Surgery for adult acquired flatfoot due to posterior tibial tendon dysfunction reduces pain, improves function and health related quality of life

Clinical outcomes of subtalar arthroereisis for the treatment of stage 1 flexible progressive collapsing foot deformity

BACKGROUND

The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD.

METHODS

A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate.

RESULTS

Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102).

CONCLUSION

Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal.

LEVEL OF EVIDENCE

IV.

Endoscopic assisted flexor digitorum longus transfer in flexible flatfoot

BACKGROUND

Posterior tibial tendon insufficiency is the commonest cause of adult flexible flatfoot. Transfer of the flexor digitorum longus (FDL) has been described a therapeutic arsenal in flexible flat feet and posterior tibial tendon disorders. It is often combined with bony procedure (open or percutaneous calcaneal osteotomy).

METHODS

We describe a technique and the steps endoscopic approach of FDL transfer.

RESULTS

The procedure is able to be performed safely and reproducible under perfect viewing CONCLUSION: In the future with a clinical study investigating, we purpose the results of such surgery in a cohort of patients with flexible flatfoot. Level IV Therapeutic study: case serie. No funding was received for this research project.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity

BACKGROUND

Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD.

METHODS

A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient.

RESULTS

The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo-first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone.

CONCLUSION

We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity

BACKGROUND

Population-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking.

METHODS

We analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014-2021.

RESULTS

625 feet with primary AAFD surgery were registered. Median age was 60 (range 16-83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis.

CONCLUSIONS

Patients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist.

LEVEL OF EVIDENCE

III.

Biomechanical Effects of Surgical Reconstruction for Flexible Progressive Collapsing Foot Deformity: A Systematic Review

BACKGROUND

Symptomatic progressive collapsing foot deformity (PCFD) is frequently treated with reconstructive surgery. Multiple studies have documented successful treatment based on improvements in symptoms and physical examination findings. However, it is not well-established whether there are corresponding improvements in gait function following surgical treatment for PCFD.

METHODS

A systematic review of biomechanical outcomes of treatments for flexible PCFD was conducted on PubMed. The 4 articles chosen involved patients with symptomatic flexible PCFD who underwent a reconstructive surgery. Surgical interventions included osteotomy, tendon transfer, and/or ligament repair or reconstruction. Primary outcomes involved objective quantifiable measurements of kinematic, kinetic, or temporospatial parameters.

RESULTS

The initial search yielded 605 articles, from which 26 were retained after screening the title and abstract. Twenty-two were eliminated yielding 4 articles. Temporospatial, kinematic, and kinetic parameters were all altered after the patients underwent surgical intervention. Specifically, stride length, cadence, and walking speed all improved postoperatively. Walking kinetics also improved with restoration of normal motion in the frontal and sagittal planes and improvements in the dorsiflexion angle. There were also improvements in sagittal power.

DISCUSSION

Surgical intervention to treat flexible PCFD improves objective biomechanical outcomes; however, more follow-up studies are needed to establish the reliability and durability of these improvements.

LEVEL OF EVIDENCE

Level III: Systematic review.

Functional Activity After Flatfoot Reconstruction With Lateral Column Lengthening

BACKGROUND

The objective of this study was to evaluate return to activity following flatfoot reconstruction with lateral column lengthening (LCL) by assessing functional postoperative data and identifying patient characteristics associated with poor function following surgery.

METHODS

Consecutive patients that underwent operative flatfoot correction including LCL and other necessary procedures from 2014 to 2019 by 3 fellowship trained foot and ankle orthopedic surgeons were retrospectively administered Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and FAAM Sports questionnaires with no preoperative scoring available. Patient demographic factors, comorbidities, and radiographic features were evaluated as predictors of outcome scores to simulate return to activity. Statistical analysis, including student's t-tests and analysis of variance, was performed.

RESULTS

A total of 54 patients were included. A body mass index (BMI) of 30 kg/m2 or greater was associated with a lower ADL score (P = .002) and Sports score (P = .002). Preoperative hindfoot valgus of 9° or higher was associated with higher ADL scores (P = .040). Neither age nor any flatfoot radiographic parameters yielded significant differences in functional scores.

CONCLUSION

This study demonstrated relatively high average FAAM scores in both the ADL and the sports subscales, consistent with previous studies. This study also identified lower BMI and greater preoperative hindfoot valgus as potential predictors of improved functional outcome following reconstruction.

LEVEL OF EVIDENCE

Level III: Retrospective case control.

How does the postoperative medial arch height influence the patient reported outcomes of stage Ⅱ acquired adult flatfoot deformity?

BACKGROUND

This study aimed to assess how the postoperative medial arch height influenced postoperative patient-reported clinical outcomes after surgery for stage Ⅱ acquired adult flatfoot deformity.

METHODS

A total of 30 feet of 30 patients (7 males, 23 females) who underwent surgery for stage Ⅱ acquired adult flatfoot deformity and could be followed up for at least 2 years were included. The average age at surgery was 60.0 (standard deviation, 13.0) years, and the average follow-up period was 40 (standard deviation, 15.4) months. Among them, 16 patients underwent lateral column lengthening and 14 patients did not. Patient-reported clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire. Radiographic alignment was evaluated by the talonavicular coverage angle, lateral talo-1st metatarsal angle, medial cuneiform height, medial cuneiform to 5th metatarsal height, and calcaneal pitch. The correlation between postoperative Self-Administered Foot Evaluation Questionnaire and radiographic alignment was assessed with Pearson's correlation analysis.

RESULTS

Self-Administered Foot Evaluation Questionnaire and radiographic alignment significantly improved postoperatively in all patients (P < 0.0001). In patients with severe deformity who needed lateral column lengthening, lateral talo-1st metatarsal angle was negatively and medial cuneiform to 5th metatarsal height was positively correlated with physical functioning Self-Administered Foot Evaluation Questionnaire subscales (r = -0.56 and 0.55), and medial cuneiform height was positively correlated with physical functioning, social functioning and general health Self-Administered Foot Evaluation Questionnaire subscales (r = 0.70, 0.55 and 0.73, respectively).

CONCLUSION

Postoperative medial arch height could influence physical functioning, social functioning, and general health in patients with severe stage II adult-acquired flatfoot deformity.

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m² (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

Double hindfoot arthrodesis using a single-incision medial approach in the correction of adult-acquired flatfoot deformity: a case series

BACKGROUND

Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach.

METHODS

A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed.

RESULTS

All radiographic parameters evaluated showed a significant improvement (p < .05), except the calcaneal pitch. Pain decreased by 5.1 points (p < .001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics.

CONCLUSION

Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases.

Lateral open wedge calcaneus osteotomy with bony allograft augmentation in adult acquired flatfoot deformity. Clinical and radiological results

Abstract

The aim of this study is to evaluate the results of patients underwent lateral open wedge calcaneus osteotomy with bony allograft augmentation combined with tibialis posterior and tibialis anterior tenodesis. Twenty-two patients underwent adult-acquired flatfoot deformity were retrospectively evaluated with a minimum 2-year follow-up. Radiographic preoperative and final comparison of tibio-calcaneal angle, talo–first metatarsal and calcaneal pitch angles have been performed. The Visual Analog Scale, American Orthopedic Foot and Ankle Score, the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure were used for subjective and functional assessment. The instrumental range of motion has been also assessed at latest follow-up evaluation and compared with preoperative value. There was a significant improvement of final mean values of clinical scores (p < 0.001). Nineteen out of 22 (86.4%) patients resulted very satisfied or satisfied for the clinical result. There was a significant improvement of the radiographic parameters (p < 0.001). There were no differences between preoperative and final values of range of motion. One failure occurred 7 years after surgery. Adult-acquired flatfoot deformity correction demonstrated good mid-term results and low recurrence and complications rate.

Level of evidence

Level 4, retrospective case series.

Quality of Life in Young Adults after Flatfoot Surgery: A Case-Control Study

The true impact of surgery for flatfoot deformities on patient's quality of life and health status remains poorly defined. The aim of this study is to evaluate the quality of life and the return to daily tasks and sports or physical activities in young adults after surgical correction of flatfoot deformity. Patients treated for bilateral symptomatic flat foot deformity were retrospectively studied. The healthy control group comprised a matched reference population with no history of foot surgery or trauma that was voluntary recruited from the hospital community. All subjects were asked to fill out questionnaires centered on the assessment of the health-related quality of life (Short-form 36; SF-36) and physical activity (International Physical Activity Questionnaire; IPAQ). Most study group SF-36 subscales were lower when compared to the control group. Among the study group, post-operatively, 36.6% of patients managed to resume low levels of sports activity, 40% were sufficiently active and were able to perform moderate sports activity (an activity that requires moderate physical effort and which forces the patient to breathe with a frequency only moderately higher than normal), while 23.3% of them were active or very active and were able to perform intense physical activity. Most IPAQ scores were statistically different from the control group. The present study suggests that patients treated with medializing calcaneal osteotomy and navicular-cuneiform arthrodesis for symptomatic flafoot had lower levels of quality of life and physical activity when compared to healthy subjects. After surgery, patients showed a significant improvement in the clinical scores.

Patient-reported outcome after hallux valgus surgery - a two year follow up

BACKGROUND

Patients with hallux valgus deformity may require surgery but prospective patient-reported data is scarce.

METHODS

We evaluated 53 patients with a mean age of 55.3years (SD 14.1, 50 women), who underwent surgery due to hallux valgus. They completed the PROMs SEFAS, EQ-5D and SF-36 before and 6, 12 and 24 months after surgery.

RESULTS

All patient-reported outcomes improved at 6, 12 and 24months compared with the preoperative status. The greatest improvement occurred at 6months: SEFAS Δ 10.0 (95% confidence interval 7.8-12.2), EQ-5D Δ 0.22 (0.15-0.29), EQ-VAS Δ 8.4 (4.4-12.4), PF SF-36 Δ 22.0 (14.6-29.3) and BP SF-36 Δ 30.6 (23.1-38.1).

CONCLUSIONS

Hallux valgus surgery considerably reduced pain and improved function already within 6months after surgery. The improvement between 6 and 24months' follow-up was minimal measured with PROMs.

LEVEL OF CLINICAL EVIDENCE

III - prospective observational cohort study.

Adult-Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.

Identifying Risk Factors for 30-Day Readmissions After Triple Arthrodesis Surgery

Rigid flatfoot deformity is a debilitating condition that can be managed by triple arthrodesis surgery. Triple arthrodesis has the potential to restore health-related quality of life, but it is also associated with several complications. Few studies have examined the 30-day readmission rates after triple arthrodesis. The objective of this study was to investigate risk factors for 30-day all-cause readmissions after triple arthrodesis. The nationwide readmission database was queried from 2013. By using International Classification of Disease, Ninth Revision, procedure codes, all triple arthrodesis procedures were identified. Demographic factors, comorbidities, insurance status, and hospital characteristics were statistically compared between patients who experienced a 30-day readmission and those who did not. Multivariable logistic regression was used to identify independent risk factors for 30-day readmission. Overall, 1916 triple arthrodesis cases were identified. The overall 30-day readmission rate after triple arthrodesis was 4.6%. Univariate analysis revealed a statistically higher proportion of patients with electrolyte abnormalities (13.8% vs 4.6%; p < .01) in the patients who were readmitted within 30 days compared with those who were not. Multivariable analysis demonstrated Medicaid insurance, relative to private insurance, as the only statistically significant predictor of 30-day readmission with an odds ratio of 4.43 (p < .05). These results suggest that patients of lower socioeconomic status may be at a greater risk for development of a short-term readmission after triple arthrodesis surgery. These findings are important for surgeon and patient communication, counseling, and postoperative care when choosing to pursue triple arthrodesis surgery.

Age- and Gender-Specific Normative Values for the Self-Reported Foot and Ankle Score (SEFAS)

BACKGROUND

The Self-Reported Foot and Ankle Score (SEFAS) is a foot- and ankle-specific patient-reported outcome measurement (PROM) score that has been validated with good results for a variety of foot and ankle disorders. SEFAS is sensitive detecting improvement or deterioration after surgery. However, normative values, required to put a specific patient's summary score into perspective, are lacking.

METHODS

In this report, we included 396 population-based men and 383 women (43% of the invited individuals), age 20-89 years, who had completed the SEFAS questionnaire and questions regarding anthropometrics and health. We used Mann-Whitney U test to test gender differences and Spearman correlation coefficients to determine any association between SEFAS score and age. We present gender-specific median SEFAS scores with range and 5th to 95th percentiles and mean with standard deviation.

RESULTS

The SEFAS normative values were median 48 in men (range 11-48), 5th to 95th percentiles 31 to 48 and mean 45 ± 6, and in women, median 47 (range 6-48), 5th to 95th percentiles 23 to 48 and mean 43 ± 8 (gender comparison P < .001). SEFAS normative values correlated inversely with age (r = -0.12, P < .001).

CONCLUSION

In the general population, older age was associated with lower SEFAS value, and men had higher values than women. The population-based normative SEFAS values provided in this study can facilitate quantification of disability related to foot and ankle with and without surgery in the foot and ankle.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

BACKGROUND

Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data.

METHODS

We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated.

RESULTS

At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament.

CONCLUSIONS

Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

Return to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer

PURPOSE

Medial displacement calcaneal osteotomy with flexor digitorum longus transfer is a common treatment for the management of the adult flatfoot associated with posterior tibial tendon dysfunction. In the literature, there is a paucity of information regarding the ability of patients to return to sport and recreational activities after this surgical procedure. The purpose of this retrospective clinical study was to assess the rate and type of athletic activities that patients participated in before and after medial displacement calcaneal osteotomy with flexor digitorum longus transfer.

METHODS

A consecutive series of 42 patients with a mean age at surgery of 41 years (range 19-74 years) was evaluated with a minimum follow-up of 24 months (range 18-31 months). Pre- and post-operative sporting activities were assessed. At final follow-up, patients were asked to complete a Sports Athlete Foot and Ankle Score (SAFAS). Each patient was also evaluated with weight-bearing radiographs of the foot before surgery and at final follow-up.

RESULTS

Preoperatively, 27 of 42 (64.3 %) patients were engaged in athletic activities, participating in an average of 1.4 h/week (range 0-6 h/week); post-operatively, 36/42 (85.7 %) participated in sport and recreational activities for an average of 3.5 h/week (range 0-15 h/week). Meary's angle improved significantly from 11.5 ± 6.2 degrees preoperatively to 7.0 ± 5.7 degrees at final follow-up (p < 0.01); calcaneal pitch improved significantly from 16.5 ± 4.6 degrees to 19.0 ± 5.0 degrees (p < 0.01). At final follow-up, patients demonstrated good SAFASs in symptom tolerance (86.4 %), pain tolerance (89.0 %), daily living performance (96.1 %), and sports performance (86.7 %).

CONCLUSION

The majority of patients returned to sports and recreational activity after medial displacement calcaneal osteotomy and flexor digitorum longus for the treatment of adult flatfoot associated with posterior tibial tendon dysfunction.

LEVEL OF EVIDENCE

III.

Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard

OBJECTIVE

To investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition.

MATERIALS AND METHODS

Nineteen patients (11 females; age: 46 ± 15 year, range 18-75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I-III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman's rank-order, and intraclass correlation coefficient (ICC) statistics were used.

RESULTS

ICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264).

CONCLUSION

For PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables.

Good outcome scores and high satisfaction rate after primary total ankle replacement

Background and purpose - Total ankle replacement (TAR) is gaining popularity for treatment of end-stage ankle arthritis. Large patient-centered outcome studies are, however, few. Here, we report data from the Swedish Ankle Registry. Patients and methods - We examined outcomes after primary TAR in patients from the Swedish Ankle Registry using PROMs (Patient Reported Outcome Measures; generic: EQ-5D and SF-36, region specific: SEFAS (Self-Reported Foot and Ankle Score), and a question on satisfaction). We included 241 patients registered with primary TAR between 2008 and 2016 and who completed PROMs preoperatively and postoperatively up to 24 months. We evaluated changes in PROMs following surgery and estimated effects of age, diagnosis, prosthetic design, and preoperative functional score on the outcomes. Results - All absolute scores improved from preoperative to 24 months after surgery (p ≤ 0.001). 71% of the patients were satisfied or very satisfied at the latest follow-up and 12% dissatisfied or very dissatisfied. Postoperative SEFAS correlated with age (r = 0.2, p = 0.01) and preoperative SEFAS (r = 0.3, p < 0.001), as did patient satisfaction (r = -0.2; p ≤ 0.03). Postoperative SEFAS and EQ-5D were similar between different diagnoses or prosthetic designs. Preoperative SF-36 was associated with diagnosis (p ≤ 0.03), postoperative SF-36 with age (r = 0.2, p = 0.01) and diagnosis (p < 0.03). Interpretation - We found statistically and clinically significant improvements in patient-reported outcomes following TAR surgery. The postoperative region-specific SEFAS was positively associated with older age. Prosthetic design seemed not to influence patient-reported outcome, whereas diagnosis partly did. Studies with longer follow-up are necessary to establish the long-term outcome of TAR and to elucidate whether short- and mid-term outcomes may predict implant failure.

Use of PROMIS for Patients Undergoing Primary Total Shoulder Arthroplasty

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) consists of question banks for health domains through computer adaptive testing (CAT).

Hypothesis:

For patients with glenohumeral arthritis, (1) there would be high correlation between traditional patient-reported outcome (PRO) measures and the PROMIS upper extremity item bank (PROMIS UE) and PROMIS physical function CAT (PROMIS PF CAT), and (2) PROMIS PF CAT would not demonstrate ceiling effects.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

Sixty-one patients with glenohumeral osteoarthritis were included. Each patient completed the American Shoulder and Elbow Surgeons (ASES) assessment form, Marx Shoulder Activity Scale, Short Form–36 physical function scale (SF-36 PF), EuroQol 5 Dimensions (EQ-5D) questionnaire, Western Ontario Osteoarthritis Shoulder (WOOS) index, PROMIS PF CAT, and the PROMIS UE. Correlation was defined as high (>0.7), moderate (0.4-0.6), or weak (0.2-0.3). Significant floor and ceiling effects were present if more than 15% of individuals scored the lowest or highest possible total score on any PRO.

Results:

The PROMIS PF demonstrated excellent correlation with the SF-36 PF (r = 0.81, P < .0001) and good correlation with the ASES (r = 0.62, P < .0001), EQ-5D (r = 0.64, P < .001), and WOOS index (r = 0.51, P < .01). The PROMIS PF demonstrated low correlation with the Marx scale (r = 0.29, P = .02). The PROMIS UE demonstrated good correlation with the ASES (r = 0.55, P < .0001), SF-36 (r = 0.53, P < .01), EQ-5D (r = 0.48, P < .01), and WOOS (r = 0.34, P <.01), and poor correlation with the Marx scale (r = 0.06, P = .62). There were no ceiling or floor effects observed. The mean number of items administered by the PROMIS PRO was 4.

Conclusion:

These data suggest that for a patient population with operative shoulder osteoarthritis, PROMIS UE and PROMIS PF CAT may be valid alternative PROs. Additionally, PROMIS PF CAT offers a decreased question burden with no ceiling effects.

Minimally important change, measurement error, and responsiveness for the Self-Reported Foot and Ankle Score

Background and purpose - Patient-reported outcome measures (PROMs) are increasingly used to evaluate results in orthopedic surgery. To enhance good responsiveness with a PROM, the minimally important change (MIC) should be established. MIC reflects the smallest measured change in score that is perceived as being relevant by the patients. We assessed MIC for the Self-reported Foot and Ankle Score (SEFAS) used in Swedish national registries. Patients and methods - Patients with forefoot disorders (n = 83) or hindfoot/ankle disorders (n = 80) completed the SEFAS before surgery and 6 months after surgery. At 6 months also, a patient global assessment (PGA) scale-as external criterion-was completed. Measurement error was expressed as the standard error of a single determination. MIC was calculated by (1) median change scores in improved patients on the PGA scale, and (2) the best cutoff point (BCP) and area under the curve (AUC) using analysis of receiver operating characteristic curves (ROCs). Results - The change in mean summary score was the same, 9 (SD 9), in patients with forefoot disorders and in patients with hindfoot/ankle disorders. MIC for SEFAS in the total sample was 5 score points (IQR: 2-8) and the measurement error was 2.4. BCP was 5 and AUC was 0.8 (95% CI: 0.7-0.9). Interpretation - As previously shown, SEFAS has good responsiveness. The score change in SEFAS 6 months after surgery should exceed 5 score points in both forefoot patients and hindfoot/ankle patients to be considered as being clinically relevant.

Bilateral Arthrodesis of the Ankle Joint: Self-Reported Outcomes in 35 Patients From the Swedish Ankle Registry

Bilateral ankle arthrodesis is seldom performed, and results concerning the outcome and satisfaction can only sparsely be found in published studies. We analyzed the data from 35 patients who had undergone bilateral ankle arthrodesis in the Swedish Ankle Registry using patient-reported generic and region-specific outcome measures. Of 36 talocrural arthrodeses and 34 tibio-talar-calcaneal arthrodeses, 6 ankles (9%) had undergone repeat arthrodesis because of nonunion. After a mean follow-up period of 47 ± 5 (range 12 to 194) months, the mean scores were as follows: self-reported foot and ankle score, 33 ± 10 (range 4 to 48); the EuroQol Group's EQ-5D^™ score, 0.67 ± 0.28 (range -0.11 to 1), the EuroQol Group's visual analog scale score, 70 ± 19 (range 20 to 95), 36-item Short Form Health Survey (SF-36) physical domain, 39 ± 11 (range 16 to 58); and SF-36 mental domain, 54 ± 14 (range 17 to 71). Patients with rheumatoid arthritis seemed to have similar self-reported foot and ankle scores but possibly lower EQ-5D^™ and SF-36 scores. Those with talocrural arthrodeses scored higher than did those with tibio-talar-calcaneal arthrodeses on the EQ5D^™ and SF-36 questionnaires (p = .03 and p = .04). In 64 of 70 ankles (91%), the patients were satisfied or very satisfied with the outcome. In conclusion, we consider bilateral ankle arthrodesis to be a reasonable treatment for symptomatic hindfoot arthritis, with high postoperative mid-term satisfaction and satisfactory scores on the patient-reported generic and region-specific outcome measures, when no other treatment option is available.