PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

PROMIS Physical Function and Pain Interference Scores Correlate with the Lower Extremity Toronto Extremity Salvage Score

The Toronto Extremity Salvage Score (TESS) and the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) are both utilized to measure patient-reported outcomes in adults with musculoskeletal oncologic conditions. However, the relationship between them has not been studied. We sought to describe a link between Lower Extremity (LE) TESS and PROMIS Physical Function (PF) scores, as well as between LE TESS and Pain Interference (PI) scores, to develop a method for converting scores between TESS and PROMIS and to examine whether TESS and PROMIS captured differences in pain and function between clinically relevant subgroups in our population.

Methods

Our study population consisted of 125 adult patients who underwent surgical treatment of a lower-extremity musculoskeletal tumor at a single sarcoma center between December 2015 and October 2018. The LE TESS questionnaire was administered to patients via paper and the PROMIS PF and PI were administered via iPad at a preoperative appointment. The relationship between LE TESS and PROMIS measures was analyzed with use of generalized linear modeling. Subgroup analyses were performed with a 2-tailed t test or 1-way analysis of variance.

Results

PROMIS PF had a very strong positive correlation with LE TESS (r = 0.83) and was related through the following equation: PROMIS PF = 0.00294 × (LE TESS)² + 22.6. PROMIS PI had a strong negative correlation with LE TESS (r = -0.77) and was related through the following equation: PROMIS PI = -0.00259 × (LE TESS)² + 73.8. PROMIS PF and PI performed similarly to LE TESS across multiple patient subgroups and captured the expected differences between subgroups.

Conclusions

LE TESS and PROMIS PF appeared to measure similar information in patients with an orthopaedic oncologic condition. Moreover, PROMIS PI scores were strongly correlated with functional disability as measured with the LE TESS. Understanding the relationship between TESS and PROMIS will allow the comparison and combination of data for both clinical and research purposes.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of percutaneous femoral derotational osteotomy in pediatric patients

Background

Percutaneous femoral derotational osteotomies are performed in both adult and pediatric patients. There is little published on the outcomes after femoral derotational osteotomy in pediatric patients.

Methods

A retrospective cohort study of pediatric patients treated with percutaneous femoral derotational osteotomy by one of two surgeons between 2016 and 2022 was performed. Data collected included patient demographics; surgical indications; femoral version; tibial torsion; magnitude of rotational correction; complications; time to hardware removal; pre-operative and post-operative patient-reported outcome scores, including Limb Deformity-Scoliosis Research Society and Patient-Reported Outcomes Measurement Information System; and time to consolidation. Descriptive statistics were used to summarize the data and t tests used to compare means.

Results

Thirty-one femoral derotational osteotomies in 19 patients were included with an average age of 14.7 (9-17) years. The average rotational correction was 21.5° ± 6.4° (10°-40°). The average length of follow-up was 17.9 ± 6.7 months. There were no instances of nonunion, joint stiffness, or nerve injury. No patients returned to the operating room for additional surgeries other than routine hardware removal. There were no cases of avascular necrosis of the femoral head. Of the 19 patients, 8 completed both a pre-operative and post-operative survey set. There were significant improvements in the Limb Deformity-Scoliosis Research Society Self-Image/Appearance sub-category and the Patient-Reported Outcomes Measurement Information System Physical Function sub-category.

Conclusion

Femoral derotational osteotomy using a percutaneous drill hole technique with antegrade trochanteric entry femoral nail is safe in the pediatric population and improves self-image in patients with symptomatic femoral version abnormalities.

Establishing minimal clinically important differences for the Quality of Life Instrument of Chronic Gastritis QLICD-CG(V2.0) based on distribution-based methods

BACKGROUND

To establish the lowest score reflecting meaningful changes from the perspective of patients is very important for explaining the results of patient reports. The measurement scale of quality of life in patients with chronic gastritis has been used in clinical practice, but the minimal clinically important difference (MCID) has not been worked out. In this paper, we use a distribution-based method to calculate the MCID of the scale QLICD-CG (Quality of Life Instruments for Chronic Diseases- Chronic Gastritis) (V2.0).

METHODS

The QLICD-CG(V2.0) scale was used to evaluate the quality of life in patients with chronic gastritis. Since the methods for developing MCID were diverse and there was no uniform standard, we took MCID developed by anchor-based method as the gold standard, and compared the MCID of QLICD-CG(V2.0) scale developed by various distribution-based methods for selection. Standard deviation method (SD), effect size method (ES), standardized response mean method (SRM), standard error of measurement method (SEM) and reliable change index method (RCI) are given in the distribution-based methods.

RESULTS

A total of 163 patients, with an average age of (52.37 ± 12.96) years old, were calculated according to the various methods and formulas given by the distribution-based method, and the results were compared with the gold standard. It was suggested that the results of the SEM method at the moderate effect (1.96) should be taken as the preferred MCID of the distribution-based method. And thus the MCID of the physical domain, psychological domain, social domain, general module, specific module and total score of the QLICD-CG(V2.0) scale were 9.29, 13.59, 9.27, 8.29, 13.49 and 7.86, respectively.

CONCLUSIONS

With anchor-based method as the gold standard, each method in distribution-based method has its own advantages and disadvantages. In this paper, 1.96SEM was found to have a good effect on the minimum clinically significant difference of the QLICD-CG(V2.0) scale, and it is recommended as the preferred method to establish MCID.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

Minimal clinically-important differences for the 'Liverpool Osteoarthritis in Dogs' (LOAD) and the 'Canine Orthopedic Index' (COI) client-reported outcomes measures

Client-reported outcomes measures (CROMs) have been previously validated for the evaluation of canine osteoarthritis. A published systematic review indicated that the 'Liverpool Osteoarthritis in Dogs' (LOAD) and the 'Canine Orthopedic Index' (COI) can be recommended for use in dogs with osteoarthritis; these CROMs have also been used in the context of measuring surgical outcomes of dogs with orthopaedic conditions. However, the minimal clinically-important differences (MCIDs) for these CROMs have not been investigated. Such estimates would be useful for investigators and regulators so that these CROMs can be used in clinical trials. Data from the RCVS Knowledge Canine Cruciate Registry were extracted, and baseline and 6 week follow-up data on dogs that had received surgery for cranial cruciate ligament rupture were used to make estimates of MCIDs using distribution-based and anchor-based methods. Data from 125 dogs were categorised based on the anchor question and LOAD and COI scores analysed accordingly. The four anchor-based methods provided a range of MCIDs for each CROM (1 to 8.8 for LOAD and 3.5 to 17.6 for COI). In the two different distribution-based methods, the MCIDs for LOAD ranged from 1.5 (effect size) to 2.4 (standard error of measurement) and the effect size method yielded a result of 2.2 for COI. The results showed that the value of the MCIDs depended on the method that was applied. Receiver operator characteristic curves provided areas under the curve (AUCs) greater than 0.7, which indicated that the cut-off point was acceptable; LOAD had the greater AUC at 0.867. In summary, the authors currently recommend a MCID of '4' for LOAD and '14' for COI although further work in other clinical contexts (such as osteoarthritis associated with chronic pain) is required to add confidence to these estimates. For the first time, we have provided estimates for MCIDs for these two CROMs which will facilitate sample size estimates in future clinical studies that use these CROMs as outcomes measures.

Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS

Background

Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms.

Methods

From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used.

Results

A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores.

Conclusion

Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms.

Level of Evidence

Level III, case-control study.

Early Radiographic and Clinical Outcomes of a Novel, Fixed-Bearing Fourth-Generation Total Ankle Replacement System

BACKGROUND

The Cadence Total Ankle System is a 2-component, fixed-bearing fourth-generation total ankle arthroplasty (TAA) system that was introduced for clinical use in 2016. The purpose of this study was to report non-inventor, non-industry funded survivorship, radiographic and clinical outcomes, and early complications following use of this implant at a minimum of 2 years.

METHODS

This single-center retrospective study included patients who underwent TAA by 2 surgeons with this novel fixed-bearing system between January 2017 and September 2018. Forty-eight patients were evaluated at an average of 33.6 months. Radiographic outcomes included preoperative and postoperative tibiotalar angle on anteroposterior radiographs of the ankle, sagittal tibial angle (STA) on lateral radiographs of the ankle, and periprosthetic lucency formation and location. Revision and reoperation data were collected, and patient-reported outcomes were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Subgroup analysis assessed associations between preoperative deformity, postoperative implant alignment, PROMIS scores, and periprosthetic lucency formation.

RESULTS

Survivorship of implant was 93.7%, with 3 revisions, 1 due to infection and 2 due to loosening of the implant (1 tibial and 1 talar component). Three patients had reoperations (6.3%): 2 for superficial infection and 1 for gutter debridement due to medial gutter impingement. Fifteen patients (35.8%) developed periprosthetic lucencies, all on the tibial side. PROMIS scores improved after surgery in all domains except Depression. Patients with significant postoperative periprosthetic lucency had worse postoperative PROMIS Physical function scores than patients without lucency (P < .05).

CONCLUSION

This study demonstrated excellent minimum 2-year clinical and radiographic outcomes and low revision and reoperation rates of this new fourth-generation TAA system. Future studies with longer follow-up, especially on patients with periprosthetic lucency, are necessary to investigate the long-term complications and understand the long-term functional and radiographic outcomes of this implant.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction

BACKGROUND

Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction.

METHODS

Preoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders.

RESULTS

A total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups.

CONCLUSION

While both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Association of Preoperative Opioid Use With Postoperative Opioid Use and Patient-Reported Outcomes in Ankle Fracture Fixation Patients

Background

Ankle fracture surgery is a common procedure with many patients receiving opioid medications for postoperative pain control. Whether there are factors associated with higher medication quantities or patient-reported outcomes, however, remains largely unknown.

Methods

Patients with isolated, rotational ankle fractures who underwent surgical fixation between January 2018 and March 2020 were retrospectively reviewed. Patient demographics, injury characteristics, and preoperative and postoperative opioid prescription information were recorded. Clinical follow-up and Foot and Ankle Ability Measure (FAAM) questionnaires were collected at 6 weeks and 3 months postoperatively. Multiple linear regression was used to examine the influences of age, sex, body mass index (BMI), fracture characteristics, medical comorbidities, and preoperative opioid use (OU) on postoperative opioid morphine milligram equivalent (MME) amount and FAAM scores.

Results

A total of 294 patients were included with an average age of 52.11 ± 17.13 years (range, 18-97). Fracture types were proportional to one another. Chronic pain (mean = 145.89, 95% CI = 36.72, 255.05, P = .0009), preoperative OU (mean = 178.22, 95% CI = 47.46, 308.99, P = .0077), psychiatric diagnoses (mean = 143.81, 95% CI = 58.37, 229.26, P = .001), tobacco use (mean = 137.37, 95% CI = 33.35, 229.26, P = .0098), and trimalleolar fractures (mean = 184.83, 95% CI = 86.82, 282.84, P = .0002) were associated with higher postoperative opioid MME amounts. Older age (mean = ‒0.05, 95% CI = ‒0.08, -0.02, P = .0014) and higher BMI (mean = ‒0.06, 95% CI = ‒0.12, 0.00, P = .048) were both independently associated with lower FAAM scores at 6 weeks. At 3 months, higher BMI (mean = ‒0.09, 95% CI = ‒0.13, -0.04, P = .0002), bimalleolar fractures (mean = ‒1.17, 95% CI = ‒2.17, -0.18, P = .021), and higher postoperative MME amounts (mean = ‒0.10, 95% CI = ‒0.19, -0.01, P = .0256) were each independently associated with lower FAAM scores.

Conclusion

In this study, we found that patients with chronic pain, preoperative OU, psychiatric diagnoses, tobacco use, and trimalleolar fractures were more likely to have higher amounts of opioid prescribed following ankle fracture surgery. However, only age, BMI, bimalleolar fractures, and postoperative MME amount were associated with lower FAAM scores postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Relationship Between Preoperative PROMIS Scores and Postoperative Outcomes in Hallux Rigidus Patients Undergoing Cheilectomy

BACKGROUND

Previous studies have demonstrated that preoperative patient-reported outcome measures are associated with postoperative outcomes in foot and ankle surgery, and also in specific procedures such as bunionectomy, flatfoot reconstruction, and total ankle replacement. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, pain intensity, and depression scores were associated with the ability of patients undergoing cheilectomy for hallux rigidus to achieve a minimal clinically important difference (MCID) of improvement.

METHODS

This retrospective study included preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 125 feet in 118 patients undergoing cheilectomy collected from an institutional review board (IRB)-approved foot and ankle registry database. MCIDs were established using distribution-based methods to determine clinical significance of improvements in PROMIS scores. Receiver operating characteristic (ROC) curves and area under the curve analyses were used to determine which preoperative PROMIS scores were associated with patients meeting the MCID.

RESULTS

ROC analysis found statistically significant areas under the curve (AUCs) for the physical function domain (AUC 0.71), pain intensity (AUC 0.70), and depression (AUC 0.79) PROMIS domains. Subsequent analyses were unable to identify clinically useful 95% sensitivity and specificity preoperative thresholds, with the exception of the 95% sensitivity PROMIS physical function threshold. A preoperative physical function score of greater than 53.2 resulted in a 63% probability of achieving the MCID. The pain interference PROMIS domain did not demonstrate a statistically significant AUC.

CONCLUSION

Preoperative PROMIS physical function, pain interference, pain intensity, and depression scores are minimally associated with preoperative to 2-year postoperative improvement in patients undergoing cheilectomy. It may be difficult to determine which patients improve from a cheilectomy based on the severity of symptoms they exhibit preoperatively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimal Clinically Important Differences of PROMIS PF in Ankle Fracture Patients

BACKGROUND

Evaluating the minimal clinically important differences (MCIDs) in patient-reported outcome scores is essential for use of clinical outcomes data. The purpose of the current study was to calculate MCID of Patient Reported Outcome Information System Physical Function (PROMIS PF) scores for ankle fracture patients.

METHODS

All patients who underwent operative fixation for ankle fractures at a single level 1 trauma center were identified by Current Procedural Terminology code. PROMIS PF scores were collected. Patients had to complete an anchor question at 2 time points postoperatively to be included in this study. Anchor-based and distribution-based MCIDs were calculated.

RESULTS

A total of 331 patients were included in the distribution-based analysis, and 195 patients were included in the anchor-based analysis. Mean age was 45.3 years (SD 17.5), and 59.4% of participants were female. MCID for PROMIS PF scores was 5.05 in the distribution-based method and 5.43 in the anchor-based method.

CONCLUSION

This study identified MCID values based on 2 time points postoperatively for PROMIS PF scores in the ankle fracture population. Both methods of MCID calculation resulted in equivalent MCIDs. This can be used to identify patients outside the normal preoperative and postoperative norms and may help to make clinically relevant practice decisions.

LEVEL OF EVIDENCE

Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion for Treatment of Hallux Rigidus

Background

Patients with hallux rigidus who do not experience significant pain relief after cheilectomy often require a conversion to metatarsophalangeal (MTP) fusion. However, it is unclear whether the previous cheilectomy affects outcomes of the subsequent fusion. The aim of this study was to compare patient-reported outcomes and complications in patients undergoing MTP fusion for hallux rigidus between patients with a history of cheilectomy and those undergoing a fusion as a primary procedure.

Methods

This retrospective cohort study included patients who underwent MTP fusion who had preoperative and minimum 1-year postoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores. Patients were divided into a "primary MTP fusion" cohort and a "prior cheilectomy" cohort based on their history of a previous cheilectomy. Preoperative, postoperative, and improvement in PROMIS scores, along with rates of complications including nonunion, infection, interphalangeal (IP) joint pain, and removal of hardware were compared between groups.

Results

The prior cheilectomy group had significantly lower preoperative physical function scores than the primary MTP fusion group (P < .05). Postoperatively, the prior cheilectomy group had worse physical function (P < .017) and global physical health (P < .017) scores. However, there were no significant differences in pre- to postoperative change in PROMIS scores. There were no significant differences in rates of nonunion (P = .99), infection (P = .99), or hardware removal (P = .99). More patients in the prior cheilectomy group had IP joint pain (P = .034).

Conclusion

This study found that a prior cheilectomy may not affect serious complication rates of a subsequent fusion, but it may be associated with worse baseline function. Overall, our results suggest that a prior failed cheilectomy does not influence the amount of improvement in function and pain from MTP fusion.

Level of Evidence

Level III, retrospective cohort study.

Responsiveness of the PROMIS physical function measure in orthopaedic trauma patients

OBJECTIVES

To compare the responsiveness of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) to the 36-Item Short Form Survey Physical Component Score (SF36-PCS) in orthopaedic trauma patients from pre-injury to one year recovery.

DESIGN AND SETTING

Prospective cohort study at a Level 1 trauma centre.

PARTICIPANTS

Patients over the age of 18 with orthopaedic trauma injuries to the pelvis, lower extremity or upper extremity between 2017 and 2018.

MAIN OUTCOMES MEASUREMENTS

The PROMIS-PF and SF36-PCS assessments were conducted at baseline, 3 months, 6 months and 12 months. Responsiveness of each measure was assessed between time points by calculating the standardized response mean (SRM), the proportions of patients exceeding minimal clinically important difference (MCID), and the floor and ceiling effects.

RESULTS

Sixty-eight patients with completed assessments at every timepoint were included: mean age 44.7 years, 39 were male and mean Injury Severity Score (ISS) was 7.4 (range: 4-16). Mean time of completion for the SF-36 at all the time points was 5.6 min vs 1.7 min for the PROMIS-PF (p<0.01). The SRM was comparable between measures at all the time points. Although a greater proportion of patients achieved MCID for SF36-PCS between all the time points, this only approached statistical significance between the 6- and 12-month assessments (47.1% vs 33.8%; p = 0.15). There was a significant ceiling effect demonstrated with the PROMIS-PF at baseline and 12-month assessments, with 34 (50.0%) patients and 7 (10.3%) patients achieving the maximum scores at each time point, respectively.

DISCUSSION AND CONCLUSIONS

PROMIS-PF has a more favourable responder burden based on lower time to completion and comparable responsiveness to the SF-36 PCS. However, there are limitations in responsiveness with the PROMIS-PF in patients who are higher functioning as demonstrated by the ceiling effects in patients at baseline pre-injury and at 12 months post-injury timepoints.

Long-Term Survival of HINTEGRA Total Ankle Replacement in 683 Patients: A Concise 20-Year Follow-up of a Previous Report

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

How Do PROMIS Scores Correspond to Common Physical Abilities?

BACKGROUND

The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly used as a general-purpose tool for measuring orthopaedic surgery outcomes. This set of questionnaires is efficient, precise, and correlates well with specialty-specific measures, but impactful implementation of patient-specific data, especially at the point of care, remains a challenge. Although clinicians may have substantial experience with established patient-reported outcome measures in their fields, PROMIS is relatively new, and the real-life meaning of PROMIS numerical summary scores may be unknown to many orthopaedic surgeons.

QUESTIONS/PURPOSES

We aimed to (1) identify a small subset of important items in the PROMIS Physical Function (PF) item bank that are answered by many patients with orthopaedic conditions and (2) graphically display characteristic responses to these items across the physical function spectrum in order to translate PROMIS numerical scores into physical ability levels using clinically relevant, familiar terms.

METHODS

In a cross-sectional study, 97,852 PROMIS PF assessments completed by 37,517 patients with orthopaedic conditions presenting to a tertiary-care academic institution were pooled and descriptively analyzed. Between 2017 and 2020, we evaluated 75,354 patients for outpatient orthopaedic care. Of these, 67% (50,578) were eligible for inclusion because they completed a PROMIS version 2.0 physical function assessment; 17% (12,720) were excluded because they lacked information in the database on individual item responses, and another < 1% (341) were excluded because the assessment standard error was greater than 0.32, leaving 50% of the patients (37,517) for analysis. The PROMIS PF is scored on a 0-point to 100-point scale, with a population mean of 50 and SD of 10. Anchor-based minimum clinically important differences have been found to be 8 to 10 points in a foot and ankle population, 7 to 8 points in a spine population, and approximately 4 points in a hand surgery population. The most efficient and precise means of administering the PROMIS PF is as a computerized adaptive test (CAT), whereby an algorithm intelligently tailors each follow-up question based on responses to previous questions, requiring only a few targeted questions to generate an accurate result. In this study, the mean PROMIS PF score was 41 ± 9. The questions most frequently used by the PROMIS CAT software were identified (defined in this study as any question administered to > 0.1% of the cohort). To understand the ability levels of patients based on their individual scores, patients were grouped into score categories: < 18, 20 ± 2, 25 ± 2, 30 ± 2, 35 ± 2, 40 ± 2, 45 ± 2, 50 ± 2, 55 ± 2, 60 ± 2, and > 62. For each score category, the relative frequency of each possible response (ranging from "cannot do" to "without any difficulty") was determined for each question. The distribution of responses given by each score group for each question was graphically displayed to generate an intuitive map linking PROMIS scores to patient ability levels (with ability levels represented by how patients responded to the PROMIS items).

RESULTS

Twenty-eight items from the 165-question item bank were used frequently (that is, administered to more than 0.1% of the cohort) by the PROMIS CAT software. The top four items constituted 63% of all items. These top four items asked about the patient's ability to perform 2 hours of physical labor, yard work, household chores, and walking more than 1 mile. Graphical displays of responses to the top 28 and top four items revealed how PROMIS scores correspond to patient ability levels. Patients with a score of 40 most frequently responded that they experienced "some difficulty" with physical labor, yard work, household chores, and walking more than 1 mile, compared with "little" or "no" difficulty for patients with a score of 50 and "cannot do" for patients with a score of 30.

CONCLUSION

We provided a visual key linking PROMIS numerical scores to physical ability levels using clinically relevant, familiar terms. Future studies might investigate whether using similar graphical displays as a patient education tool enhances patient-provider communication and improves the patient experience.

CLINICAL RELEVANCE

The visual explanation of PROMIS scores provided by this study may help new users of the PROMIS understand the instrument, feel empowered to incorporate it into their practices, and use it as a tool for counseling patients about their scores.

In-Office Needle Arthroscopy for the Treatment of Anterior Ankle Impingement Yields High Patient Satisfaction With High Rates of Return to Work and Sport

PURPOSE

To evaluate the clinical outcomes of in-office needle arthroscopy (IONA) for the treatment of anterior ankle impingement in the office setting and also evaluate patient experience of the IONA procedure.

METHODS

A prospectively collected database of 31 patients undergoing IONA for the treatment of anterior ankle impingement between January 2019 and January 2021 was retrospectively reviewed. Inclusion criteria for this study were patients ≥18 years of age, clinical history, physical examination, radiographic imaging, and magnetic resonance imaging findings consistent with anterior ankle impingement for which each patient underwent IONA and had a minimum of 12-month follow-up. Clinical outcomes were evaluated using the following methods preoperatively and at final follow-up: the Foot and Ankle Outcome Scores (FAOS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity domains. A 5-point Likert scale regarding patient satisfaction with their IONA procedure was evaluated at final follow-up. Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores.

RESULTS

In total, 31 patients were included in this study, including 18 male and 13 female, with a mean age of 41.7 ± 15.5 years (range, 17-69 years) and mean body mass index of 27.3 ± 5.7 (range, 19.37-41.5). The mean follow-up time was 15.5 ± 4.9 months. The mean postoperative FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 79.4 ± 11.9, 82.9 ± 15.3, 83.5 ± 15.4, 71.9 ± 18.5 and 64.3 ± 21.4 at final follow-up respectively. Minimal clinically important difference was achieved by 84% of patients for FAOS pain, 77% for FAOS symptoms, 75% for FAOS Quality of Life, 74% for FAOS sports, 65% for PROMIS Pain Interference, 61% for FAOS Activities of Daily Living, and 42% for PROMIS Pain Intensity. Lastly, 29 patients (94 %) expressed willingness to undergo the same procedure again.

CONCLUSIONS

The current study demonstrates that IONA treatment of anterior ankle impingement results in significant pain reduction, a low complication rate and excellent patient reported outcomes with high rates of return to work/sport. Additionally, IONA for anterior ankle impingement leads to high patient satisfaction with a significant willingness to undergo the same procedure again.

LEVEL OF EVIDENCE

IV, Case series study.

Impact of Asymptomatic Flatfoot on Clinical and Radiographic Outcomes of the Modified Lapidus Procedure in Patients With Hallux Valgus

Background

Patients with hallux valgus commonly present with concomitant flatfoot deformity. First-ray hypermobility, among other biomechanical factors, has been suggested as a potential link between these deformities. However, not all hallux valgus patients exhibit symptoms associated with flatfoot deformity, and the necessity of correcting the asymptomatic flatfoot at the time of hallux valgus correction is unclear. We aimed to investigate the relationship between asymptomatic flatfoot and patient-reported and radiographic outcomes after the Lapidus procedure.

Methods

This study included 142 patients who underwent the Lapidus procedure for hallux valgus at a single institution. Sixty-one patients met radiographic criteria for flatfoot. No patients exhibited symptoms related to flatfoot deformity on review of clinical notes. Preoperative, minimum 1-year postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores between asymptomatic flatfoot and control groups were compared. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary angle, talonavicular coverage angle (TNCA), and calcaneal pitch (CP) were compared.

Results

Preoperatively, the flatfoot group had higher BMI 22.6 vs 24.6 (P < .01) and IMA 15.32 vs 14.0 degrees (P < .05). Both groups demonstrated preoperative to postoperative improvement in PROMIS physical function (P < .01), pain interference (P < .001), pain intensity (P < .001), and global physical health (P < .001). There were no preoperative or postoperative differences in PROMIS scores between groups. Postoperatively, there were no differences in HVA or IMA between groups; however, the flatfoot group exhibited greater deformity in Meary angle, TNCA, and CP (all P < .001).

Conclusion

There were no significant postoperative differences in patient-reported outcomes of the Lapidus procedure between patients with and without asymptomatic flatfoot, and both groups achieved similar radiographic correction of their hallux valgus deformity. The Lapidus procedure appears to be a reasonable surgical option for hallux valgus correction in patients with asymptomatic flatfoot deformity.Level of Evidence: Level III, retrospective cohort study.

Modified Broström With and Without Suture Tape Augmentation: A Systematic Review

The Modified Broström has become the gold standard for operative management of chronic lateral ankle instability. Despite overall good clinical outcomes with this procedure, recent biomechanical data have called into question the strength and durability of this technique. Accordingly, the addition of suture tape to the Modified Broström construct has been described in an attempt to more closely recreate the natural biomechanical properties of the ankle lateral ligament complex. We performed a systematic review of the literature was using PubMed, Embase, and CINAHL to identify English-language articles from 2009 to present discussing outcomes with the augmented Modified Broström technique. A total of 4 studies (2 retrospective cohort studies, 2 case series) involving 156 patients with Modified Broström with augmentation met inclusion criteria. Average follow-up time was 13.8 months. Of the 3 studies reporting patient-reported outcome measures both pre- and postoperatively, there was a significant improvement in all measures (p < .05). Two studies compared the Modified Broström directly with and without augmentation, one of which found a statistically significant difference in the Foot and Ankle Ability Measure in favor of the augmentation group (93.1 vs 90.5, p = .027), while American Orthopaedic Foot and Ankle Society score was not significantly different (p > .05) between the 2 procedures across studies. There were no significant differences in complications between techniques. Modified Broström with suture tape augmentation for chronic lateral ankle instability can produce good short-term clinical outcomes with few complications, comparable to the Modified Broström alone.

Association of First Metatarsal Pronation Correction With Patient-Reported Outcomes and Recurrence Rates in Hallux Valgus

BACKGROUND

The purpose of this study was to determine if a postoperative decrease in first metatarsal pronation on 3-dimensional imaging was associated with changes in patient-reported outcomes as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, and pain intensity domains or recurrence rates in patients with hallux valgus (HV) who undergo a first tarsometatarsal fusion (modified Lapidus procedure).

METHODS

Thirty-nine consecutive HV patients who met the inclusion criteria and underwent a modified Lapidus procedure had preoperative and ≥2-year postoperative PROMIS scores and had first metatarsal pronation measured on preoperative and at least 5-month postoperative weightbearing CT scans were included. Multivariable regression analyses were used to investigate differences in the change in PROMIS domains preoperatively and 2 years postoperatively between patients with "no change/increased first metatarsal pronation" and "decreased first metatarsal pronation." A log-binomial regression analysis was performed to identify if a decrease in first metatarsal pronation was associated with recurrence of the HV deformity.

RESULTS

The decreased first metatarsal pronation group had a significantly greater improvement in the PROMIS physical function scale by 7.2 points (P = .007) compared with the no change/increased first metatarsal pronation group. Recurrence rates were significantly lower in the decreased first metatarsal pronation group when compared to the no change/increased first metatarsal pronation group (risk ratio 0.25, P = .025).

CONCLUSION

Detailed review of this limited cohort of patients who underwent a modified Lapidus procedure suggests that the rotational component of the HV deformity may play an important role in outcomes and recurrence rates following the modified Lapidus procedure.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Are Patient Reported Outcome Measurement Information System scales responsive in patients attending physical therapy with foot and ankle diagnoses?

BACKGROUND

Patient-reported outcomes (PROs) have been used to provide insight into the patient experience while uncovering an opportunity to improve patient care. Current studies document responsiveness of outcomes using the Patient Reported Outcome Measurement Information System (PROMIS) for a variety of orthopedic problems but are not specific to a physical therapy interval of care.

PURPOSE

The main purpose of this study was to examine responsiveness of the PROMIS Physical Function (PF) and Pain Interference (PI) scales across an interval of care for physical therapy in patients with foot and ankle conditions.

METHODS

Adult records (299 records, averaged 45.1 ± 15.4 years; 61% female) were assessed. Comparisons between pre- and post-physical therapy intervals of care were evaluated using a repeated-measures ANOVA, and the effect size was reported using Cohen's d.

RESULTS

PROMIS PF scores significantly improved from 38.5 ± 8.8 to 45.2 ± 9.1 (6.6; p < .001; Cohen's d = 1.0). PROMIS PI scores significantly improved from 56.8 ± 8.8 to 53.0 ± 9.8 (-3.8; p < .001; Cohen's d = 0.52).

CONCLUSIONS

The person-centered PROMIS PF and PI outcome measures were responsive to change following an interval of care in physical therapy for a large sample of orthopedic patients with foot and ankle diagnoses. The magnitude of change was dependent on starting score and diagnosis.

Does the Canadian Orthopaedic Foot and Ankle Society Postoperative COFAS End-Stage Ankle Arthritis Classification System Correlate With Pre- and Postoperative PROMIS Scores for Total Ankle Arthroplasty?

Background:

Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores.

Methods:

From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed.

Results:

Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function.

Conclusion:

The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes. Level of Evidence: Level IV, retrospective analysis of prospectively collected data.

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review

PURPOSE

This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy.

METHODS

A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria.

RESULTS

Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases.

CONCLUSION

The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment.

LEVEL OF EVIDENCE

Level IV.

Minimum Clinically Important Difference: A Metric That Matters in the Age of Patient-Reported Outcomes

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As the Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly utilized in orthopaedic research and clinical practice, there is not a consensus regarding the minimum clinically important difference (MCID) calculation.

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The varied MCID calculation methods can lead to a range of possible values, which limits the translatability of research efforts.

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The completion rate and follow-up period also influence MCID values and should be reported alongside study results.

Similar Functional Gains Using Radial Versus Combined Shockwave Therapy in Management of Plantar Fasciitis

Plantar fasciitis is a common condition that causes foot pain. While shockwave therapy has been shown to provide successful results, comparative outcomes from different forms of shockwave therapy have yet to be described for this condition. In this retrospective cohort study, we describe findings from a quality improvement initiative assessing safety and functional outcomes for patients with plantar fasciitis treated with radial shockwave therapy (n = 20) or radial and focused shockwave therapy (combined shockwave, n = 18). Most were runners (n = 31, 81.6%), mean age was 43.3 ± 12.9 years, and average symptom duration 12.1 ± 11.1 months. All patients were prescribed an exercise program focusing on foot intrinsic strengthening. We hypothesized both groups would have improvement in function using the foot and Ankle Ability Measure, with a similar safety profile. Both radial and combined groups received similar number of total treatments (4.9 ± 2.5 and 4.1 ± 2.4, respectively; p = .33). Within group score changes for the Activities of Daily Living and Sports subscales were observed for both the radial (16.5 ± 16.3, p < .001; 31.7 ± 23.1, p < .001) and combined groups (19.8 ± 10.8, p = .001; 26.0 ± 21.5, p = .003). There was no difference in proportion of patients meeting the minimal clinically important difference between radial and combined groups regarding the Activities of Daily Living (14 (70%) vs 14 (77.8%), p = .58) and Sports subscales (17 (85%) vs 12 (75%), p = .45). Collectively, these findings suggest that a majority of patients with chronic plantar fasciitis may achieve functional gains using either form of shockwave therapy.

Modified Lapidus vs Scarf Osteotomy Outcomes for Treatment of Hallux Valgus Deformity

BACKGROUND

The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy.

METHODS

This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders.

RESULTS

A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA; <9 degrees) was 25% lower (P = .04) with the scarf osteotomy compared with the Lapidus procedure.

CONCLUSION

Although the modified Lapidus procedure led to a higher probability of achieving a normal IMA, both procedures yielded similar improvements in 1-year patient-reported outcome measures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Clinical and Patient-Reported Outcomes Following Peroneus Brevis Reconstruction With Hamstring Tendon Autograft

BACKGROUND

Peroneal tendon injuries are a common cause of lateral ankle pain and instability. While the use of hamstring autograft has been proposed as a viable surgical option for peroneus brevis reconstruction, reported outcomes with this technique are limited in the literature. We present patient-reported and clinical outcomes for patients who underwent peroneus brevis reconstruction with hamstring autograft.

METHODS

Thirty-one patients were retrospectively identified who underwent a procedure including peroneus brevis reconstruction with hamstring autograft for peroneal tendinopathy between February 2016 and May 2019. All patients who had a peroneus brevis reconstruction were included, and all concomitant procedures were noted. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were prospectively collected preoperatively and at a minimum of 1 year postoperatively (mean, 24.3; range, 12-52.7) months. Retrospective chart review was performed to evaluate the incidence of postoperative complications and reoperations.

RESULTS

When evaluating pre- and postoperative patient-reported outcome surveys (n = 26; 84%), on average, patients reported improvement in every PROMIS domain evaluated, with significant improvement in Physical Function (+5.99; P = .006), Pain Interference (-8.11; P < .001), Pain Intensity (-9.02; P < .001), and Global Physical Health (+7.29; P = .001). Three patients reported persistent pain at a minimum of 1 year postoperatively, of whom 2 required reoperation. No patient reported persistent pain or discomfort at the harvest site of the hamstring autograft.

CONCLUSION

Patients undergoing peroneus brevis reconstruction with hamstring autograft experienced clinically significant improvement in patient-reported and clinical outcomes. Few postoperative complications were observed, and patients reported improvements across all patient-reported outcome domains, with significant improvements for pain and function domains. Reconstruction with hamstring autograft represents a viable surgical option in the setting of peroneal tendinitis or tears.

LEVEL OF EVIDENCE

Level IV, case series.

Evaluating Prospective Patient-Reported Pain and Function Outcomes After Ankle and Hindfoot Arthrodesis

Background:

Hindfoot and ankle fusions are mechanically limiting procedures for patients. However, patient-reported outcomes of these procedures have not been well studied. This study assessed outcomes of hindfoot and ankle fusions by using Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs).

Methods:

Between 2014 and 2018, 102 patients were prospectively enrolled after presenting to a tertiary care facility for ankle and hindfoot fusions, including tibiotalar, tibiotalocalcaneal, subtalar, and triple arthrodeses. Study participants completed preoperative and 12-month postoperative PF and PI CATs. The differences between mean 12-month postoperative and preoperative PROMIS PF and PI T scores were analyzed with paired t tests. The relationship between the 12-month PF and PI differences for the overall sample and patient factors was examined using multiple regression modeling.

Results:

The sample had mean age of 57.69 years; 48% were male, and 55% were obese. Patients who underwent ankle and hindfoot arthrodesis had statistically significant improvements from preoperative to 12 months postoperative in mean PF (36.26±7.85 vs 39.38±6.46, P = .03) and PI (61.07±7.75 vs 56.62±9.81, P = .02). Triple arthrodesis saw the greatest increases in physical function (▵PF = 7.22±7.31, P = .01) and reductions in pain (▵PI = –9.17±8.31, P = .01), achieving minimal clinically important difference (MCID). Patients who underwent tibiotalar fusion had significant improvement in physical function (▵PF = 4.18±5.68, P = .04) and pain reduction that approached statistical significance (▵PI = –6.24±8.50, P = .09), achieving MCID. Older age (≥60 years ) was associated with greater improvements in PF (β = 0.20, P = .07) and PI (β = –0.29, P = .04). Preoperative PF and PI T scores were significantly associated with the 12-month change in PF and PI T scores, respectively (β = –0.74, P < .01; β = –0.61, P < .01).

Conclusion:

Hindfoot and ankle fusions are procedures with favorable patient outcomes leading to increased physical function and decreased pain at 12 months postoperation relative to preoperation.

Level of Evidence:

Level II, prospective comparative study.

Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures

BACKGROUND

Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery.

METHODS

Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships.

RESULTS

Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters.

CONCLUSIONS

These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.

Anchored Minimal Clinically Important Difference Metrics: Considerations for Bias and Regression to the Mean

Minimal clinically important differences (MCIDs) are used to understand clinical relevance. However, repeated observations produce biased analyses unless one accounts for baseline observation, known as regression to the mean (RTM). Using an International Knee Documentation Committee (IKDC) survey dataset, we can demonstrate the effect of RTM on MCID values by (1) MCID-estimate dependence on baseline observation and (2) MCID-estimate bias being higher when the posttest-pretest data correlation is lower. We created 10 IKDC datasets with 5000 patients and a specific correlation under both equal and unequal variances. For each 10-point increase in baseline IKDC, MCID decreased by 3.5, 2.7, 1.9, 1.2, and 0.7 points when posttest-pretest correlations were 0.10, 0.25, 0.50, 0.75, and 0.90, respectively, under equal variances. Not accounting for RTM resulted in a static 20-point MCID. Minimal clinically important difference estimates may be unreliable. Minimal clinically important difference calculations should include the correlation and variances between posttest and pretest data, and researchers should consider using a baseline covariate-adjusted receiver operating characteristic curve analysis to calculate MCID.

Defining Clinically Significant Improvement on the Patient-Reported Outcomes Measurement Information System Test at 1-Year Follow-up for Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome

BACKGROUND

Although minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) have been defined for hip-specific legacy patient-reported outcome measures, these metrics have not been defined for the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments for patients undergoing hip arthroscopy.

PURPOSE

To define the MCID, PASS, and SCB thresholds for the PROMIS Physical Function (PF) computerized adaptive test (CAT) and PROMIS Pain Interference (PI) instruments in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

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

METHODS

Patients undergoing primary hip arthroscopy between August 2018 and January 2019 for the treatment of FAIS were retrospectively analyzed. Patients were administered the PROMIS-PF, PROMIS-PI, Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 preoperatively and at 1 year postoperatively. MCID was calculated using the distribution method, whereas PASS and SCB were calculated using an anchor-based method. Patients achieving clinically significant outcomes (CSOs) were compared with those who did not achieve CSOs via chi-square and independent-samples t tests, and a multivariate logistic regression was conducted to determine predictors of CSO achievement.

RESULTS

124 patients with a mean age of 32.7 ± 12.3 years were included in the analysis. The threshold scores required to achieve MCID, PASS, and SCB, respectively, were as follows: PROMIS-PI (-3.1, 53.7, 51.9) and PROMIS-PF (3.3, 47.0, 49.9). Patients achieved any MCID, PASS, and SCB for PROMIS scores at a rate of 89.0%, 71.8%, and 62.1%, respectively, compared with 87.1%, 76.6%, and 71.8% for legacy patient-reported outcome measurements. For PROMIS-PF, higher preoperative PROMIS-PF score was a positive predictor of CSO achievement, and patients achieving SCB were significantly younger (30.3 ± 12 vs 35.6 ± 12 years; P = .017) with significantly lower body mass index (BMI) (24.7 ± 6.4 vs 27.9 ± 7; P = .009). Preoperative chronic pain and history of orthopaedic surgery were negative predictors of PROMIS-PI CSO achievement, whereas higher (worse) preoperative PROMIS-PI scores were a positive predictor.

CONCLUSION

Our study defined the MCID, PASS, and SCB for the PROMIS-PF CAT and PROMIS-PI CAT at 1 year postoperatively. Patients with higher preoperative PROMIS scores, younger age, and lower BMI were more likely to achieve CSO, whereas preoperative chronic pain and history of orthopaedic surgery were negative predictors of CSO achievement.

Preoperative PROMIS Physical Function Scores Predict Postoperative Outcomes Following Total Ankle Replacement

BACKGROUND

Despite good evidence that supports significant improvements in pain and physical function following a total ankle replacement (TAR) for end-stage ankle arthritis, there is a subset of patients who do not significantly benefit from surgery. The purpose of this study was to perform a preliminary analysis to determine if preoperative Patient-Reported Outcome Measurement Information System (PROMIS) scores could be used to predict which patients were at risk of not meaningfully improving following a TAR.

METHODS

Prospectively collected preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 111 feet in 105 patients were included in the study. Significant postoperative improvement was defined using minimal clinically important differences (MCIDs). Logistic regression models and area under the curve (AUC) analyses were used to determine whether preoperative PROMIS scores were predictive of postoperative outcomes.

RESULTS

Receiver operating characteristic curves found statistically significant AUCs for the PROMIS physical function (AUC = 0.728, P = .004), pain intensity (AUC = 0.720, P = .018), and depression (AUC = 0.761, P < .001) domains. The preoperative PROMIS pain interference domain did not achieve a statistically significant AUC.

CONCLUSION

Preoperative PROMIS physical function and pain intensity t scores may be used to predict postoperative improvement in patients following a fixed-bearing TAR; however, preoperative PROMIS pain interference scores were not good predictors. The results of this study may be used to guide research regarding patient-reported outcomes following TAR.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients

Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

A Staged Approach to Combined Extra-articular Limb Deformity Correction and Total Ankle Arthroplasty for End-Stage Ankle Arthritis

BACKGROUND

Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation.

METHODS

Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity-Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function).

RESULTS

Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), P = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), P = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), P < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), P = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), P = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), P = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), P = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), P = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), P = .007. There was one incidence of pin site infection and one reoperation.

CONCLUSION

Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimal important change (MIC): a conceptual clarification and systematic review of MIC estimates of PROMIS measures

We define the minimal important change (MIC) as a threshold for a minimal within-person change over time above which patients perceive themselves importantly changed. There is a lot of confusion about the concept of MIC, particularly about the concepts of minimal important change and minimal detectable change, which questions the validity of published MIC values. The aims of this study were: (1) to clarify the concept of MIC and how to use it; (2) to provide practical guidance for estimating methodologically sound MIC values; and (3) to improve the applicability of PROMIS by summarizing the available evidence on plausible PROMIS MIC values. We discuss the concept of MIC and how to use it and provide practical guidance for estimating MIC values. In addition, we performed a systematic review in PubMed on MIC values of any PROMIS measure from studies using recommended approaches. A total of 50 studies estimated the MIC of a PROMIS measure, of which 19 studies used less appropriate methods. MIC values of the remaining 31 studies ranged from 0.1 to 12.7 T-score points. We recommend to use the predictive modeling method, possibly supplemented with the vignette-based method, in future MIC studies. We consider a MIC value of 2-6 T-score points for PROMIS measures reasonable to assume at this point. For surgical interventions a higher MIC value might be appropriate. We recommend more high-quality studies estimating MIC values for PROMIS.

Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review

IMPORTANCE

Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries.

OBJECTIVE

To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies.

EVIDENCE REVIEW

Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms "anterior cruciate ligament," "peroneus longus" and "fibularis longus" alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool.

FINDINGS

Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7 mm among the different preparation techniques, which is comparable with reports of HT grafts.

CONCLUSIONS AND RELEVANCE

The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions.

LEVEL OF EVIDENCE

Level III.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Comparison Between Polyvinyl Alcohol Implant and Cheilectomy With Moberg Osteotomy for Hallux Rigidus

BACKGROUND

In 2016, the US Food and Drug Administration (FDA) approved the use of a polyvinyl alcohol (PVA) hydrogel implant for the surgical management of hallux rigidus. Though recent studies have evaluated the safety and efficacy of the implant, no study has compared outcomes following PVA implantation with those following traditional joint-preserving procedures for hallux rigidus, such as cheilectomy with Moberg osteotomy. The purpose of this study was to compare clinical and patient-reported outcomes for patients undergoing cheilectomy and Moberg osteotomy, with or without PVA implant, at a single multisurgeon academic center. Our hypothesis was that the addition of the PVA implant would result in superior clinical and patient-reported outcomes.

METHODS

In total, 166 patients were identified who underwent cheilectomy and Moberg osteotomy with (PVACM; n = 72) or without (CM; n = 94) a PVA implant between January 2016 and December 2018 by 1 of 8 foot and ankle fellowship-trained orthopedic surgeons at our institution. Of these patients, 60 PVACM and 73 CM patients had both baseline and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. The average time to survey follow-up was 14.5 months for PVACM patients and 15.6 months for CM patients. Retrospective chart review was performed to assess the incidence of postoperative complications and reoperations, with an average clinical follow-up of 27.7 (range, 16.0-46.4) months for PVACM patients and 36.6 (range, 18.6-47.8) months for CM patients.

RESULTS

Both PVACM and CM cohorts demonstrated significant improvement in the PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains when comparing preoperative and postoperative scores within each group (P < .01). When comparing scores between the PVACM and CM cohorts, preoperative scores were similar, while CM patients demonstrated significantly higher postoperative Physical Function (51.8 ± 8.7 vs 48.8 ± 8.0; P = .04) and significantly lower Pain Intensity (39.9 ± 8.3 vs 43.4 ± 8.7; P = .02) scores. The pre- to postoperative change in Physical Function was also significantly greater for CM patients (7.1 ± 8.5 vs 3.6 ± 6.2; P = .011). In the PVACM group, there were 3 revisions (5%), 1 reimplantation, 1 conversion to arthrodesis, and 1 revision to correct hyperdorsiflexion. In the CM group, there was 1 revision (1.4%), a conversion to arthrodesis (P = .21). Other postoperative complications included persistent pain (7 out of 60 PVACM patients [11.7%] and 8 out of 73 CM patients [11.0%]; P = .90) and infection in 3 PVACM patients (5%) and no CM patients (P = .05).

CONCLUSION

Though our results generally support the safety and utility of the PVA implant as previously established by the clinical trial, at 1 to 2 years of follow-up, CM without a PVA implant may provide equivalent or better relief compared with a PVACM procedure, while avoiding potential risks associated with the implant.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes of Idiopathic Flexible Flatfoot Deformity Reconstruction in the Young Patient

Background:

Operative correction of flatfoot deformity has been well studied in the older population. There is a subset of younger patients without congenital foot deformity that also develop a collapsing flatfoot. However, assessment of outcomes across age groups is limited, especially in the young demographic. The purpose of our study was to compare operative outcomes of flatfoot reconstruction between these 2 age groups.

Methods:

Seventy-six feet (41 left, 35 right) in 71 patients who underwent flexible flatfoot reconstruction were divided into 2 groups based on age: ≤30 years (n = 22) and >30 years (n = 54). Exclusion criteria included congenital causes of flatfoot (tarsal coalition, vertical talus, overcorrected clubfoot). Average age was 20.8 years (range, 14-30) and 55.4 years (range, 35-74) in the younger and older cohorts, respectively. Preoperative and minimum 2-year postoperative Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores were compared. Five radiographic parameters were assessed pre- and postoperatively: talonavicular coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, and hindfoot moment arm. Procedures performed and incidence of minor (removal of symptomatic hardware) and major (revision) reoperations were compared.

Results:

Younger patients were less likely to undergo flexor digitorum longus transfer, first tarsometatarsal fusion, spring ligament repair, and posterior tibial tendon repair (all P < .05). Both younger and older cohorts demonstrated significant improvement in multiple PROMIS domains at an average follow-up of 30.6 (range, 24-44) and 26.8 (range, 24-45) months, respectively ( P = .07). Younger patients demonstrated significantly higher pre- and postoperative Physical Function (mean difference postoperatively, 4.6; 95% confidence interval, 1.5-7.8; P = .03). There were no differences in radiographic parameters postoperatively. There were 8 (36.4%) reoperations (all minor) in the younger group, and 21 (38.9%) reoperations (6 major, 15 minor) in the older group ( P = .84).

Conclusion:

Our data suggest that age may play a role in clinical outcomes, procedures indicated, and subsequent corrective reoperations. Younger patients maintained greater physical function with comparable radiographic correction, with less frequent indication for tendon transfers, arthrodesis, and additional corrective surgeries.

Level of Evidence:

Level III, retrospective comparative study.

Contribution of First-Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult-Acquired Flatfoot Deformity

Background:

Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. However, many surgeons surgically correct the deformity without directly addressing this joint. The purpose of this study was to examine the role of first-tarsometatarsal (TMT) fusion combined with subtalar fusion in correcting deformity at the NC joint.

Methods:

We retrospectively analyzed 40 patients (41 feet) who underwent first-TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed 6 radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1-year follow-up.

Results:

The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (P < .01). Overall, patients had statistically significant improvement in all PROMIS domains (P < .01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes.

Conclusions:

Our data suggest that when addressing painful collapse of the medial arch in patients with AAFD, fusion of the first-TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint in our patient cohort at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Although TMT fusion had no effect on NC deformity, residual or worsening NC deformity did not significantly affect clinical outcomes. In addition, the NCIA was found to be a reliable radiographic parameter to assess NC deformity in the presence of talonavicular and/or first-TMT fusion.

Level of Evidence:

Level III, retrospective comparative study.

The Effect of Health Insurance Coverage on Orthopaedic Patient-reported Outcome Measures

INTRODUCTION

Patient-reported outcome measures (PROMs) are used to assess performance and value. The type of health insurance coverage may influence outcomes scores. The goal of this study was to determine if the type of insurance coverage is associated with the trends in PROMs within an orthopaedic cohort.

METHODS

We reviewed the electronic medical records of 10,745 adult foot and ankle patients who completed PROMs questionnaires from 2015 to 2017. Patients completed the Foot and Ankle Ability Measure, PROMIS Global-Mental, PROMIS Global-Physical, and PROMIS Physical Function Short Form 10a. Descriptive analyses, analysis of variance, and Tukey HSD (honest significant difference) post hoc analyses were conducted.

RESULTS

Patients with commercial insurance consistently had the highest outcomes scores, whereas those with Workers Comp/Motor Vehicle and Medicaid had the lowest. PROMs of patients with commercial insurance were statistically significantly higher than the pooled scores of all other patients. Markedly poorer scores were also seen for Workers Comp/Motor Vehicle and Medicaid. In addition, these differences in PROMs for Workers Comp/Motor Vehicle and Medicaid exceeded the minimal clinically important differences. Patients with Medicare or Free Care had generally lower scores than the pooled averages, but these results were not statistically significant.

DISCUSSION

PROMs scores vary between the patients with different insurance types in an orthopaedic foot and ankle cohort. These data suggest that patient insurance type may affect patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort.

Functional Results of All-Inside Arthroscopic Broström-Gould Surgery With 2 Anchors Versus Single Anchor

BACKGROUND

The all-inside arthroscopic Broström-Gould technique gained particular attention among clinicians and researchers due to its high rate of satisfactory results. Thus far, there is a lack of evidence regarding the differences in clinical outcomes between the use of 1 anchor and 2 anchors. The purpose of this study was to compare the differences in clinical function and activity levels in patients treated with 1 or 2 anchors in all-inside arthroscopic Broström-Gould surgery for chronic lateral ankle instability (CLAI).

METHODS

The data of 75 patients with CLAI (unilateral) admitted from May 2013 to July 2016 were retrospectively analyzed. All patients were treated with all-inside arthroscopic Broström-Gould surgery. The patients were divided into a single-anchor group (n = 36) and double-anchor group (n = 39) according to the number of anchors used. There was no statistical difference in general characteristics between the 2 groups before surgery. After 36 to 72 months of follow-up, the pain visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Foot and Ankle Outcome Score (FAOS) were used to evaluate and compare the clinical function results between the 2 groups.

RESULTS

The incidence of wound complications; reaction to the suture; injury to the nerve, blood vessel, or tendon; and length of postoperative hospitalization were similar between the 2 groups. At the last follow-up, there was no significant difference in the VAS and AOFAS scores between single- and double-anchor groups, but the KAFS and FAOS in the double-anchor group were significantly higher than in the single-anchor group. Additionally, more patients in the double-anchor group returned to preinjury sports activities.

CONCLUSION

All-inside arthroscopic Broström-Gould surgery for the treatment of CLAI yielded a better functional effect and better recovery to preinjury mobility when 2 anchors were used instead of a single anchor.

LEVEL OF EVIDENCE

Level III, comparative study.

Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study

Background

Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication.

Methods

This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points.

Results

The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance.

Conclusion

Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis.

Level of evidence

Level II, prospective single cohort study.

Operative Intervention Does Not Change Pain Perception in Patients With Diabetic Foot Ulcers

Researchers investigated pain perception in patients with diabetic foot ulcers (DFUs) by analyzing pre- and postoperative physical function (PF), pain interference (PI), and depression domains of the Patient-Reported Outcome Measurement Information System (PROMIS). They hypothesized that 1) because of painful diabetic peripheral neuropathy (DPN), a majority of patients with DFUs would have high PROMIS PI scores unchanged by operative intervention, and 2) the initially assessed PI, PF, and depression levels would be correlated with final outcomes. Seventy-five percent of patients with DFUs reported pain, most likely because of painful DPN. Those who reported high PI and low PF were likely to report depression. PF, PI, and depression levels were unchanged after operative intervention or healing of DFUs.