Leonard J. Goldner Award 2009. Intraoperative pedobarography leads to improved outcome scores: a Level I study

Developing a core outcome set for foot and ankle disorders in rheumatic and musculoskeletal diseases: A scoping review and report from the OMERACT 2022 foot and ankle special interest group session

OBJECTIVES

Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area.

METHODS

A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1.

RESULTS

Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods.

CONCLUSION

Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains.

Weight-bearing cone-beam computed tomography in the foot and ankle specialty: where we are and where we are going - an update

Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years. Weight-bearing CBCT allows clinicians to obtain weight-bearing images that can be viewed in all three planes and to construct three-dimensional models, similar to those constructed from traditional CT scans, as well as exposing patients to less radiation than do traditional CT scans. This technology has revolutionized diagnoses, improving the understanding of various lesions and surgical planning in the foot and ankle specialty. Ongoing studies of the use of weight-bearing CBCT in foot and ankle surgery are focused on fully automated and semi-automated three-dimensional measurements, as well as bone segmentation, mapping of the distances/orientation of the joints, and the production of customized implants. The aims of this review article are to show the evolution of this emerging tool in the foot and ankle specialty, to update those in related specialties on its use in current clinical practice, and to indicate where the research community is heading.

In Vivo Plantar Pressures in Adult-Acquired Flatfoot Compared to Control Using an Intraoperative Pedobarographic Device

BACKGROUND

Intraoperative pedobarography has the potential to aid surgical decisions, but no parameters exist to guide its use.

QUESTIONS/PURPOSES

This study compared supine plantar pressures between flatfoot patients and controls using a previously validated intraoperative pedobarographic device and examined associations between supine, walking, and standing plantar pressures.

METHODS

Ten preoperative patients with stage II adult-acquired flatfoot deformity (AAFD) were compared to ten healthy controls. Supine plantar pressures were assessed using the pedobarographic device. Standing and walking plantar pressures were assessed with an EMED-XT sensor array (Novel). Maximum force (MF) and peak pressure (PP) were calculated for nine anatomical foot regions adjusting for age and BMI.

RESULTS

No differences in plantar pressures were found between flatfoot patients and controls in the supine or standing positions. During walking, flatfoot patients had greater MF of the first, second, and third metatarsals (p ≤ 0.018) and greater PP of the first and second metatarsals than controls (p ≤ 0.010). Supine MF and PP were both strongly positively correlated with their respective pressure measurements for both standing and walking in multiple foot regions (p ≤ 0.05, all analyses). Correlations in the first metatarsal region were generally weak and not statistically significant.

CONCLUSION

This device did not show differences in supine plantar pressures of flatfoot patients and healthy subjects, highlighting the limitations of intraoperative devices in guiding flatfoot correction. The differences between flatfoot and controls during walking and the correlations between supine and walking conditions suggest that dynamic plantar pressures are a more useful parameter in guiding flatfoot reconstruction.

Combination of pedCAT® for 3D Imaging in Standing Position With Pedography Shows No Statistical Correlation of Bone Position With Force/Pressure Distribution

pedCAT(®) (CurveBeam, Warrington, PA) is a technology for 3-dimensional (3D) imaging with full weightbearing that has been proved to exactly visualize the 3D bone position. For the present study, a customized pedography sensor (Pliance; Novel, Munich, Germany) was inserted into the pedCAT(®). The aim of our study was to analyze the correlation of the bone position and force/pressure distribution. A prospective consecutive study of 50 patients was performed, starting July 28, 2014. All patients underwent a pedCAT(®) scan and simultaneous pedography with full weightbearing in the standing position. The following parameters were measured on the pedCAT(®) image for the right foot by 3 different investigators 3 times: lateral talo-first metatarsal angle, calcaneal pitch angle, and minimum height of the fifth metatarsal base, second to fifth metatarsal heads, and medial sesamoid. From the pedography data, the following parameters were defined using the standardized software algorithm: midfoot contact area, maximum force of midfoot, maximum force of midfoot lateral, maximum force of entire foot, and maximum pressure of first to fifth metatarsal. The values of the corresponding pedCAT(®) and pedographic parameters were correlated (Pearson). The intra- and interobserver reliability of the pedCAT(®) measurements were sufficient (analysis of variance, p > .8 for each, power >0.8). No sufficient correlation was found between the pedCAT(®) and pedographic parameters (r < 0.05 or r > -0.38).3D bone position did not correlate with the force and pressure distribution under the foot sole during simultaneous pedCAT(®) scanning and pedography. Thus, the bone positions measured with pedCAT(®) do not allow conclusions about the force and pressure distribution. However, the static pedographic parameters also do not allow conclusions about the 3D bone position.one position and force/pressure distribution are important parameters for diagnostics, planning, and follow-up examinations in foot and ankle surgery.

The diagnostic value of pedobarography

Pedobarography can quantify static and dynamic foot pressure. Despite an increase in the clinical use of pedobarography, the results and the clinical diagnosis do not always correlate, leading to confusion and misdiagnosis. The authors evaluated the potential of pedobarography to diagnose several diseases associated with abnormal pressure across the plantar surface. The study included 72 patients (96 cases) between January 2009 and August 2012 with symptoms of excessive plantar pressure. The average age was 50.9 years (range, 18-92). Patients had the lesion for an average of 17 months (range, 8-29). Pedobarographic measurements were used to evaluate the compatibility between the highest pressure on pedobarography and the clinical peak pressure with plantar ulcers or calluses. Maximal peak pressure was evaluated by static and dynamic measurements using numeric and graphic measurements in pedobarography. The diagnostic validity of pedobarography was analyzed by comparing clinical peak pressure and pedobarographic measurements. The diagnostic validity of pedobarography was 17.7% to 51% for static measurement and 13.5% to 49% for dynamic measurement. The diagnostic validity of pedobarography was low for intractable plantar keratosis and metatarsal head callus associated with metatarsophalangeal dislocation in rheumatoid arthritis. However, it was 57% to 100% for Charcot arthropathy with midfoot ulcers. When used to compare numeric pressure and graphic peak pressure for each part of the foot, pedobarography showed low diagnostic correlation. Based on the study results, the diagnostic validity of pedobarography is low.

Gait analysis in orthopedic foot and ankle surgery--topical review, part 1: principles and uses of gait analysis

Gait analysis, the systematic study of human walking, is a field that has been studied for well over 100 years. With the technological and scientific advancements of the last several decades, there has been substantial improvement in our understanding of the mechanics of human walking. Particularly important has been the advancement in understanding of the differences between normal and pathological gait. The purpose of this paper is to review the principles of gait analysis, with a particular focus on the underlying methods and science. This will assist orthopedic foot and ankle surgeons in better understanding the methods and meaning of gait research and the publications that commonly appear in the orthopedic foot and ankle surgery literature.

LEVEL OF EVIDENCE

Level V, expert opinion.

Computer aided surgery in foot and ankle: applications and perspectives

PURPOSE

At the beginning of the twenty-first century, the computer has supplemented the possibilities of orthopaedic surgery. This article analyses the feasibility and potential clinical benefit of intraoperative three-dimensional imaging (3D), computer assisted surgery (CAS) and intraoperative pedography (IP) in foot and ankle surgery.

METHODS

The feasibility, accuracy and clinical benefit of 3D, CAS and IP were analysed in ongoing experimental and prospective studies at the institution in which the inventor of IP and principal user of 3D and CAS in foot and ankle surgery operates.

RESULTS

Three dimensional imaging: In approximately one third of the cases, reduction/correction and/or implant position was corrected after intraoperative 3D scan during the same procedure in different prospective, consecutive, non-controlled studies (Level III). CAS: CAS guidance for the correction of deformities of the ankle, hindfoot and midfoot/tarsometatarsal (TMT) joint provided higher accuracy, a faster correction process and better scores at a minimum follow-up of two years in comparison without CAS guidance in a single-centre matched-pair follow-up study (Level II). IP: Additional use of IP as the only difference between two groups with correction and/or arthrodesis at foot and/or ankle led to improved clinical outcome scores at a mean of two years follow-up in a prospective randomised controlled study (Level I).

CONCLUSIONS

Three dimensional imaging provides important information which could not be obtained from two-dimensional C-arm alone. The benefit of CAS is high when improved accuracy may lead to an improved clinical outcome. Intraoperative pedography is useful when intraoperative biomechanical assessment may lead to an immediate improvement of the achieved surgical result.

Four-stage regimen for operative treatment of diabetic foot ulcer with deformity - a results of 300 patients

BACKGROUND

An operative four-stage regimen (stage 1, debridement; stage 2, closure; stage 3, unloading; stage 4, correction) for operative treatment of diabetic foot ulcer with deformity, and first clinical results are introduced.

METHODS AND RESULTS

335 patients entered stage 1 between 01/09/2006 and 31/08/2010. Stage 1: In 189 cases (56%), one debridement resulted in sterile postoperative specimens. Stage 2: 210 cases (63%) sustained secondary closure, 97 (29%) local shifted skin graft, and 20 (6%) functional amputation. Stage 3: 304 (90%) finished stage 3, 14 (4%) presented with recurrent ulcer. Stage 4: In 185 cases (55%), correction arthrodeses were performed successfully.

FOLLOW-UP

300 (90%) completed follow-up at 26months on average (12-48months). Recurrent ulcer was registered in 46 (15%). Overall amputation rate was 14%, the majority at digital or midfoot level. Four cases (1%) required a below-knee amputation.

CONCLUSIONS

The management of diabetic foot ulcer combined with deformity with the introduced regimen showed low major amputation rate and low recurrent ulcer rate compared with the literature.

What's new in foot and ankle surgery

This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2009 and July 2010. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot & Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on March 13, 2010, in New Orleans, Louisiana, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), held on July 7 through 10, 2010, in National Harbor, Maryland.

Complications of heel surgery

Surgical complications of the calcaneus are unique to that structure but do not have a greater incidence than in any other part of the foot or ankle. The first tenet of any complication, however, is to recognize it. When all is said and done, recognition is probably the most important step when a complication arises.