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

Comparison of shock wave therapy and Low-dye tape method in patients with plantar fasciitis: A randomized controlled study

Plantar fasciitis is a common musculoskeletal issue that can cause severe pain and limit functionality. This study aimed to compare the effectiveness of Extracorporeal shock-wave therapy and Low-dye taping in relieving pain and improving functionality in plantar fasciitis. The study included cases with a confirmed diagnosis of plantar fasciitis, which were randomly divided into two groups: Extracorporeal shock-wave therapy and Low-dye taping. The subjects in the Extracorporeal shock-wave therapy group were treated with Extracorporeal shock-wave therapy, while the subjects in the Low-dye taping group were treated with Low-dye taping and sham Extracorporeal shock-wave therapy. Both treatments were administered in three sessions, once a week. Pain and functionality levels were evaluated using the Visual analog scala and Foot&Ankle Outcome Score. Evaluations were conducted pre- and post-treatment, and at the six-week follow-up. Seventy-two subjects completed the study, and at the end of the treatment and follow-up periods, both groups showed a significant decrease in pain levels (p≤0.001) and an increase in functionality levels (p≤0.001) compared to the beginning. However, there was no significant difference between the groups regarding pain and functionality levels at the end of the treatment and follow-up period (p > 0.05). Therefore, both Extracorporeal shock-wave therapy and Low-dye taping treatments were found to have similar effects in treating plantar fasciitis. These findings can guide clinicians in choosing the most effective conservative treatment for plantar fasciitis patients.

Outcome measures after foot and ankle surgery: A Systematic Review

BACKGROUND

Research on outcomes measures after foot and ankle surgery is limited and methodological quality is not always assessed. We aimed to evaluate the measurement properties of patient-related outcome measures used in patients after foot- and ankle surgery.

METHODS

A Medline, Embase and Web of Sciences systematic review was performed including dates from 2000 up to April 2022. Inclusion criteria were foot and/or ankle surgery, described outcome(s) and it's assessed measurement properties. Methodological quality assessment was performed using the NOS-scale and the COSMIN-criteria.

RESULTS

143 studies (n = 18383) were included for final review, 82 about PROMs, 61 about clinical outcomes. A total of 23 different PROMs were evaluated, with a positive result in all measurement properties for the FAOS. There were positive results too for most measurement properties of the LEFS and the MOXFQ. Most clinical outcomes were radiological measures, with a high reliability for most measurements on plain radiographs and CT-scans.

CONCLUSIONS

To monitor foot and ankle outcome and evaluate treatment, we recommend the FAOS as the most suitable foot and ankle PROM.

LEVEL OF CLINICAL EVIDENCE

2.

Augmentation with the inferior extensor retinaculum may facilitate earlier recovery in all-inside arthroscopic management of chronic lateral ankle instability

BACKGROUND

To compare the clinical outcomes of inferior extensor retinaculum (IER) augmentation following repair of the anterior talofibular ligament (ATFL) with isolated ATFL repair in patients with an arthroscopically confirmed grade 3 lesion of the ATFL.

METHODS

We conducted a retrospective study of consecutive chronic lateral ankle instability (CLAI) patients who underwent arthroscopic ATFL repair between March 2018 and August 2022. The average age of the patients was 31.5 ± 7.4 years (range, 16-50 years). All patients underwent all-inside arthroscopic repair, and were divided into two groups based on the ligament repair method: the Broström-Gould group (n = 64) and the Broström group (n = 67). At 3, 6, 12 and 24 months after surgery, ankle inversion stress tests and anterior drawer tests were employed to assess the stability of the ankle joint. The American Orthopedic Foot and Ankle Society ankle hindfoot scale(AOFAS-AH) and Karlsson ankle function score (KAFS) were employed to assess ankle function; the Tegner score was employed to assess the patient's level of exercise; the Foot and Ankle Outcome Score [FAOS, including score of symptoms-diseases, pain, function-daily living score, function in sports and recreational activities, and quality of life] was used to assess the patient's daily activity ability.

RESULTS

The Tegner score, FAOS-function-daily living score, and FAOS-function in sports and recreational activities in the Broström-Gould group consistently outperformed the Broström group at 3 months and 6 months post-surgery, with the differences being statistically significant (all P < 0.05). However, although the differences are statistically significant, the clinical relevance of this statistical significance remains uncertain. At 12 and 24 months, there were no statistically significant differences between the two groups.

CONCLUSIONS

For CLAI patients with arthroscopic grade 3 lesion of the ATFL, both the all-inside arthroscopic Broström-Gould procedure and the Broström procedure provide stability and enhance ankle joint function, resulting in similar functional outcomes at a 2-year follow-up. IER augmentation following ATFL repair may facilitate earlier recovery exercises compared to isolated all-inside ATFL repair.

Establishment of Minimum Clinically Important Difference and Patient Acceptable Symptom State Thresholds for Foot and Ankle Ability Measure and Visual Analog Scale Scores After Hallux Valgus Surgery

BACKGROUND

Although clinically relevant thresholds such as minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) have been widely described across orthopaedics, their application in hallux valgus surgery remains scarce. The purpose of this study was to determine the MCID and PASS thresholds for the visual analog scale (VAS) and Foot and Ankle Ability Measure (FAAM) scores after hallux valgus surgery.

METHODS

A retrospective review was performed in patients undergoing hallux valgus surgery at a single institution from January 2021 through December 2022. Patient-reported outcome measures (PROMs) were collected preoperatively and 1 year postoperatively. The specific PROMs used were the FAAM-activities of daily living (FAAM-ADL), Single Assessment Numeric Evaluation (SANE), and VAS scale. Two methods were used to calculate MCID and PASS thresholds: a distribution-based approach for MCID and an anchor-based approach using responses to a 1-year postoperative satisfaction question for PASS. The analysis identified optimal cutoff points that maximized sensitivity and specificity based on the Youden index. Overall, 86% (136/158) completed baseline PROMs, and 73% (99/136) completed 1-year PROMs.

RESULTS

The distribution-based MCID for FAAM-ADL, SANE, and VAS were calculated to be 10.8, 14.1, and 1.2, respectively. The percentage of patients who achieved MCID thresholds was 54% for FAAM-ADL, 42% for SANE, and 96% for VAS. The PASS threshold for FAAM-ADL, SANE, and VAS were ≥78.5, ≥85, and ≤ 2, respectively. The percentage of patients who achieved PASS thresholds was 78% for FAAM-ADL, 72% for SANE, and 69% for VAS.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds of FAAM-ADL, SANE, and VAS scores at 1-year follow-up for patients undergoing hallux valgus surgery. Overall, despite not meeting the MCID thresholds, patients undergoing hallux valgus surgery were still likely to be satisfied with their surgery.

Concomitant Chronic Lateral Ankle Instability Affects Postoperative Functional Outcomes in Patients With Osteochondral Lesions of the Talus but Does Not Affect Cartilage Repair After Restoration of Ankle Stability

PURPOSE

To investigate the effect of concomitant chronic lateral ankle instability (CLAI) on postoperative clinical outcomes in patients with osteochondral lesions of the talus (OLTs).

METHODS

Patients who underwent surgery for OLTs between January 2018 and May 2022 were retrospectively evaluated. OLT patients underwent debridement, microfracture, or bone grafting, whereas patients with concomitant CLAI underwent lateral ligament repair or reconstruction. Functional assessments included the visual analog scale score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), and Tegner score, with a minimum follow-up of 24 months. Cartilage repair was evaluated using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 1 and MOCART 2.0 scores based on postoperative magnetic resonance imaging. Additionally, multiple linear regression analysis was performed to explore the effects of potential factors, and Spearman correlation coefficients (rs) were calculated to assess the relationship between these factors and outcome scores.

RESULTS

A total of 85 patients were included, with 39 in the OLT group and 46 in the OLT-CLAI group. The mean follow-up times were 46.95 ± 17.00 months (range, 24-76 months) and 41.80 ± 15.10 months (range, 24-76 months), respectively (P = .347). Compared with the OLT group, the OLT-CLAI group showed lower postoperative AOFAS and FAOS scores, with a significantly smaller overall improvement in the AOFAS score (P < .05). There was no significant difference in the number of patients achieving the minimal clinically important difference in functional scores between the groups. Multiple linear regression analysis showed that CLAI surgery negatively affected postoperative AOFAS (standardized β = -0.344, P = .001) and FAOS (standardized β = -0.332, P = .001) scores, with Spearman analysis indicating a moderate correlation (rs = -0.442 [P < .001] and rs = -0.339 [P = .002], respectively). No significant differences were observed between the groups in terms of MOCART 1 (61.52 ± 12.38 vs 65.89 ± 14.47) or MOCART 2.0 (68.70 ± 16.53 vs 73.75 ± 14.76) scores (P > .05), and multiple linear regression as well as Spearman analysis did not yield positive results.

CONCLUSIONS

OLT patients with concomitant CLAI had lower postoperative functional outcomes than those without CLAI. However, after surgical treatment of CLAI, cartilage repair in OLT patients was not affected.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of short term recovery in patients with midportion Achilles tendinopathy with varying degrees of kinesiophobia treated with the Silbernagel protocol: A prospective single cohort analysis

OBJECTIVE

To assess short term recovery between individuals with Achilles tendinopathy with varying degrees of kinesiophobia when treated with the Silbernagel protocol. Secondarily to investigate short term change in degree of kinesiophobia.

DESIGN

Prospective single cohort analysis.

SETTING

University/Clinical.

PARTICIPANTS

116 participants with midportion Achilles tendinopathy were grouped from their baseline Tampa Scale of Kinesiophobia (TSK) score: Low (≤33), Medium (34-41), and High (≥42).

MAIN OUTCOME MEASURES

Symptom severity, Achilles tendon structure, and function were assessed at baseline and 8-weeks following initiation of the Silbernagel protocol. Differences in recovery between TSK groups were analyzed.

RESULTS

No group by time interactions were observed for symptoms, structure, or function. A significant interaction of group by time was observed for TSK score. The Medium (n = 66) and High (n = 28) TSK groups significantly decreased TSK score after 8 weeks by 2.4 and 4.4 points respectively while the Low TSK group (n = 22) did not change.

CONCLUSION

There were no differences in short term recovery of symptoms, Achilles tendon structure, and function in individuals with midportion Achilles tendinopathy treated with the Silbernagel protocol regardless of baseline degree of kinesiophobia. Those with moderate and high levels of kinesiophobia at baseline decreased TSK score in the short term.

Direct repair of the chronic ochronotic Achilles tendon rupture: a case report

BACKGROUND

Alkaptonuria (AKU) is a rare hereditary disease. Ochronotic arthropathy, tendinopathy, and osteopenia/osteoporosis are generally musculoskeletal manifestations in patients with AKU. Because of the ochronotic tendinopathy and osteopenia, the surgical strategy for chronic ochronotic Achilles tendon rupture may be challenging. No studies have reported the surgical treatment of chronic Achilles tendon rupture in patients with AKU.

CASE PRESENTATION

We report a case of AKU that required surgical treatment for chronic Achilles tendon rupture. A 60-year-old woman was referred to our department for the assessment of left hindfoot pain that persisted for more than nine months after an ankle sprain. Three years prior to the first presentation to our hospital, she was diagnosed with AKU due to pigmented hip cartilage at the time of total hip arthroplasty. The patient was diagnosed as chronic Achilles tendon rupture based on the results of physical examination and magnetic resonance imaging (MRI). The MRI showed enlarged scar tissue of the Achilles tendon with an intrasubstance high signal intensity. We performed resection of the central part of the scar tissue (total length, 24 mm) followed by direct repair using the proximal and distal stumps of the scar tissue. The MRI at 12months after surgery showed continuity of the repaired Achilles tendon. At 18 months after surgery, the Achilles Tendon Total Rupture Score improved from 22 points preoperatively to 84 points postoperatively. The foot and ankle outcome score also improved.

CONCLUSIONS

We reported a case of AKU with chronic Achilles tendon rupture in which direct repair using scar tissue between the tendon stumps was effective. Careful selection of the surgical procedure for the treatment of chronic ochronotic Achilles tendon rupture is recommended because of concomitant ochronotic tendinopathy and osteopenia/osteoporosis.

The minimal important change is not a universal fixed value across diagnoses when using the FAOS and FAAM in patients undergoing elective foot and ankle surgery

PURPOSE

This study aimed to calculate region and diagnosis-specific minimal important changes (MICs) of the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) in patients requiring foot and ankle surgery and to assess their variability across different foot and ankle diagnoses.

METHODS

The study used routinely collected data from patients undergoing elective foot and ankle surgery. Patients had been invited to complete the FAOS and FAAM preoperatively and at 3-6 months after surgery, along with two anchor questions encompassing change in pain and daily function. Patients were categorised according to region of pathology and subsequent diagnoses. MICs were calculated using predictive modelling (MICPRED) and receiver operating characteristic curve (MICROC) method and evaluated according to strict credibility criteria.

RESULTS

Substantial variability of the MICs between forefoot and ankle/hindfoot region was observed, as well as among specific foot and ankle diagnoses, with MICPRED and MICROC values ranging from 7.8 to 25.5 points and 9.4 to 27.8, respectively. Despite differences between MICROC and MICPRED estimates, both calculation methods exhibited largely consistent patterns of variation across subgroups, with forefoot conditions systematically showing smaller MICs than ankle/hindfoot conditions. Most MICs demonstrated high credibility; however, the majority of the MICs for the FAOS symptoms subscale and forefoot conditions exhibited insufficient or low credibility.

CONCLUSION

The MICs of the FAOS and FAAM vary across foot and ankle diagnoses in patients undergoing elective foot and ankle surgery and should not be used as a universal fixed value, but recognised as contextual parameters. This can help clinicians and researchers in more accurate interpretation of the FAOS and FAAM change scores.

LEVEL OF EVIDENCE

Level IV.

Responsiveness of specific and generic patient-reported outcome measures in patients with plantar fasciopathy

PURPOSE

To evaluate and compare responsiveness characteristics for the Foot Function Index revised short form (FFI-RS), RAND-12 Health Status Inventory (RAND-12), and Numeric Rating Scale (NRS), in patients with plantar fasciopathy receiving non-surgical treatment.

MATERIALS AND METHODS

This study was conducted on a sub-group of patients from an ongoing randomised controlled trial. One-hundred fifteen patients were included. The patient-reported outcome measures (PROMs) were applied at baseline and after 6 months. Responsiveness was calculated using standardised response mean and area under the receiver operating characteristic (ROC) curve. ROC curves were used to compute the minimal important change (MIC) for the outcome measures.

RESULTS

The region specific FFI-RS had best responsiveness and the NRS at rest had lowest responsiveness.

CONCLUSION

FFI-RS were marginally more responsive than the other PROMs. Responsiveness and MIC estimates should be regarded as indicative rather than fixed estimates.

Assessing Functional Ankle Instability in Sport: A Critical Review and Bibliometric Analysis

Functional Ankle Instability (FAI) is the subject of extensive research in sports and other environments. Given the importance of accurately measuring this latent construct, it is imperative to carry out a careful assessment of the available tools. In this context, the aim of this review was to take an in-depth look at the six most cited measurement tools to assess FAI, with a specific focus on patient-reported outcome measures related to ankle and foot. Four electronic databases (Web of Science, Scopus, Pubmed, and SportDiscus) were searched (up to November 2022) to identify the six most cited questionnaires for assessing FAI. Our analysis showed that the most cited questionnaires are the following: the Lower Extremity Functional Scale (LEFS), the Foot Function Index (FFI), the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the Olerud and Molander Ankle Score (OMAS), and the Cumberland Ankle Instability Tool (CAIT). Each questionnaire was thoroughly assessed and discussed in three sections: Development, Reliability, and Summaries. In addition, bibliometric data were calculated to analyze the relevance of each questionnaire. Despite variations in terms of validity and reliability, conceptualization, structure, and usefulness, the six questionnaires proved to be robust from a psychometric point of view, being widely supported in the literature. The bibliometric analyses suggested that the FAOS ranks first and the FFI ranks sixth in the weighted average of the impact factors of their original publications.

Favorable Short-Term Outcomes of a Patient With Symptomatic Bipartite Navicular Bone Treated by Screw Fixation

Bipartite navicular bone is an uncommon foot pathology that generally occurs in adolescent patients. However, some patients may become symptomatic during adulthood. When conservative treatment fails, surgical treatment is performed. However, due to a lack of high-quality evidence, the optimal surgical strategy for bipartite navicular remains unclear. The talonavicular arthrodesis and internal fixation of the fragment have been reported as the surgical choice of the symptomatic bipartite navicular. The internal fixation of the fragment may have a high risk of postoperative nonunion. However, talonavicular arthrodesis results in the limitation of the motion and function of the midfoot, which may cause dysfunction or osteoarthritis of the adjacent joints. This paper aims to present an adult case of symptomatic bipartite navicular that was treated by the internal fixation of the fragment using screws, with a favorable short-term outcome.

The Influence of Hip-Strengthening Program on Patients with Chronic Ankle Instability

Background and Objectives: Repetitive ankle sprains lead to mechanical instability of the ankle. Patients with chronic ankle instability may experience decreased muscle strength and limited postural control. This study investigated the effects of a hip-strengthening exercise program on muscle strength, balance, and function in patients with chronic ankle instability. Materials and Methods: A total of 30 patients participated in the study and were randomly assigned to the two groups. Among the 30 participants, 14 were assigned to the hip joint-strengthening exercise group and 16 to the control group. The experimental group underwent a hip-strengthening exercise program and received training for 40 min per session twice a week for four weeks. The control group received the same frequency, duration, and number of sessions. Measurements were performed before and after the training period to assess changes in hip strength, balance, and function. Results: In the within-group and between-group comparisons, both groups showed significant differences in hip joint strength, static balance, dynamic balance, and function (FAAM; foot and ankle ability measures) (p < 0.05). Statistically significant differences were observed in the time × group interaction effects among the hip abductors and external rotation in hip joint strength, path length in static balance, posterolateral and posteromedial in dynamic balance, and FAAM-ADL and FAAM-SPORT functions (p < 0.05). Conclusions: Accordingly, this study confirmed that hip joint-strengthening exercises have a positive effect on the strength, balance, and function of patients with chronic ankle instability, and we believe that hip joint-strengthening exercises will be recommended as an effective intervention method for patients suffering from chronic ankle instability.

Differences in Baseline Physical Function and Mental Health PROM Scores in Patients With Foot and Ankle Conditions

BACKGROUND

This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated PROMIS scores and to compare the correlation between these 2 outcomes across common diagnoses. Additionally, it investigated the effects associated with chronic vs acute conditions and specific diagnoses on mental health.

METHODS

We reviewed baseline PROMIS Physical Function 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,245 patients with one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model including age, sex, language, race, ethnicity, education level, income, and Charlson Comorbidity Index was used to determine the associated effect of diagnosis on PGM score.

RESULTS

On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, whereas patients with hallux valgus had the highest (PF10a = 33.9 vs 46.7, P < .001). Patients with foot/ankle osteoarthritis had the lowest mean self-reported mental health, whereas patients with hallux rigidus had the highest (PGM = 49.9 vs 53.4, P < .001). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r = 0.511) and weakest in patients with ankle fractures (r = 0.232) or sprains (r = 0.280). Chronic conditions, including hammertoes (β = -5.1, 95% CI [-5.8, -4.3], P < .001), foot/ankle osteoarthritis (β = -5.0, 95% CI [-5.7, -4.3], P < .001), and hallux valgus (β = -4.8, 95% CI [-5.5, -4.1], P < .001) were associated with the largest negative effects on patients' mental health.

CONCLUSION

Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic conditions. The associations between diagnosis and mental health scores appear larger for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function.

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

Reliability and Validity of the Korean Version of Foot and Ankle Disability Index

The Foot and Ankle Disability Index (FADI) is one of the most commonly used tools for evaluating foot and ankle function. Due to the lack of a Korean version for properly evaluating Koreans, it was not possible to compare Korean data with data from other countries using FADI. Therefore, we created a Korean version of the FADI questionnaire and evaluated its reliability and validity. We translated the English version of FADI and FADI-sport into Korean and then back into English. The Korean version of the FADI and FADI-sport, the previously verified visual analog scale (VAS) score, and the previously validated Medical Outcomes Study Short-Form 36-item questionnaire (SF-36) were administered to outpatients with chronic foot and ankle pain. A total of 64 patients who visited the outpatient clinic for chronic foot and ankle pain from January 2023 to March 2023 were included. To evaluate test-retest reliability and internal consistency, we used the intraclass correlation coefficient and Cronbach's alpha, respectively. We also assessed the concurrent and construct validity of the Korean version of FADI and FADI-sport by comparing them with the VAS and SF-36. Cronbach's alpha values were 0.953 and 0.945 for the FADI and FADI-sport, respectively, indicating good internal consistency. The reproducibility was good, and a strong correlation was observed between FADI, VAS, and SF-36. Therefore, the validation of the Korean version of the FADI was successfully performed, and it is a reliable questionnaire for self-evaluation of a patient's foot and ankle condition.

Functional outcome of routine versus on-demand removal of the syndesmotic screw

Aims

The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS).

Methods

All patients included in the 'ROutine vs on DEmand removal Of the syndesmotic screw' (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups.

Results

The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092).

Conclusion

This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation.

Bilateral lower extremity gait and function after unilateral total ankle arthroplasty: a case report

BACKGROUND

End-stage ankle osteoarthritis is one of the leading causes of chronic disability in North America. The main purpose of this case report was to describe the functional recovery of a person following total ankle arthroplasty (TAA) surgery using the INFINITY™ system for end stage osteoarthritis of the left ankle.

CASE DESCRIPTION

We report a case of a 55-year-old male who had attempted conservative management for end stage ankle osteoarthritis in his left ankle but ultimately elected to undergo TAA using The INFINITY™ Total Ankle System. He not only had significant left ankle pain limiting his daily function, but also had developed severe right knee pain. We performed gait analysis both before and 6 months after his TAA surgery to examine the sagittal and frontal-plane motions of bilateral ankle, knee, and hip joints during gait.

OUTCOMES

At 6 months post-surgery, the patient demonstrated a 44-point improvement in his Foot and Ankle Outcome questionnaire scores as well as an increase in both left knee and left ankle motion in the sagittal and frontal planes. Kinematic deviations in the left ankle, hip, and knee joints during gait also reduced post-surgery. Despite improvement in his left ankle and overall function, the participant's right knee pain and altered kinematics of the right limb during gait worsened after surgery.

DISCUSSION

Interventions, either before or after ankle surgery, should consider bilateral lower extremities simultaneously in order to optimize patient care and minimize future secondary complications for individuals with unilateral ankle osteoarthritis.

Greek Cross-Cultural Adaptation, Reliability, and Validity of the Quick Foot and Ankle Ability Measure Questionnaire

CONTEXT

An easy-to-administer, function-based questionnaire to assess patients with various foot problems was required for a Greek-speaking population. This study aimed to translate and cross-culturally adapt the Quick Foot and Ankle Ability Measure (Quick-FAAM) into Greek and evaluate its reliability and validity.

DESIGN

Cross-sectional study.

METHODS

Established international guidelines for the cross-cultural adaptation of questionnaires were followed. The face and content validity of the Greek version of the Quick-FAAM (Quick-FAAM-GR), as well as the internal consistency and test-retest reliability upon repeated administration after 5 days, were examined. In addition, the construct validity of the scale was examined via exploratory factor analysis as well as by testing for associations with the Manchester Foot Pain and Disability Index, the 12-item Short-Form Survey (version 2), and a functional balance assessment test-the Y-Balance Test.

RESULTS

Sixty participants (18 women) with self-reported chronic ankle instability symptoms, with a median (interquartile range) age of 27 (7.7) years, participated in the study. Half of the participants were included in the test-retest reliability study. The Quick-FAAM-GR demonstrated face and content validity. Excellent internal consistency (Cronbach α = .961) and intrarater test-retest reliability (intraclass correlation coefficient ICC[2,1] = .93) were demonstrated, with a comparable error margin to the original version (standard error of the measurement = 2.1, 95% minimum detectable change = 5.9). Associations of the Quick-FAAM-GR scores to other questionnaires ranged from weak to strong (Spearman rho), all being statistically significant (Manchester Foot Pain and Disability Index from -.26, P = .04, to -.67, P < .001, and 12-item Short-Form Survey, version 2, between .41 and .72, P < .001), and to the Y-Balance Test between lower-limb differences (-.35 to -.58, P < .001). The exploratory factor analysis confirmed the single-factor structure of this scale. No floor/ceiling effects were observed.

CONCLUSIONS

The Greek Quick-FAAM has proven to be a valid and reliable tool for evaluating chronic ankle instability and can be used for clinical and research purposes in Greek-speaking individuals.

Functional Outcomes After High-Energy Lisfranc Injuries

BACKGROUND

Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury.

METHODS

A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome.

RESULTS

Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes.

CONCLUSION

Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury.

LEVEL OF EVIDENCE

Level IV, retrospective, prognostic.

Quo vadis, foot & ankle research? A review

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

Is the Small Ossicle of Type 1 Accessory Navicular a Cause of Foot Pain?-A Case Report

Background and objectives: An accessory navicular (AN) bone is often classified into types 1-3 according to the Veitch classification, and symptomatic type 1 patients usually receive non-surgical treatment. However, there are cases in which AN cannot be classified into one of these three types using this classification system, and the small ossicle of type 1 AN may not be the cause of foot pain. This report aimed to present a case of symptomatic type 1 AN that required surgical treatment without the excision of the small ossicle after long-term conservative treatment had failed. Case presentation: A 15-year-old girl who was diagnosed with symptomatic type 1 AN was referred to our department. Medial-side foot pain had prevented her from playing soccer well. She had been treated conservatively for type 1 AN for more than 12 months at several orthopedic clinics. Tenderness of the prominent navicular tubercle was identified, and computed tomography and magnetic resonance imaging findings suggested that the cause of her foot pain was derived from the prominent navicular tubercle not the small ossicle itself. Osteotomy of the prominent navicular tubercle with the advancement of the tibialis posterior tendon, without excision of the ossicle, was performed. At the 12-month follow-up examination, she was completely free from foot pain, and the patient-reported outcome measures were excellent. She now plays soccer at the pre-injury level. Conclusions: We report the case of a patient with symptomatic type 1 AN who underwent osteotomy of the prominent navicular tubercle with advancement of the tibialis posterior tendon, without excision of the ossicle, and who showed favorable short-term clinical outcomes. The evaluation of symptomatic patients with AN based on the Veitch classification alone may lead to inappropriate management. The small ossicle of type 1 AN was not the cause of foot pain in the present case.

Evaluating and Comparing the Correlation and Performance of PROMIS and FAAM ADL in a Foot and Ankle Patient Population

BACKGROUND

There is a paucity of literature assessing 2 of the commonly used static Patient-Reported Outcomes Measurement Information System (PROMIS) forms (PROMIS Global-10 and PROMIS Physical Function Short Form 10a [PF SF 10a]) and the Foot and Ankle Ability Measure Activities of Daily Living (FAAM ADL).

METHODS

The PROMIS Global-10, PROMIS PF SF 10a, and FAAM ADL were compared among new foot and ankle patients. Spearman rho (ρ) correlations were calculated, and ceiling and floor effects were determined.

RESULTS

The FAAM ADL demonstrated strong correlations with PROMIS PF SF 10a, P = .88, 95% confidence interval (CI): 0.86-0.90, P < .001, and PROMIS Global-10 Physical Health (P = .75, 95% CI: 0.71-0.78, p < .001). The FAAM ADL and PROMIS Global-10 Mental Health demonstrated a moderate correlation (P = .41, 95% CI: 0.34-0.47, P < .001). No PROM demonstrated an appreciable floor effect. The PROMIS Global-10 Physical Health demonstrated the lowest ceiling effect (n=11 [1.6%]).

CONCLUSION

Because the PROMIS Global-10 captures physical health adequately, provides mental health insight, and performs as well (if not better), we recommend the PROMIS Global-10 among the PROMs studied.Level of Evidence: Level III.

Association Between Fulfillment of Preoperative Expectations and Diagnosis in Foot and Ankle Surgery

BACKGROUND

There has been growing interest in patient-reported outcomes in foot and ankle surgery, and the fulfillment of patient expectations is a potentially powerful tool that compares preoperative expectations and perceived postoperative improvement. Prior work has validated the use of expectation fulfillment in foot and ankle surgery. However, given the wide spectrum of pathologies and treatments in foot and ankle, no study has examined the association between expectation fulfillment and specific diagnosis.

METHODS

This is a retrospective cohort study consisting of 266 patients who completed the Foot & Ankle Expectations Survey and the Foot and Ankle Outcome Survey (FAOS) preoperatively and 2 years postoperatively. A fulfillment proportion (FP) was calculated using the pre- and postoperative Foot & Ankle Expectations Survey scores. An estimated mean fulfillment proportion for each diagnosis was calculated using a multivariable linear regression model, and pairwise comparisons were used to compare the FP between diagnoses.

RESULTS

All diagnoses had an FP less than 1, indicating partially fulfilled expectations. Ankle arthritis had the highest FP (0.95, 95% CI 0.81-1.08), whereas neuromas and mid/hindfoot diagnoses had the lowest FPs (0.46, 95% CI 0.23-0.68; 0.62, 95% CI 0.45-0.80). Higher preoperative expectations were correlated with lower fulfillment proportions.

CONCLUSION

FP varied with diagnosis and preoperative expectations. An understanding of current expectation fulfillment among different diagnoses in foot and ankle surgery helps highlight areas for improvement in the management of expectations for presumed diagnoses.

LEVEL OF EVIDENCE

Level III, retrospective review of prospective cohort study.

The effect of perturbation training with and without applying the dry needling on leg muscles in patients with chronic ankle sprain

INTRODUCTION

Ankle sprain is a common musculoskeletal injury that leads to recurrent instability. Repeated ankle sprain can be a mechanism for creating trigger point. Proper treatment of trigger points, in addition to preventing recurrence of sprains, may reduce pain and improve muscle function. This improvement can be the result of preserving the surrounding tissues from excessive pressure.

OBJECTIVE

Investigate the added value of dry needling into perturbation training protocol for chronic ankle sprain.

DESIGN

Randomized clinical trial; assessor-blind; before and after comparison.

SETTING

Treatment of patients referred to the institutional rehabilitation clinics.

MAIN OUTCOME MEASURE(S)

Functional assessment with FAAM questionnaire score, Pain with NPRS scale, ankle instability severity with Cumberland tool.

METHODS

Twenty-four patients with chronic ankle instability participated in this clinical trial and were randomly divided into two groups. Intervention was 12 sessions in which one group received only perturbation training and the other group received perturbation training along with dry needling. Repeated measures ANOVA was used to investigate the effect of treatment.

RESULTS

Data Analysis showed significant difference in NPRS and FAAM and Cumberland score before and after treatment in each group (P < 0.001). Comparison of the results between the groups did not show any significant difference (P > 0.05).

CONCLUSION

The findings showed that adding dry needling technique to the perturbation training does not have greater effects on the pain and function of patients with chronic ankle instability.

Is the EQ-5D-5L a responsive test to evaluate results in elective foot and ankle surgery?

PURPOSE

To analyze the responsiveness and the minimally clinical important change (MCIC) of the EuroQol (EQ) 5D-5 L score in patients that had undergone foot/ankle surgery.

METHODS

Patients that underwent elective foot/ankle surgery from January 2019 to December 2020 were included. They were assessed with the EQ-5D-5L, visual analogue pain scale and Manchester Oxford Foot Questionnaire (MOXFQ) preoperatively and 1 year postoperatively. The pre-post differences of all variables, Effect Size (ES) and MCIC were analyzed.

RESULTS

167 patients. All variables showed a significant pre-post improvement. The ES for EQ-index and EQ-VAS were 0.61 and 0.33 respectively. MCIC for EQ-index was 0.17 and EQ-VAS was 8.54. MOXFQ index ES was 1.46 and the MCIC was 23.8. VAS decreased from 59.4 to 26.62.

CONCLUSION

The EQ-5D-5L is a sensitive test to detect changes after elective foot and ankle surgery with good responsiveness relative to the ES values in the EQ-index.

LEVEL OF EVIDENCE

II.

Short-term outcomes of one-stage debridement and fusion for ankle joint tuberculosis

PURPOSE

Tuberculosis remains a worldwide health problem, as well as its complications including arthritis in various joints. End-stage arthritis in weight-bearing joint would require surgery either arthroplasty or arthrodesis, in order to achieve painless and stable gait. In general, staged surgery consisted of debridement and subsequent definitive procedure is accepted. However, multiple surgery would be disadvantageous in terms of clinical and economic burdens. This study reported the short-term result of one-stage debridement and fusion for ankle joint tuberculosis.

METHODS

Retrospective evaluation of twenty-six patients with history of one-stage debridement and ankle fusion was conducted. Basic anthropometric measurement, local status, and surgical technique were recorded. Functional score using Foot and Ankle Ability Measures (FAAM) activities of daily living (ADL) was assessed pre-operatively and at two and half year post-surgery follow-up visit along with radiological fusion rate. Paired t test was used to analyse the improvement of the clinical scores.

RESULTS

There was improvement in FAAM score from 43.38 ± 9.51 to 62.19 ± 6.63% (p < 0.001). All sinuses had been subsided, albeit at various time spans. Modified radiographic union score for tibia (RUST) revealed various fusion rate results, ranged from 5 to 11.

CONCLUSION

One-stage debridement and fusion is proven efficacious for end-stage joint tuberculosis, with less surgery occasion compared with staged surgery. However, patient selection is important since any comorbidities or secondary infection may complicate the fusion.

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.

Investigation on the site of coronal deformities in Hallux valgus

Hallux valgus (HV) is a common foot deformity that is more prevalent in females, characterised by abnormal adduction of the first metatarsal (MT) and valgus deviation of the phalanx on the transverse plane. Increasing evidence indicates that HV is more than a 2D deformity but a 3D one with rotational malalignment. Pronation deformity is seen during clinical examination for HV patients, but the exact origin of this rotational deformity is still unknown. Some attribute it to first tarsometatarsal (TMT) joint rotation, while others attribute it to intra-metatarsal bony torsion. In addition, the correlation between the rotational and transverse plane deformity is inconclusive. Identifying the origin of the rotational deformity will help surgeons choose the optimal surgical procedure while also enhancing our understanding of the pathophysiology of HV. This study aims to (1) develop an objective method for measuring the first MT torsion and first TMT joint rotation; (2) investigate the exact location of the coronal deformity in HV; (3) investigate the relationship between the severity of deformity on the transverse and coronal planes as well as the correlation between deformity severity and foot function/symptoms in HV. Age-matched females with and without HV were recruited at the Foot and Ankle Clinic of the Department of Orthopaedics and Traumatology. Computed tomography was conducted for all subjects with additional weight-bearing dorsal-plantar X-ray examination for HV subjects. Demographic information of all subjects was recorded, with symptoms and functions related to HV evaluated. The intra-class correlation was used to explore the relationship between deformities on different planes and the deformity severity and functional outcomes, respectively. An Independent t-test was used to compare joint rotation and bone torsion degrees. TMT joint rotation is significantly correlated with foot function. HV patients had more TMT joint rotation but not MT torsion compared to normal controls. No relationship was found between the coronal rotation and the 1,2-intermetatarsal angle (IMA) or Hallux valgus angle (HVA) on the transverse plane. Our results indicate that coronal deformities in HV may originate from TMT joint rotation. In addition, the severity of the TMT joint coronal rotation correlates with worse foot function; thus, multi-plane assessment and examination will be necessary for more precise surgical correction.

Clinical Outcomes of the Lateral Trabecular Metal Total Ankle Replacement at a 5-Year Minimum Follow-up

BACKGROUND

The Trabecular Metal (Zimmer Biomet, Warsaw, IN) total ankle arthroplasty (TAA) system uses a lateral approach with a fibular osteotomy to gain access to the tibiotalar joint and a sagittally curved tibial component. This is the first TAA system to laterally approach the ankle, and few studies have explored outcomes associated with this implant. This study aimed to report the 5-year clinical and radiographic outcomes as well as the survivorship of the implant.

METHODS

Over a 3-year period, 2 fellowship-trained foot and ankle surgeons used this implant system to treat 38 end-stage arthritic ankles. Reoperation and revision data were collected from all patients (100%) as part of the local prospective database. Patients completed the Foot and Ankle Outcome Score (FAOS) questionnaire preoperatively and at each annual follow-up visit; scores for a minimum of 5 years were available for 28 (73.7%) patients. A radiographic analysis compared postoperative coronal and sagittal alignment in weightbearing radiographs at a minimum of 5 years with that at 3 months postoperatively, as well as cyst or lucency formation, which was available for 21 patients (55.3%).

RESULTS

At 5 years, there were 3 revisions (7.9%) and 9 reoperations (23.7%). Reoperations included 4 fibular hardware removal and 5 medial gutter debridement procedures. The FAOS significantly improved for all domains (P < .05). Implant positioning did not significantly change between 3 months and 5 years postoperatively.

CONCLUSION

Our 5-year results in this small series using this unique prosthesis showed good overall survivorship (92.1%) and a reoperation rate of 23.7%, along with clinically significant improvement in patient-reported outcomes.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

Medial malleolar osteotomy for the correction of tibiotalar varus deformity during total ankle arthroplasty: Results in 95 ankles

BACKGROUND

The importance of deformity correction before or during total ankle replacement (TAR) has been recognized for a long time. Our results of TAR, combined with medial malleolar lengthening osteotomy, for the reconstruction of osteoarthritic ankles with varus deformity are hereby reported.

METHODS

All ankles in which a medial malleolar osteotomy was performed during implantation of an ankle prosthesis during the period 1998-2018 were filtered out of our database. Preoperative coronal talar alignment was evaluated by measuring the angle between the tibial shaft and talar dome on the weightbearing mortise ankle radiograph. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). A Kaplan-Meier survival curve was constructed and the number of revisions per 100 observed component years was calculated for interprosthetic comparison.

RESULTS

A total of 95 TARs were included, consisting of the Alpha Ankle Arthroplasty (n = 22); Buechel-Pappas (n = 14) and the Ceramic Coated Implant Evolution (n = 59) prostheses. The preoperative average talar angle in these ankles was 12.4 degrees varus. In 33% (31/95) corrective procedures, in addition to the medial malleolar osteotomy, were performed. A reoperation rate of 44% (42/95) was found, including 28 revisions (revision rate 29% (4% septic; 25% aseptic) at an average follow-up of 5.9 years, resulting in a survival of 0.69 for the total cohort at 10 years of follow-up. At an average follow-up of 6.6 years the average FAOS scores were: FAOS_symptoms 66, FAOS_pain 73, FAOS_function 78, FAOS_sport 45 and FAOS_{quality of life} 56 respectively. The FAAM_adl score averaged 64.

CONCLUSION

This is the largest cohort of TAR combined with medial malleolar osteotomy to date. A 29% revision rate at 5.9 years of average follow-up compares unfavorably with regular cohort studies and with most other results in varus-deformed ankles. Scores on the FAOS and FAAM are comparable to those obtained in regular cohorts with similar length of follow-up. TAR in varus-deformed ankles necessitating medial malleolar osteotomy has an even higher failure rate than regular TAR. Obtaining a stable prosthesis with a neutrally-aligned hindfoot at the end of the procedure is of paramount importance.

LEVEL OF EVIDENCE

IV.

Simultaneous Total Ankle Replacement and Contralateral Ankle Arthrodesis for Bilateral Ankle Osteoarthritis: A Retrospective Study Focused on Clinical Outcomes and Cost-effectiveness

Objective

Total ankle replacement (TAR) and ankle arthrodesis (AA) are two common surgical treatment options for end‐stage ankle osteoarthritis. However, few reports compare the outcomes of simultaneous TAR and contralateral AA for bilateral ankle osteoarthritis. The aim of this study was to assess changes in pain, joint range of movement (ROM), functional outcomes, patient satisfaction, and cost‐effectiveness following simultaneous TAR and contralateral AA.

Methods

A retrospective study was conducted on 12 patients with bilateral end‐stage ankle osteoarthritis who underwent simultaneous TAR and contralateral AA in our institution between May 2016 and August 2018, and who had a minimum of two‐year follow‐up data. Clinical and radiological follow‐up data for all patients were collected after 4 months, 1 year and 2 years. The results were assessed clinically on a visual analogue scale (VAS) and included ROM, American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score, and satisfaction questionnaire. The total hospital costs of patients were also recorded. Independent sample t tests were conducted to compare continuous variables between groups. Paired sample t‐tests were conducted to compare changes from the preoperative to postoperative evaluations within each group.

Results

Both surgical groups presented with pain reduction (P < 0.001) at the one‐year postoperative session, which was generally consistent until the two‐year follow‐up. There was a significant increase (P < 0.001) in the mean AOFAS score postoperatively in both ankles. The functional outcomes at the one‐ and two‐year follow‐up were significantly better in patients in the TAR group than in those in the AA group (P < 0.001). Joint ROM differences were observed between the two groups after surgery (decreased ankle ROM in arthrodesis, P < 0.001; increased ankle ROM in arthroplasty, P < 0.001). The mean satisfaction score was 2 (range, 1–4) for the TAR group and 3 (range, 1–5) for the AA group. A significant difference in the satisfaction score was observed between the two groups (P = 0.036). Simultaneous TAR and contralateral AA was 34.1% less expensive than simultaneous bilateral TAR. No intraoperative complications were noted in either group. Wound healing occurred without problems within 2 weeks after surgery. No symptomatic deep venous thrombosis was found during follow‐up.

Conclusion

TAR had better patient‐perceived post‐operative function and preserves more anatomic sagittal plane motion compared to ankles undergoing AA. In addition, simultaneous TAR and contralateral AA are more cost‐effective than simultaneous bilateral TAR, with lower costs for the average patient.

Structural and Construct Validity of the Foot and Ankle Ability Measure (FAAM) With an Emphasis on Pain and Functionality After Foot Surgery: A Multicenter Study

The Foot and Ankle Ability Measure (FAAM) is a patient-reported outcome measure that is available in several languages. We aim to assess the structural and construct validity of the FAAM with an emphasis on pain and functionality after foot surgery. The activities of daily living (ADL) and Sports subscales of the Finnish version of the FAAM were completed by 182 patients who underwent operative treatment for disorders of the foot. Convergent validity was assessed by principal component analysis using Spearman's correlation coefficient between the FAAM subscales and the principal components (Function-PC and Pain-PC) derived from validated patient-reported outcome measures. Subscales were studied for floor and ceiling effects, internal consistency and unidimensionality. Internal consistency was examined with Cronbach's alpha and the subscale structure with exploratory factor analysis. FAAM-ADL had high correlation with the Function-PC (r = 0.87, 95% confidence interval [CI] 0.81-0.91) and the Pain-PC (r = 0.75, 95% CI 0.65-0.83). FAAM-Sports had moderate correlation (r = 0.64, 95% CI 0.50-0.74) with the Function-PC and high correlation (r = 0.74, 95% CI 0.64-0.82) with the Pain-PC. No floor or ceiling effects were observed. Cronbach's alpha was 0.97 (95% CI 0.96-0.98) for the ADL and 0.93 (95% CI 0.91-0.95) for the Sports subscales. The results supported the unidimensionality of the FAAM-Sports. Within the ADL subscale, 3 factors were identified, suggesting a 3-factor model for the FAAM overall. Results highlighted the inter-relationship of pain and physical function. Further research on longitudinal validity is needed.

Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects

Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament^® G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament^® for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament^® G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 ± 17.2 months (95%CI 12.1–28.3). Ten of these patients needed at least one revision (2.0 ± 1.3 revisions per patient (95%CI 1.1–2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament^® G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data.

Patient reported outcome measures in ankle replacement versus ankle arthrodesis - A systematic review

OBJECTIVES

Compare the functional outcomes of comparative studies of ankle arthrodesis (AA) and total ankle replacements (TAR).

DESIGN

Systematic review using PRISMA guidelines.

DATA SOURCES

Medline, Cochrane and EMBASE databases in July 2020.

ELIGIBILITY CRITERIA

Studies that directly compared TAR and AA which reported patient reported outcomes measures (PROMs) of pain, function and quality of life.

DATA EXTRACTION AND SYNTHESIS

Two authors independently reviewed all papers. PROMs were allocated into pain, function or quality of life domains. Two summary statistics were created to allow for analysis of the PROMs. These statistics were the mean difference in post-operative score and the mean difference in the change of score.

RESULTS

1323 papers were assessed of which 20 papers were included. 898 ankle arthrodesis and 1638 ankle replacements were evaluated. The mean follow up was 3.3 years (range 0.5-13.0 years). AA patients had a mean age of 55.7 (range 20-82) and TAR 62.5 (range 21-89). There was major heterogeneity in outcomes used. We were unable to find a significant difference between the reported change in PROMs following TAR and AA. 29.3% of PROMs and their subscores showed TAR had better outcomes, 68.7% showed no significant difference and only 2.0% showed AA to have better outcomes.

CONCLUSIONS

The majority of published studies found equality in patient reported outcomes following TAR and AA although the quality of the studies was of low-level evidence. There is an urgent need for randomised controlled studies to definitively answer this important clinical question.

Identification of tools used to assess the external validity of randomized controlled trials in reviews: a systematic review of measurement properties

Background

Internal and external validity are the most relevant components when critically appraising randomized controlled trials (RCTs) for systematic reviews. However, there is no gold standard to assess external validity. This might be related to the heterogeneity of the terminology as well as to unclear evidence of the measurement properties of available tools. The aim of this review was to identify tools to assess the external validity of RCTs. It was further, to evaluate the quality of identified tools and to recommend the use of individual tools to assess the external validity of RCTs in future systematic reviews.

Methods

A two-phase systematic literature search was performed in four databases: PubMed, Scopus, PsycINFO via OVID, and CINAHL via EBSCO. First, tools to assess the external validity of RCTs were identified. Second, studies investigating the measurement properties of these tools were selected. The measurement properties of each included tool were appraised using an adapted version of the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

Results

38 publications reporting on the development or validation of 28 included tools were included. For 61% (17/28) of the included tools, there was no evidence for measurement properties. For the remaining tools, reliability was the most frequently assessed property. Reliability was judged as “sufficient” for three tools (very low certainty of evidence). Content validity was rated as “sufficient” for one tool (moderate certainty of evidence).

Conclusions

Based on these results, no available tool can be fully recommended to assess the external validity of RCTs in systematic reviews. Several steps are required to overcome the identified difficulties to either adapt and validate available tools or to develop a better suitable tool.

Trial registration

Prospective registration at Open Science Framework (OSF): 10.17605/OSF.IO/PTG4D.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01561-5.

Preexisting and treated concomitant ankle instability does not compromise patient-reported outcomes of solitary osteochondral lesions of the talus treated with matrix-induced bone marrow stimulation in the first postoperative year: data from the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to compare the subjective ankle function within the first year following matrix-induced bone marrow stimulation (M-BMS) of patients with a solitary osteochondral lesion of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

METHODS

Data from the German Cartilage Registry (KnorpelRegister DGOU) for 78 patients with a solitary OCLT and a follow-up of at least 6 months were included. All patients received M-BMS for OCLT treatment. The cohort was subdivided into patients with OCLT without CAI treated with M-BMS alone (n = 40) and patients with OCLT and CAI treated with M-BMS and additional ankle stabilisation (n = 38). The Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), and the Numeric Rating Scale for Pain (NRS) were used to assess patient-reported outcomes (median (minimum-maximum)).

RESULTS

From preoperatively to 12 months postoperatively, patients with OCLT without CAI treated with M-BMS alone had a significant improvement of all subscales in the FAAM [activity of daily living 64.3 (10-100) to 88.1 (39-100); sports 34.4 (0-100) to 65.6 (13-94), functional activities of daily life 50 (0-90) to 80 (30-100), functional sports 30 (0-100) to 70 (5-100)] and FAOS [pain 61.1 (8-94) to 86.1 (50-100), symptoms 60.7 (18-96) to 76.8 (29-100), activities of daily living 72.1 (24-100) to 91.9 (68-100), sport/recreational activities 30.0 (0-70) to 62.5 (0-95), quality of life 31.3 (6-50) to 46.9 (19-100)]. Within the first year, patients with OCLT and CAI treated with M-BMS and ankle stabilisation also showed significant improvement in the FAAM [activity of daily living 68.8 (5-99) to 90.5 (45-100); sports 32.8 (0-87.5) to 64.1 (0-94), functional activities of daily life 62.5 (25-100) to 80 (60-90), functional sports 30 (0-100) to 67.5 (0.95)] and the FAOS [pain 66.7 (28-92) to 87.5 (47-100), symptoms 57.1 (29-96) to 78.6 (50-100), activities of daily living 80.1 (25-100) to 98.5 (59-100), sport/recreational activities 35.0 (0-100) to 70.0 (0-100), quality of life 25.0 (0-75) to 50.0 (19-94)]. The pain level decreased significantly in both groups. No significant difference was found between both groups regarding the subscales of FAAM, FAOS and the NRS 1 year postoperatively.

CONCLUSION

Improvements in subjective ankle function, daily life activities and sports activities were observed within the first year following M-BMS. Our results suggest that preexisting and treated ankle instability did not compromise subjective outcome in patients treated with M-BMS in the first postoperative year.

LEVEL OF EVIDENCE

Level IV.

Autologous osteophyte grafting for ankle arthrodesis

PURPOSE

Various graft sources had been identified to facilitate gap-filling in ankle arthrodesis procedures with related articular defects. This was a preliminary study with the aim of analyzing the efficacy and feasibility of using autologous osteophyte as a grafting source.

METHODS

Retrospective evaluation of ten patients having ankle arthrodesis procedure using identical anterior approach and plate fixation technique was conducted. Basic anthropometric measurements and underlying disease were recorded. Functional outcome and fusion rate were assessed at a 12-month post-surgery follow-up visit.

RESULTS

The underlying diseases include primary osteoarthritis (OA), post-traumatic OA, rheumatoid arthritis, and Charcot arthropathy. The patient's age mean was 56.6 years (range 36-71 years), and BMI varied from 17.9 kg/m2 to 29.3 kg/m2. Nearly all patients had improved functional outcomes as described by foot and ankle ability measure (FAAM) score and fusion rate as described by modified radiographic union score for tibia (RUST). One patient had failed surgery due to implant failure with diminished protective foot sensory.

CONCLUSION

Osteophytes from the distal tibia and talar neck were a viable source of bone graft, especially for ankle arthrodesis using anterior approach among various ages and BMI, in which the surgeons would not need additional incision for graft harvesting.

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

Background

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

Methods

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

Results

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

Conclusions

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

Structural validity of the foot and ankle outcome score for orthopaedic pathologies with Rasch Measurement Theory

BACKGROUND

The Foot and Ankle Outcome Score (FAOS) is one of the most frequently used patient-reported outcome measures for foot and ankle conditions. The aim is to test the structural validity of the Finnish version of the FAOS using Rasch Measurement Theory.

METHODS

FAOS scores were obtained from 218 consecutive patients who received operative treatment for foot and ankle conditions. The FAOS data were fitted into the Rasch model and person separation index (PSI) calculated.

RESULTS

All the five subscales provided good coverage and targeting. Three subscales presented unidimensional structure. Thirty-eight of the 42 items had ordered response category thresholds. Three of the 42 items had differential item functioning towards gender. All subscales showed sufficient fit to the Rasch model. PSI ranged from 0.73 to 0.94 for the subscales.

CONCLUSIONS

The Finnish version of the FAOS shows acceptable structural validity for assessing complaints in orthopaedic foot and ankle patients.

Minimal important change for Foot and Ankle Outcome Score (FAOS)

BACKGROUND

Although Foot and Ankle Outcome Score (FAOS) is a widely used patient-reported outcome measure (PROM) for foot and ankle conditions, research on its longitudinal validity is still needed. Minimal important change (MIC) values for the FAOS were determined using predictive modeling.

METHODS

Overall, 134 patients that underwent operative treatment for foot and ankle conditions were included. An anchor based predictive logistic modeling method was used for estimating the MIC values for the FAOS subscales after surgery.

RESULTS

Mean score changes in the improved and the unimproved groups were 17.7 and 0.43 points for Pain, 3.9 and -3.3 points for Symptoms, 21.3 and 1.8 points for Activities and daily living (ADL), 8.7 and -2.8 points for Sport, and 12.5 and -3.3 points for quality of life subscale, respectively. MIC was successfully determined to four out of five subgroups as follows: Pain 9.5 (94% CI -6.4 to 24.6); ADL 11.7 (95% CI -19.6 to 46.6); Sport (95% CI -10.4 to 15.4); QoL 5.0 (95% CI -2.6 to 12.9). The Symptoms subgroup presented with low MIC of 0.3 (95% CI -11.7 to 13.4) fitting to the measurement error.

CONCLUSION

ADL, Sports, Pain, and QoL subscales of the FAOS presented logical MIC values. The MIC can be further evaluated for specific conditions.

Efficacy of moxibustion in diabetes peripheral neuropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus. The main clinical manifestations of DPN include pain, numbness, paraesthesia, and weakness of the lower limbs which often leads to diabetic foot ulceration, eventually resulting in amputation. Based on Traditional Chinese Medicine theory, moxibustion has a great effect on treating and preventing DPN. However, randomized clinical trials done to evaluate the efficacy of this treatment are still lacking. Hence, this study is carried out to evaluate the effectiveness and safety of moxibustion therapy on diabetic peripheral neuropathy.

METHODS

This study will be a pilot, interventional, randomized, 2-armed, parallel, singled-masked, controlled trial. A total of 40 diabetes mellitus patients with peripheral neuropathy will be recruited and assigned randomly into 2 groups (moxibustion group and waiting group) at a 1:1 ratio. This trial consists of an 8-week intervention period and a 4-week follow-up period. During the intervention period, the moxibustion group will take 3 moxibustion sessions per week, whereas no intervention will be done on the waiting group to act as the control group. The outcome will be assessed by an outcome assessor who is unaware of the group assignment. The primary outcome will be pain assessment measured with algometry, Leeds Assessment of Neuropathic Symptoms and Signs pain scale, visual analogue scale, and neuropathy pain scale. The secondary outcome will be an evaluation of functional performance capacity with 6 minutes walking test, evaluation of the Foot and Ankle Ability Measure, and serum HbA1c and albumin levels.

DISCUSSION

We hope that this trial will provide valuable insights on the efficacy of moxibustion in the management of diabetic peripheral neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov Registry No.: NCT04894461 (URL: https://clinicaltrials.gov/ct2/show/NCT04894461?term=NCT04894461&draw=2&rank=1) Registered on May 20, 2021.

Functional Outcomes of Arthroscopic Os Trigonum Excision in Adolescents

BACKGROUND

Outcomes of symptomatic os trigonum excision have been well described as a successful treatment in adults; however, the literature lacks information on standardized longer term functional outcomes in the pediatric population. This study intends to report functional outcomes of arthroscopic os trigonum excision in adolescents who failed conservative management, with the hypothesis that these younger patients would have similar, successful outcomes of adult patients.

METHODS

A retrospective study was performed on adolescents who underwent arthroscopic os trigonum excision at a single institution between 2011 and 2017. Patient demographic, clinical history, radiographic, and operative data were documented. Outcome measures included the Foot and Ankle Ability Measure (FAAM) score comprised of the Activities of Daily Living (ADL) and Sports subscales, Single Assessment Numeric Evaluation (SANE) score, ability to return to the same level of sport, and any additional foot/ankle surgery.

RESULTS

Ten patients (12 ankles) met criteria with a mean age at surgery of 15.4 years (range, 12 to 18 y) and a mean follow-up of 6.5 years (range, 2.8 to 9.1 y). Mean FAAM ADL subscale, Sports subscale, and SANE scores were 91.0±15.5, 76.3±29.1, and 88.6±15.1, respectively. A chronic duration of symptoms before surgery was associated with a lower FAAM Sports current level of function score (P=0.032). Four patients (40%) discontinued their sport due to continued ankle issues and reported significantly lower FAAM ADL subscale (P=0.01), Sports subscale (P<0.001), and SANE scores (P=0.002).

CONCLUSIONS

Os trigonum syndrome in the adolescent population may not have the same rate of success as that seen in adult athletes over the long-term. However, if proven to be refractory to conservative measures and surgical intervention is indicated, patients and their families should be counseled about the risk for persistent ankle symptoms and the possibility that they may not be able to return to their previous level of sport.

LEVEL OF EVIDENCE

Level IV-case series.

Patients perspective on treatment and early rehabilitation after an ankle fracture: A longitudinal qualitative study

Worldwide, ankle fractures are among the most common fractures encountered in emergency departments. To inform healthcare professionals about what is important to patients when organizing an individualized, high-quality treatment plan, patient perspectives on treatment, care, and early rehabilitation are highly relevant. This longitudinal interview study aims to explore the perspectives of patients with surgically (ST) and conservatively (CT) treated ankle fractures within ten days and six weeks after an ankle fracture. Fourteen patients were interviewed using a semi-structured interview guide. Data were analyzed according to qualitative content analysis. Findings revealed themes regarding pain, independence, information, and worries about the future. Initially, all patients had a pragmatic attitude toward the future, but this attitude was significantly different after 6 weeks as many of the ST patients were still in pain and were more worried about the future. Patients' feelings of uncertainty were linked to a lack of information. Our findings indicate a need for further research to develop a more specific description of symptoms patients should expect as treatment progresses for patients with ankle fractures. With the goal of decreasing psycho-social concerns regarding mobility, autonomy, and working ability post fracture.

[Foot and ankle ability measure: Validation of a Spanish version with 29 items in rehabilitation setting]

OBJECTIVE

The Foot and Ankle Ability Measure (FAAM) is an internationally widely used outcome measure of foot and ankle disorders available in several languages. The purpose of this study was to develop and validate a FAAM Spanish-version with 29 items of Activities of Daily Living (ADL) and SPORT subscales in rehabilitation setting.

MATERIALS AND METHODS

A two-stage observational study was conducted. The FAAM was cross-culturally adapted to Spanish through a double-forward translation and a double-backward translation; the psychometric properties were then validated. The participants (n = 147), with various chronic foot and ankle disorders, completed the Spanish version of the Foot and Ankle Ability Measure ADL and SPORT, SF-36, and a pain intensity visual analogue scale (Pain VAS). The full sample was used to determine the factor structure, the internal consistency, and the convergent criterion validity, and a subgroup (n = 46) was used to determine the reliability at 48-72 h.

RESULTS

The factor structure of Spanish version of FAAM ADL and SPORT subscales were both one-dimensional, demonstrating high internal consistency (α = 0.97 and α = 0.93, respectively). The reliability values were ICC = 0.90 and ICC = 0.76, respectively. The convergent validity criterion of Spanish version of FAAM with the Pain VAS (r = 0.50) and Physical Function of SF-36 (r = 0.64) were moderately correlated.

CONCLUSIONS

The Spanish version of FAAM with 29 items are a valid foot and ankle disorder outcome measure with similar psychometric properties to the original version and versions in other languages.

A Prospective Cohort Study Comparing Functional Outcomes of Primary and Revision Ankle Replacements

BACKGROUND

The number of ankle and revision ankle replacements performed is increasing. There is limited research into functional outcomes, especially in revision ankle replacements. The primary aim of this cohort study was to determine the functional improvements following primary and revision ankle replacements and compare which gave the greatest improvement in functional scores.

METHODS

A single-center prospective cohort study was undertaken between 2015 and 2018. All patients were followed up for a minimum of 2 years. Patients undertook a preoperative and 2-year Manchester Oxford Foot Questionnaire (MoxFQ) score. The Mann Whitney test was undertaken.

RESULTS

A total of 33 primary and 23 revision ankle replacements were performed between 2015 and 2018. The mean age was 69.3 years for primary replacements and 64.7 years for revision replacements. All primary replacements were the Infinity ankle replacement. Revision replacements were either the Inbone II or Invision. The indication for revision was 9 aseptic loosening, 6 infections, 5 cysts, and 3 malposition. Seventeen were performed as a single stage and 6 as a 2-stage revision. The overall MoxFQ improved by a mean of 48.8 for primaries and 20.2 for revisions (P = .024). The walking/standing domain improved by 57.5 for primaries and 22.5 for revisions (P = .016), the pain score improved by 43.0 and 32.3 (P = .009), and the social interaction improved by 40.0 and 11.7 (P = .128).

CONCLUSION

Both primary and revision ankle replacements result in improved functional scores. In this relatively small cohort with the implants used, primary ankle replacements though have a significantly greater improvement in functional scores compared to revision ankle replacements.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Internal Fixation of a Lateral Inverted Osteochondral Fracture of the Talus (LIFT) Lesion Using an Innovative Surgical Approach: Inverting the Capsulo-Lateral Fibulotalocalcaneal Ligament (LFTCL)-Fibular Periosteum Complex

Osteotomy of the distal fibula or anterolateral corner of the tibia is usually required to fix a displaced osteochondral fracture of the talus that is located central to posterior area of the lateral talar dome. However, osteotomy is an invasive procedure and is associated with complications, including nonunion, persistent pain, and hardware-related problems. Lateral inverted osteochondral fracture of the talus (LIFT) lesion is an extremely rare type of displaced osteochondral lesion of the talus. We describe a case in which a LIFT lesion was fixed using an innovative surgical approach, inverting capsulo-lateral fibulotalocalcaneal ligament (LFTCL)-fibular periosteum complex, with a favorable short-term clinical outcome.

Fundamental Outcome Measurement: Selecting Patient Reported Outcome Instruments and Interpreting the Data they Produce

Over the past 40 years literally thousands of generic and disease specific patient reported outcome (PRO) instruments have been developed. While most were developed for a specific study and were never used again, there is still the question of how manufacturers and others should select a PRO instrument for a study. These studies may be clinical pivotal trials or observational tracking studies to support therapy response. Formulary committees also need to be able to interpret PRO data to make decisions about whether to accept claims for therapy response. It is possible to argue that the many different approaches to outcome measurement have resulted from the lack of agreed methodologies. However, a more likely explanation is that the authors have failed to apply the axioms of fundamental measurement when creating their measures. The result is a plethora of ordinal PRO instruments that inform little about the impact of interventions. Clinical trials rarely report PRO data. Where they do, analyses are generally restricted to (for example) changes in the experimental group's scores. Comparisons between the treatment and placebo groups or between active groups are infrequently reported, most likely due to the failure of the instrument to show differences or changes in outcome. This is unfortunate as it means no assessment is made of the value that patients gain from the intervention. This commentary is intended to make researchers and formulary committees aware of the issues that need to be addressed when selecting PRO instruments for a study or evaluating publications and claims for therapy response. The latter is crucial as reported data influence the selection of medicines and healthcare products. In the latter case a particular concern is with PRO claims embedded in simulation models.

Matrix-associated autologous chondrocyte implantation with autologous bone grafting of osteochondral lesions of the talus in adolescents: patient-reported outcomes with a median follow-up of 6 years

BACKGROUND

This study presents patient-reported outcome measures after combined matrix-associated autologous chondrocyte implantation and autologous bone grafting in high-stage osteochondral lesions of the talus in adolescents.

METHODS

A total of 12 adolescent patients (13 ankles) received matrix-associated autologous chondrocyte implantation and autologous bone grafting for a solitary osteochondral lesion of the talus at a single centre. The Foot and Ankle Outcome Score and Foot and Ankle Ability Measure were defined as outcome measures (median follow-up 80 months [range 22-107 months]). Pre- and postoperative ankle radiographs were evaluated according to the van Dijk ankle osteoarthritis scale.

RESULTS

The study population consisted of four male and nine female cases (mean age at the time of surgery, 17.7 ± 2.1 years). Eight lesions were classified as traumatic and five as idiopathic. Twelve lesions were located medial vs one lateral in the coronal plane and all central in the sagittal plane. The median lesion size and depth were 1.3 cm2 (range 0.9-3.2 cm2) and 5 mm (range 5-9 mm), respectively. There were no perioperative complications in any of the cases. In 9 cases patient-reported outcome measures were available. The results of the Foot and Ankle Outcome Score subscales were symptoms, 70 ± 14; pain, 83 ± 10; activities of daily living, 89 ± 12; sports/recreational activities, 66 ± 26; and quality of life, 51 ± 17. The mean overall Foot and Ankle Outcome Score was 78 ± 13. The results of the Foot and Ankle Ability Measure subscales were activities of daily living, 81 ± 20; function/activities of daily living, 84 ± 13; sports, 65 ± 29; and function/sports, 73 ± 27. According to the function overall subscale of the Foot and Ankle Ability Measure, in two cases, the patients assessed the ankle function as normal, in three as nearly normal, and in three as abnormal (missing data, n = 1). Preoperative van Dijk scale: stage 0 in five cases and stage I in eight cases; postoperative van Dijk scale: stage 0 in four cases, stage I in 9 cases CONCLUSIONS: Patient-reported outcome measures following matrix-associated autologous chondrocyte implantation and autologous bone grafting for high-stage osteochondral lesions of the talus in adolescents show heterogeneous results. Long-term limitations mainly affect sports and recreational activities. Osteochondral lesions of the talus are associated with osteoarthritis, even preoperatively. However, we did not find significant osteoarthritis progression after matrix-associated autologous chondrocyte implantation and autologous bone grafting in the long term.

Re-operation rate after surgical treatment of osteochondral lesions of the talus in paediatric and adolescent patients

BACKGROUND

The aim of this study is to analyse the re-operation rate after surgical treatment of osteochondral lesions of the talus (OCLTs) in children and adolescents.

METHODS

Between 2009 and 2019, 27 consecutive patients with a solitary OCLT (10 male, 17 female; mean age 16.9 ± 2.2 years; 8 idiopathic vs. 19 traumatic) received primary operative treatment (arthroscopy + bone marrow stimulation [BMS], n = 8; arthroscopy + retrograde drilling, n = 8; autologous chondrocyte implantation [ACI]/autologous bone grafting, n = 9; arthroscopy + BMS + retrograde drilling; n = 1; flake fixation, n = 1). Seventeen OCLTs were located at the medial and ten at the lateral talus. 'Re-operation' as the outcome measure was evaluated after a median follow-up of 42 months (range 6-117 months). Patients were further subdivided into groups A (re-operation, n = 7) and B (no re-operation, n = 20). Groups A and B were compared with respect to epidemiological, lesion- and therapy-related variables.

RESULTS

Seven of 27 patients needed a re-operation (re-operation rate 25.9% after a median interval of 31 months [range 13-61 months]). The following operative techniques were initially used in these seven patients: arthroscopy + BMS n = 2, arthroscopy + retrograde drilling n = 4, ACI + autologous bone grafting n = 1. A comparison of group A with group B revealed different OCLT characteristics between both groups. The intraoperative findings according to the International Cartilage Repair Society (ICRS) classification revealed significantly more advanced cartilage damage in group B than in group A (p = 0.001).

CONCLUSIONS

We detected a re-operation rate of 25.9% after primary surgical OCLT treatment. Patients with re-operation had significantly lower ICRS classification stages compared to patients without re-operation.

Setting and maintaining standards for patient-reported outcome measures: can we rely on the COSMIN checklists?

As test-developers we have often been troubled by published reviews of patient-reported outcome measures (PROMs). Too often minor issues are judged important while other reviews exclude the best measures available. Perhaps this led several groups to make recommendations for evaluating the quality of PROMs. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist is the latest set of recommendations. While reviewing the COSMIN literature and reviews conducted using their recommendations several concerns became apparent. The checklist is not evidence-based, relying on the opinion of researchers experienced in health-related quality of life. PROMs measuring other types of outcomes are inadequately covered by the checklist. COSMIN choose to focus on Classical Test Theory and the checklists are not appropriate for use with PROMs developed using modern measurement. Such an approach only obstructs progress in the field of outcome measurement. The retrospective nature of the evaluations also penalizes new PROMs. While the checklists imply that composite, ordinal level measurement is acceptable, crucial aspects of instrument development and quality are excluded. Reviews based on the COSMIN checklist produce contradictory conclusions and fail to provide evidence to support the recommendations. These problems suggest that the checklists themselves lack reliability and validity. It is also clear that several reviewers lack the expertise to apply the checklists. Researchers require a good grounding in instrument development and psychometrics to produce quality reviews. The science of modern PROM development is still in an early phase. Few available PROMs have sufficient quality, limiting the need for complex reviews. Standards need to be agreed for high quality outcome measurement. The issue is who should set these standards? Most published reviews merely scratch the surface and lack essential detail. All reviews of PROMs should be treated with caution, irrespective of whether the COSMIN checklist was employed.