Quality of research and level of evidence in foot and ankle publications

Quo vadis, foot & ankle research? A review

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

Chronic Achilles tendon rupture in elderly treated with a combination of the side-locking loop suture technique and early rehabilitation protocol: two cases report

A chronic Achilles tendon rupture (ATR) is generally defined as a rupture that occurs more than 4-6 weeks after the initial injury. A variety of corrective techniques have been reported, such as direct repair, V-Y plasty, turndown flap, tendon transfer and free tendon grafting. These procedures generally produce good results, but have the disadvantage of requiring prolonged immobilization and weight-bearing restrictions. This may be a risk factor for falls and decreased function in the lower limbs, especially in older patients. Side-locking loop sutures (SLLS) were first introduced in 2010 as a direct repair technique for acute ATR. This technique provides higher tensile strength, which may allow for early rehabilitation protocols such as early range of motion and early weight-bearing of the ankle without postoperative immobilization. In this report, we describe two cases of chronic ATR in elderly patients treated with SLLS and an early rehabilitation protocol.

A scoping review of foot and ankle telemedicine guidelines

Background and Aims

The COVID-19 pandemic accelerated the adoption of telemedicine in general. Its use has been widely adopted in the healthcare sector, but relatively little research has been conducted on the use of telemedicine for podiatry. This review aimed to explore and compare existing guidelines on telemedicine related to foot and ankle pathologies within a primary care setting.

Methods

The preferred reporting guidelines for the extension of scoping reviews were used in this review, and a set of inclusion and exclusion criteria were developed and implemented. This study made use of both databases and gray literature searches. Between 2012 and 2022, these databases were searched using various subject headings and free-text terms for the keywords "telemedicine" "foot health" and "guidelines" with appropriate Boolean operators.

Results

The search yielded 356 articles, which were reduced to 283 after removing duplicates. Six more records were discovered through a Google and Google Scholar search and one through an article reference search. Six articles and three institutional practice guidelines were selected for synthesis after screening. The findings were classified according to the level of evidence and research quality, the function of telemedicine and the communication used, the research outcomes sought, and the type of recommendations and guidelines made available.

Conclusion

This review highlights the lack of podiatric telemedicine guidelines for foot and ankle pathologies. Although foot and ankle guidelines for orthopedic and musculoskeletal virtual consultations have been mentioned, they do not cover the full range of potential case scenarios that fall within the remit of podiatric consultations in a primary care setting. This review suggests the development of foot and ankle telemedicine guidelines with recommendations on how they can better provide accessible care to their patients, making foot and ankle care management not only a hand-on-one but also reachable virtually, where applicable.

Characteristics and research trends of 50 most-cited hallux rigidus papers

BACKGROUND

The bibliometric studies in the field of orthopaedics have gained popularity since they can determine the characteristics and research trends of most influential papers in specific subjects. This study aimed to evaluate the 50 most-cited articles related to hallux rigidus, and analyze possible factors associated with increased citation counts.

METHODS

The available literature about hallux rigidus on Web of Science database until January 2021 were analyzed and the 50 most-cited articles were determined. The characteristics of the papers were documented and analyzed for any relationship or correlation with total citation or citation per year (citation density) values.

RESULTS

The average citation number and citation density were 52.8 (range: 26-243) and 3 (range: 0.8-12.8), respectively. The average author number was 3.4, while the average institution number was 1.9. The USA had the highest number of articles with 29. Twenty-six papers were case-series, only 3 studies had level 1 and only 2 had level 2 evidence. The highest number of articles were published in Foot and Ankle International with 22 papers. Forty papers were clinical studies while 10 were reviews. Five studies were multicentric.

CONCLUSION

This study provided the general characteristic and research trends of 50 most influential hallux rigidus papers. The number of institutions and references were positively correlated with citation density, indicating a higher chance of getting cited for papers with collaborations from different institutions and papers using more references from other works. Publication year was also positively correlated with citation density, indicating the better performance of more recent articles.

LEVEL OF CLINICAL EVIDENCE

Level 3.

A Bibliometric Evaluation of Worldwide Research of the Podiatry Field from 1965 to 2017

BACKGROUND

To identify the strengths and weaknesses in a given research area, it is necessary to analyze the published literature. International studies on podiatry research productivity are scarce. This study aimed to analyze scientific productivity in the area of podiatric medicine from 1965 to 2017.

METHODS

This was a retrospective, observational, bibliometric study. The MEDLINE database was used to identify research published between 1965 and 2017. Literature searches were performed in 2010 and 2017 through RefWorks, and research production per year, author, document type, country, institution, journal, and language were calculated. Podiatry's contribution to global scientific production was measured by calculating the ratio of podiatry publications to total production, and Price's law was applied to analyze the temporal evolution. Author productivity index, coauthorship, geographic distribution, and the distribution by institution type and journal (Bradford's law) were analyzed.

RESULTS

The MEDLINE search yielded 1,256 publications, representing 4.75 articles per 100,000 publications in global scientific research. The growth rate followed Price's law after linear adjustment. The 2,229 identified authors presented a transience index of 85.73%; 0.38% were highly productive authors. The coauthorship index increased from 1.40 in 1965 to 5.80 in 2017. The most common document type was the journal article, whereas 2.1% were clinical trials. Only one document reported a controlled clinical trial. The United States led scientific production, with 77.15% of the documents; 60.5% of the publications were concentrated in four journals.

CONCLUSIONS

Podiatry is still an emerging research field, and literature is concentrated in a small number of journals, categorized into different subjects.

Twenty Five-Year Publication Trends in Foot and Ankle Literature: Improved Methodological Quality and Internationality With Time

Background:

Methodological quality and author internationality are increasing in orthopaedic surgery. The purpose of this study was to evaluate the methodological quality and author geography trends from 1994 to 2019 in high-quality foot and ankle journals.

Methods:

Analyses of 1,242 foot and ankle publications in Foot and Ankle International, American Journal of Bone and Joint Surgery, and American Journal of Sports Medicine were done for 1994, 1999, 2004, 2009, 2014, and 2019. Articles were classified according to study type, level of evidence (LOE), and author's country of publication.

Results:

The most common clinical study was therapeutic (65.4). Significant increases were noted in the proportion of therapeutic (P < 0.01) and prognostic (P < 0.01) articles. The average LOE increased from 3.96 ± 1.01 to 3.19 ± 0.97 (P < 0.01). The proportion of Level I (P = 0.29) and level IV articles (P = 0.21) remained constant, level II (P < 0.01) and level III (P < 0.01) articles increased, and level V (P < 0.01) articles decreased. United States authorship decreased from 78.1% in 1994 to 44.8% in 2009, then remained constant through 2019 (P < 0.01).

Conclusion:

This study demonstrated an improvement in LOE of foot and ankle publications across a 25-year period in three high-quality orthopaedic journals. Increasing internationality was also observed.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon

Background:

The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture.

Methods:

A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up.

Results:

Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up ( P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively ( P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery.

Conclusion:

The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery.

Level of Evidence:

Level IV, retrospective case series.

Publishing Characteristics of Foot and Ankle Research Over a 15-Year Time Interval: A Review of The Journal of Bone & Joint Surgery from 2004 to 2018

BACKGROUND

As the foot and ankle subspecialty continues to grow in orthopaedics, trends in published literature provide valuable insights to help understand and strengthen the field. The current study evaluates the changes in the characteristics of foot and ankle articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS-A) from 2004 to 2018.

METHODS

Foot and ankle-related articles in JBJS-A from 2004 to 2018 were identified and categorized by type of study, level of evidence, number of authors, academic degree(s) of the first and last authors, male and female authorship, number of citations, number of references, region of publication, and use of patient-reported outcomes (PROs).

RESULTS

A total of 336 foot and ankle articles from 2004 to 2018 were reviewed. The type of study published has changed over time, with more clinical therapeutic evidence and less case reports. The level of evidence grades, as rated by JBJS-A and objective evaluators, have increased over the past 15 years. The total number of authors per article has increased, and female authorship has increased significantly. The number of references per article has increased, and the number of citations per year has decreased. The field of foot and ankle surgery has seen an increase in global publications.

CONCLUSIONS

The results of this study suggest that the foot and ankle literature that has been published in JBJS-A has continued to increase in quality and diversity over the past 15 years.

Trends in Publication and Levels of Evidence in Foot & Ankle International From 2000 to 2015

Background:

As the movement toward evidence-based medicine grows and publication rates rise each year, critical analysis of the orthopedic literature has become increasingly important. To aid readers in assessing the scientific quality of published research, Foot & Ankle International ( FAI) began assigning levels of evidence to all clinical articles in 2008. The purpose of this study was to analyze trends in the characteristics and levels of evidence of articles published in FAI between 2000 and 2015.

Methods:

All articles published in FAI from the years 2000, 2005, 2010, and 2015 were reviewed and categorized into article type (clinical, basic science, review, or technical tip). Each clinical article was assigned a level of evidence (I-V) and study type (prognostic, therapeutic, economic, or diagnostic). Descriptive information was gathered pertaining to country of origin, author credentials, and funding. Statistical analysis was performed using chi-squared tests to detect any trends in levels of evidence and publication characteristics.

Results:

A total of 647 articles were reviewed. From 2000 to 2015, there was a statistically significant increase in the publication of clinical research articles (70% to 83%; P = .013), while the number of basic science articles decreased (29% to 17%; P = .013). Of the clinical articles, there was a significant increase in therapeutic studies (41% to 58%; P = .003). During the study period, the publication of Level I and II evidence significantly increased (2% to 14%; P = .002). Although Level III and V evidence also increased (65% to 71%, P > .99), this was not found to be statistically significant. Publications originated from a total of 39 countries, with a significant increase in the proportion of international papers (33% to 48%; P = .007) over the study period. The proportion of articles authored by Doctors of Podiatric Medicine (DPMs) during the study period significantly decreased (4% to 2%, P = .035). Finally, the percentage of studies that disclosed the use of outside funding increased during the study period, with reported funding from grants or professional groups rising from 3% to 16% ( P < .001) and reported funding from commercial sources rising from 0% to 9% ( P = .002).

Conclusion:

The proportion of Level I and II studies published in FAI significantly increased from 2000 to 2015. The publication of clinical research rose, with a majority being therapeutic studies. There was a significant increase in articles published by international authors and a significant decrease in articles published by DPMs. During the same time period, there was a rise in the proportion of articles reporting the use of outside funding, both professional and commercial.

Systematic review of bone marrow stimulation for osteochondral lesion of talus - evaluation for level and quality of clinical studies

AIM

To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score.

RESULTS

This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality.

CONCLUSION

The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.

Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review

BACKGROUND

The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm² in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs.

PURPOSE

To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes.

RESULTS

Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm² in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm², while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm². The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies.

CONCLUSION

An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm² in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

Parameters influencing complaints and joint function in patients with osteochondral lesions of the ankle-an investigation based on data from the German Cartilage Registry (KnorpelRegister DGOU)

INTRODUCTION

Patients with osteochondral lesions of the ankle represent a heterogeneous population with traumatic, posttraumatic and idiopathic forms of this pathology, where the etiology of the idiopathic form is principally unknown. The aim of this study was to classify the heterogeneous patient population according to the patients' complaints and joint function. Data from the German Cartilage Registry (KnorpelRegister DGOU) was analyzed for this purpose to investigate whether traumatic and posttraumatic lesions cause more complaints and loss of joint function than idiopathic lesions. Moreover, it was sought to determine if lesion localization, defective area, stage, patient age, gender, and body mass index (BMI) are related to patients' complaints and loss of joint function.

MATERIALS AND METHODS

A 117 patients with osteochondral lesions of the ankle were operated in 20 clinical centers in the period between October 2014 and January 2016. Data collection was performed by means of a web-based Remote Data Entry system at the time of surgery. Patients' complaints and joint function were assessed with online questionnaires using the German versions of the Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Outcome Score (FAOS), followed by statistical data evaluation.

RESULTS

No significant difference was indicated between the groups with traumatic/posttraumatic lesions and idiopathic lesions with regard to most of the patients' complaints and joint function, excluding the category Life quality of the FAOS score, where patients with idiopathic lesions had a significantly better quality of life (p = 0.02). No significant association was detected between lesion localization, defective area, patient age, gender, and BMI on the one hand, and patients' complaints and joint function on the other. Similarly, no significant association was found between lesion stage according to the International Cartilage Repair Society (ICRS) classification and patients' complaints and joint function. However, a higher lesion stage according to the classification of Berndt and Harty, modified by Loomer, was significantly associated with more complaints and loss of joint function in some categories of the FAAM and FAOS scores (p ≤ 0.04).

CONCLUSIONS

Etiology of the lesion, lesion localization, defective area, lesion stage according to the ICRS classification, patient age, gender, and BMI do not seem to be of considerable relevance for prediction of patients' complaints and loss of joint function in osteochondral lesions of the ankle. Using the classification of Berndt and Harty, modified by Loomer, seems to be more conclusive.

Levels of Evidence for Foot and Ankle Questions on the Orthopaedic In-Training Examination: 15-Year Trends

BACKGROUND

The foot and ankle (FA) content domain is a component of the orthopaedic in-training examination (OITE). Levels of evidence (LoE) have been infrequently studied on the OITE. The purpose of this study is to determine if LoE for primary journal articles referenced for FA questions increased over a 15-year period. We also aim to determine if reference characteristics and question taxonomy have changed during this period.

METHODS

All 132 questions and 261 references in the FA content domain from 1995 to 1997 and from 2010 to 2012 were included. We defined the characteristics of each reference and taxonomy of each question. Every primary journal article was assigned a LoE based on American Academy of Orthopaedic Surgeons (AAOS) guidelines.

RESULTS

Foot & Ankle International (FAI) was the most frequently cited journal. The change in the distribution of the Buckwalter classifications was statistically significant (p = 0.0286) with an increase in the number of clinical management questions. There were more level I studies on the 2010 to 2012 OITE (p = 0.0478) 6/54 (11%) of questions on the 2010 to 2012 OITE cited level I or II evidence compared with 3/78 (4%) on the 1995 to 1997 examinations (p = 0.1035).

CONCLUSIONS

There is a trend toward improved LoE for journal articles within the FA content domain on the OITE over a 15-year period, particularly when analyzing the increase in level I studies. FAI is the most frequently cited journal and questions increasingly test clinical management concepts.

CLINICAL RELEVANCE

Our results can be used to help improve resident self-study and suggest that reviewing recent FAI articles may aid OITE preparation.

LEVEL OF EVIDENCE

Basic Science.

Trends in the Level of Evidence in Clinical Hand Surgery Research

BACKGROUND

The application of evidence-based medicine (EBM) to the practice of hand surgery has been limited. Production of high-quality research is an integral component of EBM. With considerable improvements in the quality evidence in both orthopedic and plastic and reconstructive surgery, it is imperative that hand surgery research emulates this trend.

METHODS

A systematic review was performed on all hand surgery articles published in 6 journals over a 20-year period. The journals included Plastic and Reconstruction Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, Journal of Hand Surgery-European Volume, Journal of Hand Surgery-American Volume, Journal of Bone & Joint Surgery, and the Bone & Joint Journal. The level of evidence of each article was determined using the Oxford level of evidence. The quality of methodology of randomized controlled trials (RCTs) was assessed using Jadad scale. Statistical analysis involved chi-squares and Student t test (P < .05).

RESULTS

A total of 972 original hand surgery research articles were reviewed. There was a significant increase in the average level of evidence of articles published between1993 and 2013. High-quality evidence only accounted for 11.2% of evidence published, with a significant increase over the study period (P = 0.001). Quantitative evaluation of the 26 published RCTs, using Jadad scale, revealed a progressive improvement in study design from 0.3 in 1993 to 3.33 in 2013.

CONCLUSIONS

Hand surgery research has mirrored trends seen in other surgical specialties, with a significant increase in quality of evidence over time. Yet, high-quality evidence still remains infrequent.

Vitamin D in Foot and Ankle Fracture Healing: A Literature Review and Research Design

Vitamin D is a generic name for a group of essential vitamins, or secosteroids, important in calcium homeostasis and bone metabolism. Specifically, efficacy of vitamin D with regard to bone healing is in question. A literature review was performed, finding mostly large studies involving vitamin D effects on prevention of fractures and randomized animal model studies consisting of controlled fractures with vitamin D interventions. The prevention articles generally focus on at-risk populations, including menopausal women and osteoporotic patients, and also most often include calcium in the treatment group. Few studies look at vitamin D specifically. The animal model studies often focus more on vitamin D supplementation; however the results are still largely inconclusive. While recent case reports appear promising, the ambiguity of results on the topic of fracture healing suggests a need for more, higher level research. A novel study design is proposed to help determine the efficacy on vitamin D in fracture healing.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Systematic Review.

Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot

BACKGROUND

Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity.

METHODS

We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications.

RESULTS

Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems.

CONCLUSIONS

Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures

BACKGROUND

Distinguishing stable supination-external rotation (SER) 2 from unstable SER 4 ankle fractures, using standard radiographs, is controversial. Examination under anaesthesia (EUA), gravity-stress (GS) and weight-bearing (WB) radiographs can aid surgical decision-making. We evaluated the effect of three methods of fracture stability assessment.

METHODS

Radiographs and case-notes of 312 consecutive patients with SER 2/4 fractures were reviewed. We recorded ankle stability assessment (plain film (PF) and EUA vs. GS vs. WB radiographs), management (conservative vs. operative), unplanned surgery and complications.

RESULTS

Forty five percent assessed with GS underwent surgery (6% for PF/EUA, 4% for WB; P=0.0001). Amongst GS patients, 11% underwent additional surgery (0.1% PF/EUA, 0% WB; P=0.0001). Complications occurred in 2% of the WB group (8% for PF/EUA, 22% for GS; P=0.007).

CONCLUSION

This study associates GS assessment with higher rates of surgery and complications. Subsequent studies may determine the longer term effect stability assessments have on post-traumatic arthritis.

Screw size and insertion technique compared with removal rates for calcaneal displacement osteotomies

BACKGROUND

The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique.

METHODS

We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed.

RESULTS

The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings.

CONCLUSION

Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs.

LEVEL OF EVIDENCE

Level III, comparative series.

Diagnostic accuracy of 3.0 Tesla magnetic resonance imaging for the detection of articular cartilage lesions of the talus

BACKGROUND

Talar chondral defects can be a source of persistent ankle pain and disability. If untreated, there is an increased risk of osteoarthritis. The purpose of our study was to determine diagnostic accuracy of 3T MRI in detecting Outerbridge grades 3 and 4 articular cartilage lesions of the talus in a clinical setting, utilizing a standardized clinical MRI protocol.

METHODS

Patients who had a 3T ankle MRI and subsequent ankle surgery, by a single surgeon, were included in this study. MRI exams were performed 180 days or less before surgery. Seventy-nine ankles in 78 patients (mean age of 42.3 years) were included in this study. Mean body mass index was 26.3. A standard clinical MRI exam was performed on a 3T MRI scanner. Mean days from MRI to surgery was 39 days. All MRI exams were read and findings recorded by a musculoskeletal radiologist. Arthroscopic examination was performed by a single orthopaedic surgeon. Detailed arthroscopic findings and demographic data were collected prospectively and stored in a data registry. Of the 78 patients, 31 (39.2%) reported previous ankle surgery. Pain was the primary reason for seeking medical attention as reported by 95% of patients, followed by instability in 44% and loss of function with 42%.

RESULTS

Prevalence of Outerbridge grade 3 and 4 talar articular cartilage defects identified at arthroscopy was 17.7%. The 3T MRI demonstrated a sensitivity of 0.714, specificity of 0.738, positive predictive value of 0.370, and negative predictive value of 0.923.

CONCLUSION

Sensitivity and specificity levels were acceptable for detection of grades 3 and 4 articular cartilage defects of the talar dome using 3T MRI. The high negative predictive value may be beneficial in preoperative planning. While these values are acceptable, a high index of suspicion should be maintained in the appropriate clinical setting.

The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle

INTRODUCTION

There is an increasing need for orthopaedic practitioners to measure and collect patient-reported outcomes data. In an effort to better understand outcomes from operative treatment, the American Orthopaedic Foot & Ankle Society (AOFAS) established the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network, a national consortium of foot and ankle orthopaedic surgeons. We hypothesized that the OFAR Network could successfully collect, aggregate, and report patient-reported outcome (PRO) data using the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS).

METHODS

Ten sites enrolled consecutive patients undergoing elective surgery for 1 of 6 foot/ankle disorders. Outcome instruments were collected preoperatively and at 6 months postoperatively using the PROMIS online system: Foot and Ankle Ability Measure (FAAM), Foot Function Index (FFI), and PROMIS physical function (PF) and pain computerized adaptive tests (CAT). During the 3-month period, 328 patients were enrolled; 249 (76%) had completed preoperative patient-reported outcomes data and procedure-specific data. Of these, 140 (56%) also completed 6-month postoperative patient- reported outcomes data.

RESULTS

Ankle arthritis and flatfoot demonstrated consistently worse preoperative scores. Five of 6 disorders showed significant improvement at 6 months on PF CAT and FAAM, 4 of 6 showed improvement on pain interference CAT, and no disorders showed improvement on FFI. Ankle arthritis and flatfoot demonstrated the greatest magnitude of change on most patient-reported outcomes scales.

CONCLUSION

We were able to enroll large numbers of patients in a short enrollment period for this preliminary study. Data were easily aggregated and analyzed. Substantial loss of follow-up data indicates a critical area requiring further effort. The AOFAS OFAR Network is undergoing expansion with goals to ultimately facilitate large, prospective multicenter studies and optimize the quality and interpretation of available outcome instruments for the foot and ankle population.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Aftercare following syndesmotic screw placement: a systematic review

For ankle fractures, in general, several studies have been published on immobilization (e.g., cast or boot) versus early motion after surgical treatment. However, no studies have been performed to determine the best aftercare strategy for surgically treated patients with ankle fractures with concomitant acute distal tibiofibular syndesmotic injuries. The aim of the present review was to compare the functional outcomes of ankle fractures with syndesmotic injury treated with a cast or boot versus early motion. We performed a systematic review using the electronic databases from January 1, 2000 to September 1, 2012 of the Cochrane Library, PubMed MEDLINE(®), EMbase, and Google Scholar. The included studies were those in which ankle fractures with acute distal tibiofibular syndesmotic injuries had been treated with 1 or more syndesmotic screws, with a mean follow-up period of at least 12 months and at least 25 patients included. The functional outcomes, measured using the American Orthopaedic Foot Ankle Society Hindfoot scale, Olerud-Molander Ankle Scale, and Short Musculoskeletal Function Assessment, were compared. A total of 9 studies were identified with a total of 531 patients. The number of included patients ranged from 28 to 93. The mean follow-up period was 12 to 101 months. Of the 9 studies, 3 used an early motion protocol (195 patients) and 6 (336 patients) a protocol of immobilization for at least 6 weeks. For the American Orthopaedic Foot Ankle Society Hindfoot scale, the mean scores for immobilization were 86 to 91 points and for early motion, 84 to 89. For the Olerud-Molander Ankle Scale, the scores for immobilization were 47 to 90 and for early motion, 46 to 82 points. The Short Musculoskeletal Function Assessment score for immobilization was 11 and for early motion ranged from 12 to 27 points. No apparent differences could be detected in the published data considering the functional outcomes between immobilization versus an early motion protocol in ankle fractures with acute distal tibiofibular syndesmotic injuries treated with a syndesmotic screw. However, level 1 and 2 studies on this subject are lacking.

Level of evidence gap in orthopedic research

Level of evidence is the most widely used metric for the quality of a publication, but instances exist in which a Level I study is neither feasible nor desirable. The goal of this study was to evaluate the level of evidence gap in current orthopedic research, which the authors defined as the disparity between the level of evidence that would be required to optimally answer the primary research question and the level of evidence that was actually used. Five orthopedic surgeons (K.D.B., J.B., J.A., S.D.M., W.N.S.) evaluated blinded articles from the first 6 months of 2010 in the Journal of Bone and Joint Surgery (American Volume) (JBJS-Am), classifying the study type and design and extracting a primary research question from each article. Each evaluator then defined the study type and method, along with the level of evidence that would ideally be used to address the primary research question. The level of evidence gap was then calculated by subtracting the actual level of evidence of the manuscript from the level of evidence of the idealized study. Of the 64 JBJS-Am manuscripts eligible for analysis, the average level of evidence was between Level II and III (mean, 2.73). The average level of evidence gap was 1.06 compared with the JBJS-Am-designated level of evidence and 1.28 compared with the evaluators' assessment. Because not all questions require Level I studies, level of evidence alone may not be the best metric for the quality of orthopedic surgery literature. Instead, the authors' concept of a level of evidence gap may be a better tool for assessing the state of orthopedic research publications.