacking. Selection of a PROM is among other reasons, often based on measurement properties without considering the methodological quality of the studies that evaluate these measurement properties. The aim of current study was first to identify the most frequently used foot and ankle-specific PROMs in recent orthopaedic foot and ankle literature, and second to conduct a systematic review to synthesize and critically appraise the measurement properties of these PROMS.

METHODS

Six PubMed indexed journals focussing on foot and ankle research were screened to identify most commonly used foot and ankle-specific PROMs over a 2 year period (2015-2016). Subsequently, a systematic literature search was performed in PubMed, EMBASE, SPORTDiscus and Scopus to identify relevant studies on their measurement properties. Methodological quality assessment was performed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist, criteria for good measurement properties were applied, and a level of evidence was determined for the measurement properties of each domain of the questionnaires.

RESULTS

The three most frequently reported PROMs were the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Activity Measure (FAAM). Among 2046 unique citations, 50 studies were included evaluating these PROMs. Evidence to support the measurement properties of the FFI was mainly lacking due to poor methodological quality. More evidence was available for the measurement properties of the FAOS and the FAAM, but overall evidence supporting all measurement properties is not yet sufficient.

CONCLUSION

The best available evidence retrieved in this review showed that the FAOS and the FAAM are promising outcome measures for evaluation of patients with foot and ankle conditions, but their shortcomings should be taken into account when interpreting results in clinical setting or trials.

LEVEL OF EVIDENCE

I.

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Prospective Cohort Study

Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in the treatment of osteochondral lesions of the talus. Previous studies have presented promising short-term results for AMIC talar osteochondral lesion repair, a 1-step technique using a collagen type I/III bilayer matrix. The aim of the present study was to investigate the mid-term effects. The 5-year results of a prospective cohort study are presented. All patients underwent an open AMIC procedure for a talar osteochondral lesion. Data analysis included general demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1 and 5 years after surgery. The primary outcome variable was the longitudinal effect of the procedure, and the influence of various variables on the outcome was tested. Of 47 consecutive patients, 21 (45%) were included. Of the 21 patients, 8 were female (38%) and 13 were male (62%), with a mean age of 37 ± 15 (range 15 to 62) years and a body mass index of 26 ± 5 (range 20 to 38) kg/m². The defect size was 1.4 ± 0.9 (range 0.2 to 4.0) cm². The FFI-D decreased significantly from preoperatively to 1 year postoperatively (56 ± 18 versus 33 ± 25; p = .003), with a further, nonsignificant decrease between the 1- and 5-year follow-up examination (33 ± 25 versus 24 ± 21; p = .457). Similar results were found for the FFI-D subscales of function and pain. The body mass index and lesion size showed a positive correlation with the preoperative FFI-D overall and subscale scores. These results showed a significant improvement in pain and function after the AMIC procedure, with a significant return to sports by the 5-year follow-up point. The greatest improvement overall was seen within the first year; however, further clinical satisfaction among the patients was noticeable after 5 years.

Using the Oxford Foot Model to determine the association between objective measures of foot function and results of the AOFAS Ankle-Hindfoot Scale and the Foot Function Index: a prospective gait analysis study in Germany

OBJECTIVE

After cross-cultural adaption for the German translation of the Ankle-Hindfoot Scale of the American Orthopaedic Foot and Ankle Society (AOFAS-AHS) and agreement analysis with the Foot Function Index (FFI-D), the following gait analysis study using the Oxford Foot Model (OFM) was carried out to show which of the two scores better correlates with objective gait dysfunction.

DESIGN AND PARTICIPANTS

Results of the AOFAS-AHS and FFI-D, as well as data from three-dimensional gait analysis were collected from 20 patients with mild to severe ankle and hindfoot pathologies.Kinematic and kinetic gait data were correlated with the results of the total AOFAS scale and FFI-D as well as the results of those items representing hindfoot function in the AOFAS-AHS assessment. With respect to the foot disorders in our patients (osteoarthritis and prearthritic conditions), we correlated the total range of motion (ROM) in the ankle and subtalar joints as identified by the OFM with values identified during clinical examination 'translated' into score values. Furthermore, reduced walking speed, reduced step length and reduced maximum ankle power generation during push-off were taken into account and correlated to gait abnormalities described in the scores. An analysis of correlations with CIs between the FFI-D and the AOFAS-AHS items and the gait parameters was performed by means of the Jonckheere-Terpstra test; furthermore, exploratory factor analysis was applied to identify common information structures and thereby redundancy in the FFI-D and the AOFAS-AHS items.

RESULTS

Objective findings for hindfoot disorders, namely a reduced ROM, in the ankle and subtalar joints, respectively, as well as reduced ankle power generation during push-off, showed a better correlation with the AOFAS-AHS total score-as well as AOFAS-AHS items representing ROM in the ankle, subtalar joints and gait function-compared with the FFI-D score.Factor analysis, however, could not identify FFI-D items consistently related to these three indicator parameters (pain, disability and function) found in the AOFAS-AHS. Furthermore, factor analysis did not support stratification of the FFI-D into two subscales.

CONCLUSIONS

The AOFAS-AHS showed a good agreement with objective gait parameters and is therefore better suited to evaluate disability and functional limitations of patients suffering from foot and ankle pathologies compared with the FFI-D.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

No superior surgical treatment for secondary osteochondral defects of the talus

PURPOSE

The purpose of this systematic review was to identify the most effective surgical treatment for talar osteochondral defects after failed primary surgery.

METHODS

A literature search was conducted to find studies published from January 1996 till July 2016 using PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL. Two authors screened the search results separately and conducted quality assessment independently using the Newcastle-Ottawa scale. Weighted success rates were calculated. Studies eligible for pooling were combined.

RESULTS

Twenty-one studies with a total of 299 patients with 301 talar OCDs that failed primary surgery were investigated. Eight studies were retrospective case series, twelve were prospective case series and there was one randomized controlled trial. Calculated success percentages varied widely and ranged from 17 to 100%. Because of the low level of evidence and the scarce number of patients, no methodologically proper meta-analysis could be performed. A simplified pooling method resulted in a calculated mean success rate of 90% [CI 82-95%] for the osteochondral autograft transfer procedure, 65% [CI 46-81%] for mosaicplasty and 55% [CI 40-70%] for the osteochondral allograft transfer procedure. There was no significant difference between classic autologous chondrocyte implantation (success rate of 59% [CI 39-77%]) and matrix-associated chondrocyte implantation (success rate of 73% [CI 56-85%]).

CONCLUSIONS

Multiple surgical treatments are used for talar OCDs after primary surgical failure. More invasive methods are administered in comparison with primary treatment. No methodologically proper meta-analysis could be performed because of the low level of evidence and the limited number of patients. It is therefore inappropriate to draw firm conclusions from the collected results. Besides an expected difference in outcome between the autograft transfer procedure and the more extensive procedures of mosaicplasty and the use of an allograft, neither a clear nor a significant difference between treatment options could be demonstrated. The need for sufficiently powered prospective investigations in a randomized comparative clinical setting remains high. This present systematic review can be used in order to inform patients about expected outcome of the different treatment methods used after failed primary surgery.

LEVEL OF EVIDENCE

IV.

Translation and cultural adaptation of the revised foot function index for the Portuguese language: FFI-R Brazil

BACKGROUND

The revised foot function index (FFI-R) is used to evaluate the functionality of patients with conditions that affect the feet. The objective here was to produce the Brazilian Portuguese version of this index.

DESIGN AND SETTING

Translation and validation study conducted at the Federal University of São Paulo, Brazil.

METHODS

The translation and cultural adaptation process involved translation by two independent translators, analysis by an expert committee, back translation into the original language, analysis by the expert committee again and a pretest. The Portuguese-language version was administered to 35 individuals with plantar fasciitis and metatarsalgia to determine their level of understanding of the assessment tool.

RESULTS

Changes were made to the terms and expressions of some original items to achieve cultural equivalence. Terms not understood by more than 10% of the sample were altered based on the suggestions of the patients themselves.

CONCLUSION

The translation and cultural adaptation of the FFI-R for the Portuguese language were completed and the Brazilian version was obtained.

Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up

The isolated gastrocnemius contracture present in neurologic healthy patients results in a significant limitation of ankle dorsiflexion causing pathologic gait patterns and a greater risk of further foot disorders. Gastrocnemius recession is an established procedure to increase ankle dorsiflexion. However, little evidence is available of the use of gastrocnemius recession in these patients. Complication rates, recurrence of gastrocnemius contracture, and the prevalence of additional foot disorders needs further evaluation. A study group of 64 operated limbs undergoing gastrocnemius recession was evaluated to determine the prevalence of foot disorders, pre- and postoperative ankle dorsiflexion, and incidence of complications. A subgroup of 15 (23.4%) patients without additional operative procedures was examined regarding ankle dorsiflexion, strength (Janda method), sensitivity in the operated limb, and the pre- and postoperative Foot Function Index scores. The prevalence of foot disorders showed pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At 31 months of follow-up, the patients had significantly benefited from increased ankle dorsiflexion of 13.3° ± 7.9° (p < .001). Postoperatively, 16% patients experienced complications. In the subgroup of 15 patients, the follow-up examination after 44 months showed ankle dorsiflexion of 14° ± 7.1°. The plantarflexion strength was 4 of 5 (Janda method). The Foot Function Index score had improved significantly from 65.4 ± 26.5 points to 33.4 ± 19.5 points (p < .001). Patients with isolated gastrocnemius contracture seem to have a high prevalence of symptomatic foot disorders. At a mid-term follow-up examination, gastrocnemius recession (Strayer) was shown to be an effective procedure to significantly improve ankle dorsiflexion, functionality, and pain symptoms. More attention should be given to the development of postoperative complications.

Dynamic plantar pressure distribution, strength capacity and postural control after Lisfranc fracture-dislocation

Substantial progress has been made in the operative treatment of Lisfranc fractures, however, the prognosis remains poor. We hypothesized that Lisfranc injuries change the postural control and muscle strength of the lower limb. Both are suggested to correlate with the clinical outcome and quality of life. 17 consecutive patients suffering from a Lisfranc fracture dislocation were registered, underwent open reduction and internal fixation and were followed-up for 50.5±25.7months (Mean±SDM). Biomechanical analysis of muscle strength capacities, postural control and plantar pressure distribution was assessed >6 month postoperatively. Results were correlated to clinical outcome (AOFAS, FFI, Pain, SF-36). The isokinetic assessment revealed a significant reduction in plantar flexor and dorsal extensor peak torque of the injured limb compared to the uninjured limb. The dorsal extensor peak torque thereby correlated well with clinical outcome. Altered postural control was evident by a significant reduction in unilateral stance time, from which we calculated a strong correlation between stance time and the isokinetic strength measurement. Plantar pressure measurements revealed a significant reduction in peak pressure under the midfoot and of Force-Time Integral beneath the second metatarsal. Sufficient rehabilitation is crucial to the clinical outcome following anatomical open reduction of Lisfranc fracture-dislocation. The present study supports a rehabilitation approach focussing on restoring proprioception and calf muscular strength including isometric exercises of the dorsal extensors.

The reliability and validity of the Korean version of the foot function index for patients with foot complaints

[Purpose] The purpose of this study was to establish the reliability and validity of the Foot Function Index translated into Korean for use in patients with plantar fasciitis and foot/ankle fracture. [Subjects and Methods] Thirty-six subjects with foot complaints, 14 males and 22 females, participated in the study. Reliability was determined by using the intra-class correlation coefficient and Cronbach’s alpha for internal consistency. Validity was examined by correlating Foot Function Index scores with the Short Form-36 and the Visual Analog Scale scores. [Results] Test-retest reliability was 0.90 for the pain subscale, and 0.94 and 0.91 for the disability and activity limitation subscales, respectively. The criterion-related validity was established by comparison with the Korean version of the Short Form-36 and Visual Analog Scale. [Conclusion] The Korean version of the Foot Function Index was shown to be a reliable and valid instrument for assessing foot complaints.

Age- and Sex-Related Normative Data for the Foot Function Index in a German-Speaking Cohort

BACKGROUND

Despite increasing popularity of the Foot Function Index (FFI), normative values are still unavailable for this self-administered score. This study was designed to generate age- and sex-related normative values for the FFI-total and for both subscales FFI-pain and FFI-disability.

METHODS

We used the cross-cultural adapted and validated German version of the FFI to generate a data pool using the results of 625 individuals, including staff and visitors to our hospital and excluding persons scheduled for foot surgery or in after-treatment.

RESULTS

Mean values for FFI-total were calculated: 15.3 points (95% confidence interval [CI], 13.3-16.9), 14.9 points for FFI-pain (CI, 13.3-16.5), and 15.6 for FFI-disability (CI, 13.8-17.4). Results showed higher values for FFI-total, FFI-pain, and FFI-disability for individuals older than 40 years. In general, normative values showed a tendency for higher values with age. A slightly inconsistent distribution over different age groups with a peak for individuals in their 40s and 50s was observed, especially for FFI-pain. Men had better scores than women. Individuals with previous surgery showed lower scores in their respective score.

CONCLUSIONS

Our data calculated normative values for a German-speaking cohort for FFI-total as well as for both subscales FFI-pain and FFI-disability. Our data quantified the increase of FFI-total, FFI-pain, and FFI-disability normative values with age but also showed a slightly inconsistent distribution of normative values over all age groups. We demonstrated higher normative values for women and slightly higher normative values for individuals with previous foot or ankle surgery.

LEVEL OF EVIDENCE

II, prospective comparative study.