An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery

Kinetics of functional recovery after foot and ankle surgery. Comparison of EFAS and SF36 scores

INTRODUCTION

The EFAS score is a new recently validated European quality of life score for foot and ankle surgery, comprising 6 questions on activities of daily living (ADL) and 4 on sport. The aim of the present study was to assess the kinetics of functional recovery on the EFAS and SF36 scores, and to assess correlations between the two at 0 to 6 months then 6 months to 1 year in a population of foot and ankle surgery patients, globally and per pathology.

HYPOTHESIS

Hindfoot and ankle surgery requires at least 1 year's follow-up for assessment of recovery, whereas 6 months is sufficient to assess forefoot recovery.

MATERIAL AND METHODS

A multicenter prospective cohort study included all patients undergoing surgery for foot and ankle pathology between December 2015 and July 2016. Statistical analysis, global and per pathology, was performed preoperatively and at 6 months and 1 year.

RESULTS

In total, 98 patients were assessed at 1 year. In the global population, EFAS ADL score improved by 17.1±22.1 points (hindfoot, 16.9±24.6; forefoot, 19.7±21.4) and global SF36 score by 8.7±17.1 points (hindfoot, 10.2±19.1; forefoot, 9.6±15.9). Both scores progressed between 6 months and 1 year for hindfoot pathologies, whereas they remained constant after 6 months for the forefoot. The EFAS score showed weak correlation with SF36.

CONCLUSION

Recovery kinetics differs according to type of foot and ankle pathology. The EFAS score is more suitable than the SF36.

LEVEL OF EVIDENCE

II.

Graft and Flap: Orthoplastic Approach to Achilles Tendon Secondary Rupture

SUMMARY

Achilles tendon rupture represents one of the most common tendon ruptures. Although primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This article aims to present the authors' orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open-wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October of 2018 and October of 2020. The size of the average soft-tissue defect was 126.2 cm 2 (range, 86.1 to 175.9 cm 2 ), with a tendon gap of 8.2 cm (range, 7.1 to 10.3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure, using a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft-tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using the American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey questionnaire. Mean follow-up was 18.3 months (range, 12 to 24 months). The flap survival rate was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees versus 62 degrees). The American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey scores of all patients improved significantly ( P < 0.005) at 12 months of follow-up. A microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture, providing a reconstructed tendon that achieves satisfactory anatomic shape and function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Description of the Simple Ankle Value: A Simplified Patient-Reported Outcome Measure for the Assessment of Ankle and Hindfoot Function

Background

The Simple Ankle Value (SAV) is a patient-reported outcome measure (PROM) in which patients grade their ankle function as a percentage of that of their contralateral uninjured ankle.

Purpose/Hypothesis

The primary aims of this study were to validate the SAV and evaluate its correlation with other PROMs. It was hypothesized that the SAV would be seen as a valid score that provides results comparable with those of the Foot and Ankle Ability Measure (FAAM) and the European Foot & Ankle Society (EFAS) score.

Study Design

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

Methods

Patients seen for an ankle or hindfoot tissue were divided into those treated operatively and nonoperatively. A control group of patients treated for issues outside of the foot and ankle was also created. All patients completed the SAV followed by the FAAM and the EFAS scores. Patients treated operatively completed the questionnaires before surgery and 3 months after surgery. Patients treated nonoperatively completed the questionnaires twice 15 days apart. The correlation between the SAV score, the FAAM score, and the EFAS score was estimated with the Spearman correlation coefficient.

Results

A total of 209 patients (79 in the operative group, 103 in the nonoperative group, and 27 in the control group) were asked to complete the questionnaire, and all were included. The test-retest reliability of the SAV was excellent (intraclass correlation coefficient, 0.92; 95% CI, 0.88-0.94). No ceiling or floor effect was reported. Strong correlation was found between the SAV and the FAAM and EFAS scores. The SAV was able to discriminate patients from controls (54.18 ± 21.22 and 93.52 ± 9.589; P < .0001); however, SAV was not able to detect change from preoperative to 3 months postoperative (from 54.18 ± 21.22 to 62.53 ± 20.83; P = .44).

Conclusion

Our study suggests that the SAV is correlated with existing accepted ankle PROMs. Further work with this PROM is needed to validate the questionnaire.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis

BACKGROUND

Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation.

METHODS

A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software.

RESULTS

11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant.

CONCLUSION

Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BACKGROUND

The role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia.

METHODS

Patients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test.

RESULTS

48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes.

CONCLUSION

Superiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.

Impact of pes planus on clinical outcomes of hallux valgus surgery

BACKGROUND

Pes planus is associated with hallux valgus development. This study evaluated the impact of pes planus on clinical outcomes following hallux valgus surgery.

METHODS

191 patients underwent Scarf osteotomy for hallux valgus. Pes planus angles including talonavicular coverage angle, lateral talus-first metatarsal angle (Meary's angle) and lateral talocalcaneal angle were measured. The cohort was stratified into control (0°-4.0°), mild (4.1°-14.9°), moderate (15.0°-30.0°) and severe (> 30.0°) pes planus groups according to Meary's angle. Clinical outcomes were compared at baseline, 6 months and 24 months.

RESULTS

There were 78 controls, 95 mild and 18 moderate cases of pes planus. Meary's angle was independently associated with preoperative hallux valgus angle. Pes planus angles were not associated with pain, AOFAS, SF-36 physical or mental scores. All three groups had similar clinical outcomes and patient satisfaction.

CONCLUSION

Compared to patients with neutral foot arches, those with pes planus presented with more severe hallux valgus deformity but had similar clinical outcomes following surgical correction.

Third-Generation Minimally Invasive Chevron-Akin Osteotomy for Hallux Valgus Produces Similar Clinical and Radiological Outcomes as Scarf-Akin Osteotomy at 2 Years: A Matched Cohort Study

BACKGROUND

The minimally invasive chevron-Akin (MICA) osteotomy is an increasingly popular technique for the correction of hallux valgus. However, there is a paucity of literature comparing it with traditional open techniques. The purpose of this study was to compare the clinical and radiological outcomes of the MICA osteotomy using a new-generation MICA screw and scarf-Akin osteotomy for hallux valgus correction.

METHODS

Thirty cases of MICA osteotomy were propensity score matched 1:1 with a control group of 30 scarf-Akin osteotomy cases. The groups were matched for age, sex, body mass index, preoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) metatarsophalangeal-interphalangeal (MTP-IP) score, 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), preoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), and concomitant procedures. Outcomes were compared at 6 and 24 months postoperatively. Early postoperative VAS scores were also compared.

RESULTS

Both groups demonstrated significant improvements in VAS score, AOFAS score, and SF-36 PCS and MCS at 6 and 24 months postoperatively. For the MICA group, HVA improved from 23.5 to 7.7 degrees, and IMA improved from 13.5 to 7.5 degrees. For the scarf-Akin osteotomy group, HVA improved from 23.7 to 9.3 degrees, and IMA improved from 13.6 to 7.8 degrees. The first 24-hour postoperative VAS score was significantly lower in the MICA group compared with the scarf-Akin group (2.0 ± 2.0 vs 3.4 ± 2.6, P = .029). However, there was no significant difference in clinical or radiological outcomes between the groups at 6 and 24 months.

CONCLUSION

The MICA procedure with the new-generation MICA screw is an attractive option for the correction of hallux valgus, yielding similar midterm radiological and clinical outcomes compared with the well-established scarf-Akin osteotomy. The first 24-hour postoperative VAS score in the MICA group was also statistically lower, although its clinical significance remains to be determined.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Flexor Hallucis Longus Tenolysis and Tenosynovectomy in Dancers

The purpose of this study was to report on a series of dancers who had undergone flexor hallucis longus (FHL) tenolysis/tenosynovectomy after having failed conservative management. Institutional human subjects committee approval was obtained prior to initiating this study. This study is a retrospective case series of 58 dancers and 63 ankles who underwent FHL tenolysis/tenosynovectomy via an open posteromedial approach by a single surgeon between 1993 and 2017. All patients were interviewed and charts reviewed. Collected variables included: preoperative and postoperative pain levels, time to return to dance, and subjective satisfaction with the procedure. Age, primary dance form, and level of dance were determined. Mean preoperative pain level decreased significantly postoperatively. Mean time to return to dance was 7.1 weeks. There was a 98% (62/63) return to dance at some level while 97% (61/63) of patients returned to dance symptom-free. There were no neurovascular or other major complications. Minor complications included stiffness at follow-up (6.3%, 4/63), superficial wound infection (3.1%, 2/63), and hypertrophic scar (4.8%, 3/63). Over 97% (61/63) of dancers considered the procedure a success and 98% (62/63) of dancers would repeat the procedure. This is one of the largest series reported of isolated FHL tenolysis/tenosynovectomy in dancers who have failed nonoperative management. Satisfactory pain relief and return to dance with a low complication rate may be expected from this surgical procedure. The results of this study can be used to help dancers and their providers make informed decisions about treatment in isolated FHL tendinitis.

Results of Hallux Valgus Surgery in Diabetic Patients With Good Glycemic Control

BACKGROUND

Literature is sparse on whether diabetes affects outcomes of hallux valgus surgery. With the rising global prevalence of diabetes and diabetes being an independent predictor of poorer outcomes, particularly in foot and ankle surgery, we aimed to investigate the impact of diabetes on the outcomes of hallux valgus surgery.

METHODS

We conducted a retrospective comparative cohort study of prospectively collected registry data of 951 feet in 721 patients who underwent surgery for symptomatic hallux valgus between 2007 and 2015 at our institution. All patients with diabetes were identified and matched with patients without diabetes for age, sex, and body mass index in a 1:2 ratio to construct the matched cohorts for analysis. Glycemic control in the diabetic cohort was assessed using preoperative HbA1c. The primary outcome measure was complication rates. Secondary outcomes were (1) deformity correction using the hallux valgus and intermetatarsal angles; (2) patient-reported outcomes using visual analog scale (VAS) for pain, Short Form-36 (SF-36) Physical and Mental Health subscales, and American Orthopaedic Foot & Ankle Society (AOFAS) scores; (3) patient satisfaction; and (4) reoperation rates up to 2 years postoperatively. Forty diabetic patients were identified and matched to 80 nondiabetic patients. Although matching was only performed for age, sex, and body mass index, the diabetic and the nondiabetic cohorts were also similar in hallux valgus severity, preoperative scores, and types of procedures performed.

RESULTS

The mean preoperative HbA1c in our diabetic cohort was 7.1%. Both the diabetic and nondiabetic cohorts showed excellent AOFAS and VAS scores with no differences in degree of deformity correction, complication profiles, reoperation rates, outcome scores, and satisfaction at both 6 months and 2 years postoperatively.

CONCLUSION

We believe stringent patient selection was key to reduced complication rates and good outcomes in diabetic patients. Well-selected diabetic patients remain suitable candidates for hallux valgus surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Effect of Severity of Deformity on Clinical Outcomes of Scarf Osteotomies

BACKGROUND

Literature is sparse on whether severity of hallux valgus affects outcomes of surgery. We thus aimed to evaluate the impact of hallux valgus severity on the clinical outcomes of surgery.

METHODS

83 consecutive scarf osteotomies performed by a single surgeon for symptomatic hallux valgus between 2007 and 2011 were divided into 3 groups (mild, moderate, and severe) based on severity of their preoperative hallux valgus using the hallux valgus and intermetatarsal angles. Outcomes were assessed using the visual analog scale (VAS) for pain, 36-Item Short Form Health Survey physical functioning (SFPF) and mental health (SFMH) subscales, and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores. These were assessed preoperatively and at 6 months and 2 years postoperatively. Patient satisfaction was assessed at 6 months and 2 years postoperatively. Eleven (13.2%), 54 (65.1%), and 18 (21.7%) feet were in the mild, moderate, and severe groups, respectively.

RESULTS

There was no difference in preoperative VAS, SFPF, SFMH and AOFAS scores between the groups except for AOFAS scores for the second toe, which were poorer with increasing hallux valgus. Postoperatively, there was improvement across all outcome scores. VAS and AOFAS showed excellent scores, and patient satisfaction was high across all 3 groups (88.9%, 89.4%, and 86.7%). The severe group had slightly lower SFPF scores at 6 months (mild, 81.1; moderate, 84.0; severe, 74.3; P = .031) and 2 years postoperatively (mild, 93.4; moderate, 89.7; severe, 76.4; P = .005), and slightly poorer second toe scores for VAS (mild, 0.0; moderate, 0.1; severe, 1.2; P = .017) and AOFAS (mild, 94.7; moderate, 93.5; severe, 83.4; P = .043) at 2 years postoperatively. All other scores including patient satisfaction showed no between-group differences. Complication and revision rates between the groups were similar.

CONCLUSION

Surgery for symptomatic hallux valgus lead to excellent outcomes and high patient satisfaction regardless of severity of deformity.

LEVEL OF EVIDENCE

Level III, comparative series.

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

BACKGROUND

Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.

OBJECTIVE

To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

MATERIALS AND METHODS

Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.

RESULTS

Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).

CONCLUSION

PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.

Nwdps protocol - A simple functional outcome assessment tool for clubfoot correction and a review of literature

INTRODUCTION

Various clubfoot severity scoring systems are known to us. Dimeglio and Pirani Scoring systems are most widely used. Also, various treatment outcome measures have been proposed by researchers to assess patient satisfaction and results of treatment. None of the available methods are widely popular and amenable for routine use. A "nwdps protocol" was proposed for functional assessment of patients with clubfoot correction, where "n" was no pain during walking or running; "w" was ability to wear normal shoes; "d" was no significant difference in foot/shoe size of both sides; "p" was plantigrade foot and "s" was ability of the child to squat without heel lift-off. The aim of this study was to test this functional outcome assessment tool for easy day to day use post clubfoot correction.

METHODS

The nwdps protocol was applied to all the children at followup on a yearly basis who underwent clubfoot deformity correction in Department of Orthopaedics of our Institute between March 2016 and January 2018.

RESULTS

Eighty children were enrolled for the study, 45 had bilateral affection while 35 had unilateral affection. In all 125 feet were treated for clubfoot correction and evaluated using nwdps protocol. Each child was assessed by 2 researchers independently. There was no difference in functional assessment of 2 observers. Fifty-nine children were nwdp positive, one was nwps positive, while 2 were dwps positive at the end of 1 year. 79 children became nwdps positive at the end of 2nd year of followup.

CONCLUSION

Nwdps protocol is a very easy to remember and easy to use functional outcome assessment tool post clubfoot correction with high degree of objectivity and interobserver reliability.

LEVEL OF EVIDENCE

Level IV.

A Systematic Review of the Outcome Evaluation Tools for the Foot and Ankle

Background. The goal of this systematic review is to determine the most commonly used outcome measurement tools used by foot and ankle specialists and determine their limitations, such as whether they are validated, have floor/ceiling effects, and so on. Methods. A literature search was conducted to identify primary publications between January 1, 2012 and July 1, 2017 that concern care of the foot and ankle and use any established grading criteria to evaluate patients. Results. In 669 publications, 76 scoring systems were used. The 10 most common were American Orthopaedic Foot and Ankle Score (AOFAS), visual analog scale (VAS), Short Form-36 (SF-36), Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), SF-12, Short Musculoskeletal Function Assessment (SMFA), Ankle Osteoarthritis Scale (AOS), and Foot and Ankle Disability Index (FADI). AOFAS was used in 393 articles, VAS in 308, and SF-36 in 133 publications. AOFAS, VAS, and SF-36 were used to evaluate 23,352, 20,759, and 13,184 patients respectively. AOFAS and VAS were used simultaneously in 172 publications. Conclusion. While there are many different scoring systems available for foot and ankle specialists to use to assess or demonstrate the effectiveness of treatments, the AOFAS, while it is an unvalidated scoring system, is the most commonly used scoring system in this review. Clinical Relevance. This review presents data about commonly used patient reported outcomes systems in foot and ankle surgery. Levels of Evidence: Level III: Systematic review.

Excision of Os Trigonum in Dancers via an Open Posteromedial Approach

An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Surgical excision is indicated on failure of nonoperative management. Options for surgical excision include open excision (via a posterolateral or posteromedial approach), subtalar arthroscopy, and posterior endoscopy. Os trigonum excision via an open posteromedial approach with concomitant FHL tenolysis/tenosynovectomy is a safe and effective method for the operative treatment of a symptomatic os trigonum that allows for identification and treatment of associated FHL pathology. The major steps in the procedure, which are demonstrated in this video article, are: (1) preoperative planning with appropriate imaging; (2) patient is positioned in a supine position with the operative extremity in figure-of-4 position; (3) a 3-cm, slightly curvilinear longitudinal incision is made midway between the posterior aspect of the medial malleolus and the anterior aspect of the Achilles tendon, over the palpated FHL tendon, and the flexor retinaculum is exposed and incised; the neurovascular bundle is retracted anteriorly, exposing the FHL tendon and sheath; (4) FHL tenolysis/tenosynovectomy is performed; (5) the FHL is retracted anteriorly and a capsulotomy is performed over the os trigonum and the os trigonum is excised; (6) the capsule is repaired and closure is performed; and (7) dressings and a CAM (controlled ankle motion) walking boot are applied. The patient begins physical therapy at 2 weeks postoperatively and may return to dance at 4 to 6 weeks postoperatively as tolerated. In our series of 40 cases, 95% of patients who desired to return to dance were able to return to their pre-injury level of dance. There were no major neurovascular complications.

Minimal resection interposition arthroplasty of the first metatarsophalangeal joint

BACKGROUND

Interposition arthroplasty of the first metatarsophalangeal (MTP) joint is a viable alternative to fusion in patients with advanced hallux rigidus. The purpose of this study is to evaluate the midterm results of a modification of the technique.

METHODS

Case series of 18 interposition arthroplasties were performed on 13 female patients with Grade III-IV hallux rigidus. The technique included cheilectomy, bunionectomy when needed, minimal resection of the base of the proximal phalanx and interposition of a fascia lata allograft in the first metatarsophalangeal joint. Mean follow up was nine years (range 75-136 months). Patients were evaluated according to the AOFAS score, the ability to tip toe and their subjective satisfaction.

RESULTS

There was a significant difference between preoperative (mean 43.2, range 15-83) and postoperative (mean 77.3, range 40-100) AOFAS scores (p<0.001). The patients were able to tip toe on 12 of the 18 operated feet and 9 of the 13 patients were satisfied from the operation. All dissatisfied patients had a coexistent hallux valgus deformity.

CONCLUSIONS

The technique had satisfactory midterm outcomes in older patients with advanced hallux rigidus without hallux valgus. Advantages of the method are the preservation of tip toe function in most patients and a technically easy conversion to fusion when needed.

Os Trigonum Excision in Dancers via an Open Posteromedial Approach

BACKGROUND

An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Options for operative excision include open excision, subtalar arthroscopy, and posterior endoscopy. The purpose of this paper was to present a series of dancers who underwent excision of a symptomatic os trigonum via an open posteromedial approach.

METHODS

This study is a retrospective case series of 40 ankles in 38 dancers who underwent os trigonum excision via an open posteromedial approach with FHL tenolysis between 2000 and 2013. All patients were interviewed and charts retrospectively analyzed. Collected variables included pre- and postoperative pain level, time to return to dance, and subjective satisfaction. The average age was 19.2 years; ballet was the primary dance form in 36 (95%) of patient-cases. Eight (20%) of the patient-cases were professional dancers, and 30 (75%) were students or preprofessional dancers.

RESULTS

Average preoperative pain level was 7.7/10, which decreased to 0.6/10 postoperatively. Seventeen (42.5%) experienced concurrent preoperation-associated FHL symptomatology, all of whom experienced relief postoperatively. The average time to return to dance was 7.9 weeks, and time to pain-free dance was 17.7 weeks. Of the 37 patient-cases desiring to return to dance, 35 (94.6%) returned to their preoperative level of dance. There were no neurovascular or other major complications. Four (10%) had minor wound complications that resolved, and 38 cases (95%) considered the procedure a success.

CONCLUSION

Open posteromedial excision of an os trigonum in dancers provided satisfactory pain relief, return to dance, and complication rates compared to other approaches, and allowed for identifying and treating any associated FHL pathology.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Age- and Sex-Related Normative Data for the Foot Function Index in a German-Speaking Cohort

BACKGROUND

Despite increasing popularity of the Foot Function Index (FFI), normative values are still unavailable for this self-administered score. This study was designed to generate age- and sex-related normative values for the FFI-total and for both subscales FFI-pain and FFI-disability.

METHODS

We used the cross-cultural adapted and validated German version of the FFI to generate a data pool using the results of 625 individuals, including staff and visitors to our hospital and excluding persons scheduled for foot surgery or in after-treatment.

RESULTS

Mean values for FFI-total were calculated: 15.3 points (95% confidence interval [CI], 13.3-16.9), 14.9 points for FFI-pain (CI, 13.3-16.5), and 15.6 for FFI-disability (CI, 13.8-17.4). Results showed higher values for FFI-total, FFI-pain, and FFI-disability for individuals older than 40 years. In general, normative values showed a tendency for higher values with age. A slightly inconsistent distribution over different age groups with a peak for individuals in their 40s and 50s was observed, especially for FFI-pain. Men had better scores than women. Individuals with previous surgery showed lower scores in their respective score.

CONCLUSIONS

Our data calculated normative values for a German-speaking cohort for FFI-total as well as for both subscales FFI-pain and FFI-disability. Our data quantified the increase of FFI-total, FFI-pain, and FFI-disability normative values with age but also showed a slightly inconsistent distribution of normative values over all age groups. We demonstrated higher normative values for women and slightly higher normative values for individuals with previous foot or ankle surgery.

LEVEL OF EVIDENCE

II, prospective comparative study.

Outcome of Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears

BACKGROUND

Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears.

METHODS

Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist.

RESULTS

All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests.

CONCLUSION

The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Reliability and Validity of the Korean Version of the Foot Function Index

Although translated versions of the Foot Function Index (FFI) in several languages are available, the absence of a Korean version has precluded comparing the data from Korea with the data from other countries using the FFI. We, therefore, evaluated the reliability and validity of the adapted Korean version of the FFI. We translated the English version of the FFI into Korean and back into English. We mailed the Korean version of the visual analog scale, FFI, and the previously validated Medical Outcomes Study Short-Form 36-item questionnaire (SF-36) to 121 patients with treated foot complaints. To evaluate the test-retest reliability and internal consistency, we used the intraclass correlation coefficient and Cronbach's α, respectively. We also evaluated the concurrent and construct validity of Korean version of the FFI by comparing the visual analog scale and SF-36. Cronbach's α was 0.91 and 0.95 for the pain and disability subscales, respectively. The reproducibility was good, and a strong correlation between the FFI and the SF-36 and visual analog scale with related content was observed, indicating good construct validity.The Korean version of the FFI is a reliable and valid questionnaire for the self-assessment of pain and disability in Korean patients with foot complaints.

Prospective clinical trial of patients who underwent ankle arthroscopy with articular diseases to match clinical and radiological scores with intra-articular cytokines

OBJECTIVE

There is still a lack of reliable data on cytokine concentrations in the ankle and their value for prognosis.

METHODS

In a prospective clinical trial, lavage fluids were collected from 49 patients with an arthroscopy of the ankle. The fluids were investigated by ELISA for cytokine levels. Clinical scores (FFI, AOFAS) were evaluated both pre-operatively and then again 12 months after surgery (n = 43, 88%). Radiological changes were noted with the Kellgren-Lawrence-Score (KLS) and the Ankle Osteoarthritis Scoring System (AOSS). Based on the difference between the pre- and postoperative clinical scores, two groups were defined according to whether they had benefited from the surgical therapy (Δ score ≥ 10) or not (Δ score < 10).

RESULTS

The average clinical scores had improved to a statistically significant extent in the one-year follow-up (p < 0.01). BMP-2 (p = 0.02), IGF-1 (p = 0.04), BMP-7 (p = 0.01) and aggrecan (p = 0.04) showed significant correlations with pre-operative clinical and radiological scores (p = 0.02, p = 0.01, p = 0.01, p = 0.01). Furthermore, BMP-2 (p = 0.01), IGF-1/TPC (p = 0.03) and aggrecan (p = 0.01) correlated with scores after one year (p = 0.02, p = 0.01). High aggrecan concentrations were associated with a low clinical and a high radiological score at both time points, both indicating progress of cartilage degeneration in contrast to BMP-2 or IGF-1. Furthermore, MMP-13 concentrations were significantly higher in the non-benefit group (p = 0.02).

CONCLUSION

BMP-2, IGF-1, aggrecan and MMP-13 seem to be involved in the degenerative process of cartilage in the ankle joint. Additionally, high synovial MMP-13 concentrations indicate a worse clinical outcome.

Surgery for the correction of hallux valgus

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years.

Cite this article: Bone Joint J 2015;97-B:208–14.

Validity, reliability, and responsiveness of the Korean version of American Academy of Orthopedic Surgeons Foot and Ankle questionnaire

The American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire (AFAQ) reflects patients' subjective disorder due to foot and ankle conditions. We evaluated the validity, reliability, and responsiveness of the Korean version of the AFAQ, after translation and transcultural adaptation of the original AFAQ into the Korean language. A total of 206 patients were enrolled, including 152 with chronic problems (experimental group) and 54 with acute problems (control group). We used the intraclass correlation coefficient to assess the test-retest reliability and Cronbach's α to assess internal reliability. Pearson's correlation coefficient was used to assess the criterion validity by correlating the Korean AFAQ scores with those from other validated scales (American Orthopaedic Foot and Ankle Society Hallux-Metatarsophalangeal-Interphalangeal scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, and visual analog scale for pain). To analyze discriminant validity, we evaluated the difference between the experimental and control groups using the Student t test. Of the 152 patients in the experimental group, 29 revisited our clinic postoperatively and repeated the Korean AFAQ. To analyze responsiveness, we used paired t tests to evaluate postoperative changes. In terms of test-retest reliability, the intraclass correlation coefficient ranged from 0.979 to 0.999. In terms of internal reliability, Cronbach's α was 0.528 for the stiffness and swelling subscale and greater than 0.7 for all other subscales. In terms of criterion validity, Pearson's correlation coefficient ranged from 0.492 to 0.699. The probability of the null hypothesis for discriminant validity and responsiveness was statistically significant (p < .001 and p = .021, respectively). These results showed that the Korean version of the AFAQ had the same concept and intention as the original version and is reliable, valid, and responsive.

Supramalleolar osteotomy: techniques, indications and outcomes in a series of 83 cases

INTRODUCTION

Supramalleolar osteotomy is an alternative surgical procedure for the management of asymmetric early arthritis of the ankle. The main goal of this retrospective study was to evaluate the clinical and radiological benefits of supramalleolar osteotomy. The secondary goal was to identify prognostic factors to help decide upon this therapeutic indication.

MATERIALS AND METHODS

Eighty-three patients, mean age 45 years old (17-79), presenting with post-traumatic asymmetric early arthritis of the ankle were followed up for a mean 3.5 years (1-14 years). Sixty-two patients presented with a varus deformity (mean: 13°), and 21 with a valgus deformity (mean: 17.5°). The presence of a preoperative clinical 'sidewalk sign' was looked for and it was considered positive if pain improved when the patient walked on a surface slope that was tilted in the opposite direction of their deformity. A functional preoperative evaluation and at the final follow-up were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale. The frontal deformity was measured by the Meary angle on a weight-bearing X-ray. Varus deformities were treated by a lateral closing wedge supramalleolar osteotomy or a medial opening wedge supramalleolar osteotomy. Valgus deformities were treated by a lateral opening wedge or a medial closing wedge supramalleolar osteotomy.

RESULTS

At last follow-up, the mechanical axis in the varus group was 1.3° and 7.5° in the valgus group. The AOFAS score significantly improved (P<0.001) by 15 points in patients with a varus deformity and 13 points in patients with a valgus deformity. A positive sidewalk sign (disappearance of pain) was correlated with a good outcome and had a positive predictive value of 0.88 (CI: 0.77-0.95) (P<0.001).

DISCUSSION

The supramalleolar osteotomy is a conservative therapeutic surgical option for the management of arthritis of the ankle associated with varus or valgus deformities. The results are satisfactory for indications of arthritis with varus and valgus deformities and a positive 'sidewalk' sign (pain relief on a slope surface tilted in the opposite direction of the deformity).

LEVEL OF EVIDENCE

Level IV: retrospective case series.

An evaluation of retrospective outcome scores in elective foot and ankle surgery

BACKGROUND

Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy.

METHODS

36 patients underwent elective foot and ankle surgery. All patients were scored preoperatively using the SF-12 (including both the physical and mental subsets) and FFI. Patients then recorded both PROMs at the 3-month follow up (av. 139 days). Results were then analyzed for statistical significance.

RESULTS

36 patients (av. age 54.6): completed both sets of questionnaires. There were 15 hindfoot and 21 forefoot procedures. No retrospective scores were identical. The mean percentage difference between the preoperative scores was -7.9% (-17.3 to 1.6%, 95% CI) for Physical Component of SF12, -3.2% (-10.3 to 3.9%, 95% CI) for mental component of SF12 and 40.7% (25.3 to 56.1%, 95% CI) for FFI. This retrospective accuracy was statistically significant (p<0.001). When the scores were plotted against each other, the outcome measurements showed positive correlations (Physical SF 12 p=0.48, Mental SF 12 p=0.80 and FFI p=0.81). With both PROMs mean percentage differences combined, patients undergoing hindfoot procedures (3.5%; -5.0 to 12.1%, 95% CI) were more accurate with retrospective scoring than their forefoot counterparts (17.5%; 5.0 to 30.0%, 95% CI). This was not statistically significant (p=0.07). Using regression analysis, we found no significant statistical difference in the retrospective accuracy when compared against both time to retrospective scoring and the outcome measure at 3 months post operatively.

CONCLUSION

Retrospective scoring appears to lack accuracy when compared to prospective methods. However, our data shows the SF12 is recalled more accurately than the FFI (p<0.001) and both the mental and physical components are recalled to within 10% of the pre-operative score. These results show patients tend to recall their symptoms at a worse level preoperatively than originally described, especially those with forefoot problems.

Hallux valgus in males--part 2: radiographic assessment of surgical treatment

BACKGROUND

In an early report on this patient cohort, we concluded that a hallux valgus deformity in males is frequently hereditary in nature. An increase in the distal metatarsal articular angle (DMAA) was observed to be the major defining characteristic of hallux valgus in males. In this follow-up study, our goal was to evaluate the effectiveness of surgical treatment for this cohort of male patients.

METHODS

Data from 50 feet of male patients with hallux valgus who were surgically treated by the same surgeon between 1985 and 2005 were retrospectively analyzed. The technique was algorithmically chosen according to the severity and complexity of the deformity. Thus, 10 chevron osteotomies, 9 biplanar chevron osteotomies, 12 Mitchell osteotomies, 9 scarf osteotomies, and 10 basilar first metatarsal osteotomies were performed. The average follow-up was 10 years (range, 2-20).

RESULTS

After analyzing the angular radiological parameters, sesamoid subluxation, and the articular congruency, most procedures proved to have achieved adequate correction of the angular deformities. When examining each of the procedures separately, 4 of the 5 procedures had similar corrective capacities; the scarf osteotomy however had decidedly inferior results. The improvement in the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score demonstrated the clinical and functional improvement.

CONCLUSIONS

The algorithm was based mainly upon the presence of increased DMAA and increased severity of angular deformities. We conclude that hallux valgus deformities in males were adequately corrected with the selected techniques. Greater difficulty or resistance to surgical treatment could not be detected when we contrasted our results to females. The scarf osteotomy proved to have an inferior corrective capacity compared to the other techniques used in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Extensile decompression of the proximal and distal tarsal tunnel combined with partial plantar fascia release in the treatment of chronic plantar heel pain

BACKGROUND

Chronic heel pain that is recalcitrant to nonoperative measures is a rare but disabling condition. There are no reports in the literature of extensile proximal and distal tarsal tunnel release combined with partial plantar fasciotomy in the treatment of chronic heel pain. We present our results.

METHODS

A retrospective chart review was conducted, and charts were assessed for details of their presenting complaints, physical exam, diagnostic studies, medical history, Visual Analog Scale (VAS) scores for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores, and complications.

RESULTS

The mean AOFAS ankle-hindfoot score was 86 ± 12.9 (range = 69-100). Of 15 heels, 10 (67%) had an excellent or good rating at the time of the last follow-up visit. One of 15 (7%) reported a poor outcome. The mean VAS pain score changed from 6.3 ± 3.1 to 1.4 ± 1.8 (P = .001). There were no wound complications or infections.

CONCLUSION

This technique offers another operative option for chronic heel pain that is associated with satisfactory outcomes and rest pain relief. Despite reducing pain at rest in all patients, the majority of patients may be left with mild to moderate residual symptoms with activity that is similar to the outcomes of previously reported procedures.

Comprehensive review of the functional outcome evaluation of clubfoot treatment: a preferred methodology

Treatment outcome has been a focus of interest in those who manage clubfeet. Because of a lack of a common evaluation protocol, it has become necessary to establish a universally recognized quantitative measurement to compare and better understand the treatment outcome. The outcome is not merely morphological and radiographic, but it should also include functional and quality-of-life measurements. In this article, we will outline the most commonly used methods of long-term evaluation for congenital clubfeet and recommend the data collection parameters that are most appropriate for a comprehensive functional analysis. This will begin with pretreatment classifications that are important in prognosticating the results. The physical examinations and plain radiographs in standing position are also two fundamental evaluations of clubfoot. Several outcome evaluations have been published in the literature and may be useful depending on the desired metrics. Gait analysis is an additional useful technical tool for analyzing the motion of the foot and ankle and its relation to the whole body function; pedobarography added to the dynamics of the evaluation. Functional quality-of-life questionnaires are increasing in popularity for measuring the total body functional status and the quality of life.

Results of total ankle arthroplasty

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence. Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis. On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years. Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange. A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Measuring foot and ankle injury outcomes: common scales and checklists

Functional health outcome measures are increasingly being used in both clinica trials and practice as measures of patient health. Whilst outcome measures can be generic, there are a number of foot and ankle specific measures available and in use. These are being used as not only region specific but also disease specific measures of patient function. Unfortunately not all of these outcome measures have been completely validated which leads to challenges in applying the results of outcomes research to specific patients. Continued work however is being done in this area and these challenges provide opportunities for further investigation into the role of functional outcome scores specific to the foot and ankle.

Salvage of chronic instability of the syndesmosis with distal tibiofibular arthrodesis: functional and radiographic results

BACKGROUND

Failure to treat an injury of the syndesmosis after an ankle fracture can lead to a poor functional outcome and posttraumatic arthritis. The results after reconstruction of an ankle with an incongruous mortise, chronic diastasis of the syndesmosis, and arthritis remain unknown. The purpose of the present study was to review the radiographic and clinical results of salvaging this condition through reduction and arthrodesis of the distal tibiofibular articulation.

METHODS

Ten patients (mean age, fifty-four years) with chronic syndesmotic instability who underwent salvage by a single surgeon were evaluated retrospectively. Five parameters of mortise and syndesmotic alignment were measured on weight-bearing radiographs that were made preoperatively and at the time of the latest follow-up. The extent of arthritis in the ankle was graded with use of an established classification system. Clinical rating scores that were recorded preoperatively and at the time of the latest follow-up were culled from the medical records and were compared. Each patient's stated satisfaction with the operation and willingness to undergo the operation again were retrieved from the medical records.

RESULTS

After a mean duration of follow-up of forty-one months (minimum, two years), the medial clear space, talocrural angle, and talar tilt had improved. No ankle demonstrated progression of arthritis on the basis of the radiographic grade. The clinical rating score improved significantly because of improvements in the pain, activity, maximum walking distance, and gait subscales. Two patients had a total of three additional procedures. Both had prominent implants removed, and one subsequently underwent an ankle arthroscopy. All patients reported satisfaction with and a willingness to undergo the procedure again. At the time of the latest follow-up, no patient had undergone an ankle arthrodesis.

CONCLUSIONS

The significant improvements in the radiographic and functional measures of outcome that were observed in this small cohort suggest that chronic syndesmotic instability after ankle fracture can be salvaged with reduction and arthrodesis of the distal tibiofibular articulation. Furthermore, the reconstruction of an incongruous and arthritic ankle is an alternative to and may postpone the subsequent need for ankle arthrodesis or arthroplasty.

Calcaneal chondroblastoma with secondary aneurysmal bone cyst: a case report

We present a case of destructive chondroblastoma associated with secondary aneurysmal bone cyst involving the left calcaneus. Because of the extensive destruction of the calcaneus, total calcanectomy was the treatment of choice.

Results of metallic Hemi-Great Toe Implant for Grade III and early Grade IV hallux rigidus

INTRODUCTION

The authors the short-term and mid-term results of patients with their preoperative status who were surgically treated for advanced Grade III and early Grade IV symptomatic hallux rigidus using the Futura Hemi-Great Toe Implant.

MATERIALS AND METHODS

The authors were able to contact 23 of 33 consecutive patients. They had a detailed evaluation preoperatively and came in for a detailed mid-term evaluation. Some of the patients were able to come in routinely for detailed periodic evaluations.

RESULTS

Periodic evaluations showed most patients had a gradual improvement of function over the first 2 years. Patients with early Grade IV disease had a greater propensity to develop early recurrence of their dorsal osteophyte at or before their mid-term followup (average 6 years). In this group of patients, the Futura Hemi-Great Toe Implants lead to 88% good to excellent mid-term results and 88% patient satisfaction over a 6-year average followup.

CONCLUSION

Patients with early Grade IV hallux rigidus tend to develop progressive sesamoid arthritis and recurrent dorsal osteophyte formation more rapidly than advanced Grade III patients.

Medial capsular interpositional arthroplasty for severe hallux rigidus

BACKGROUND

Multiple surgical options have been described for severe hallux rigidus. One option is capsular interpositional arthroplasty. We report our initial results with a technique using the thicker medial capsule as our interpositional material instead of the dorsal capsule and extensor hallucis brevis (EHB).

MATERIALS AND METHODS

Twenty-two patients with grade IV hallux rigidus underwent minimal proximal phalanx resection (modified Keller) with preservation of the flexor hallucis brevis (FHB) insertion and medial capsular interpositional arthroplasty.

RESULTS

Postoperative AOFAS hallux MTP-IP scores (mean 77.8), and SF-36 scores (mean 68.7 on physical function, 79.5 role limitations) demonstrated clinical improvement compared to historical controls. Alignment and stability were well maintained (mean preoperative HV angle of 11.8 degrees, mean postoperative HV angle of 13.0 degrees). Dorsiflexion/plantarflexion arc of motion showed sustained improvement (mean 38.4 degrees preoperative, mean 62.3 degrees postoperative).

CONCLUSION

These results are comparable to other forms of interpositional arthroplasty and arthrodesis for end stage arthritis of the hallux MTPJ.

Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints

BACKGROUND

The purpose of this study was to cross-culturally adapt the Foot Function Index (FFI) for use in German-speaking patients with foot complaints.

MATERIALS AND METHODS

The FFI was adapted for the German language according to the recommended forward/backward translation protocol. The following metric properties were assessed in 53 consecutive patients (mean age, 57.2 years; 39 women) undergoing foot surgery at our department: feasibility, reliability (intraclass correlation coefficient ICC), internal consistency (Cronbach's alpha, CA), and construct validity (correlation with the Short Form (SF-36), a VAS assessing pain, a VAS assessing function, and the University of California at Los Angeles (UCLA) activity scale.

RESULTS

The German FFI (FFI-D) comprised 18 items separated into a pain and a disability subscale. Completion of the FFI-D was feasible. The reliability and the internal consistency were both excellent with an ICC of 0.98 and a CA of 0.97 for the total score. We found moderate to high correlations between the FFI-D and the physical related SF-36 domains (r = -0.43 to -0.80), the VAS pain (r = 0.81), the VAS function (r = 0.77), and the UCLA (r = -0.52). Correlation coefficients between the FFI-D and the mental health related SF-36 domains were significantly lower (r = -0.08 to -0.32; p < 0.01), indicating divergent validity.

CONCLUSION

The German version of the FFI is a reliable and valid questionnaire for the self-assessment of pain and disability in German-speaking patients with foot complaints.

Analysis of modified oblique Keller procedure for severe hallux rigidus

BACKGROUND

Several procedures have been described for treating hallux rigidus, but all have limitations. The purpose of this study is to evaluate the clinical and radiologic results of a modified oblique Keller procedure for treating hallux rigidus.

MATERIALS AND METHODS

Eleven patients (13 feet) with Grade III or IV hallux rigidus were treated by modified oblique Keller procedure. Average age was 64.7 years and followup was 27.2 months. Outcomes including range of motion (ROM) of first metatarsophalengeal joint, complications, American Orthopaedic Foot and Ankle Society (AOFAS) scores, satisfaction, osteophyte recurrence, osteonecrosis, and shortening were analyzed. Preoperative and postoperative values were statistically compared.

RESULTS

Mean preoperative and postoperative ROMs were 6.5 degrees and 51.9 degrees, respectively (p < 0.005). Two feet had numbness on the dorsum of the first toe. Transfer metatarsalgia occurred in one patient. Mean preoperative and postoperative AOFAS scores were 29.1 points and 93.6 points, respectively (p < 0.005). All patients had good or excellent results. There was no recurrence of the dorsal osteophyte. One patient had radiographic mottling of the first metatarsal head. Average preoperative and postoperative first toe length was 124.3 mm and 123.1 mm, respectively.

CONCLUSION

This technique was a good treatment alternative for patients with end-stage hallux rigidus. It was a safe and reliable procedure that preserved range of motion and has good outcomes.

Primary isolated subtalar arthrodesis: outcome after 2 to 5 years followup

BACKGROUND

Favorable to excellent clinical results have been reported for isolated subtalar joint arthrodesis. Pedobarography after subtalar bone-block distraction arthrodesis have demonstrated a more laterally shifted gait line. However pedobarographic measurements after primary in-situ isolated subtalar arthrodesis have not been reported. This is the first study considering this.

MATERIALS AND METHODS

Physical examination, AOFAS Hindfoot score, full weightbearing anterior/posterior and lateral radiographs were assessed in 15 feet. Peak pressures, ground reaction force and force distribution at foot-flat and push-off were measured.

RESULTS

Average AOFAS-Score significantly improved. Subjective satisfaction was high. Non-union was found in 1 foot (7%), screws were removed in 4 of the 15 feet (27%). One new asymptomatic arthritic talonavicular joint was found. The pressure and force distributions under the operated and contralateral foot showed a different pattern compared to a normal foot. Ground reaction force under both the operated and contralateral feet were lower than a normal foot.

DISCUSSION

This study found good clinical, subjective and radiographic results matching that of the reported literature. However, pedobarographic assessment suggests that great functional differences still remain when compared to a normal foot. Subtalar arthrodesis may induce an abnormal gait pattern by preventing compensation of axial rotation of the tibia. This is also reflected in the unaffected side, which may indicate an effort in the general locomotor control to keep a symmetrical gait pattern. This finally alters the pressure and force distribution under both feet. Nevertheless, subtalar arthrodesis is considered a valuable treatment for various isolated subtalar disorders.

A comparison between patient recall and concurrent measurement of preoperative quality of life outcome in total hip arthroplasty

The objective is to evaluate the reliability of patients' recall of preoperative pain and function during the immediate postoperation period after total hip arthroplasty. A prospective cohort of 104 patients completed a survey about their quality of life before operation, and recalled preoperative status at 3 days, 6 weeks, and 12 weeks after operation. Quality of life was measured by the Western Ontario and McMaster University Osteoarthritis Index, the Oxford-12 hip score, and the 12-item Short-Form score. The intraclass correlation coefficient and Spearman correlation coefficient were used to compare preoperative quality of life scores to the scores recalled. The reliability of recall remained high up to 3 months postoperation. Patients are able to accurately recall their preoperative function for up to 3 months after total hip arthroplasty.

Mid-term results of Futura hemi-great toe implants

BACKGROUND

This study reviews our mid-term results and patient satisfaction using the Futura hemi-great toe implant.

MATERIALS AND METHODS

The authors were able to contact 11 of 15 patients. They were seen for chart review and mid-term evaluation.

RESULTS

All patients but one were improved and satisfied at mid-term followup (average, 8 years). The one unsatisfied patient had Grade IV arthritis at the time of surgery.

CONCLUSION

Futura hemi-great toe implants lead to an 83% good to excellent mid-term results and over 92% patient satisfaction with no measureable subsidence of the implant over an 8-year average followup. Patients with Grade IV Hallux Rigidus should not be considered for Hemi-Great Toe implants and are probably best served with arthrodesis or interpositional arthroplasty at this time.

Does patient satisfaction with foot surgery change over time?

BACKGROUND

The national podiatric surgery audit tool PASCOM has a key role in determining patient satisfaction with service received and outcomes. The study aim was to examine the effects of time after surgery on satisfaction scores, by undertaking a retrospective longitudinal study utilising the patient satisfaction questionnaire known as the PSQ-10. A secondary objective was to examine test-retest reliability, since this has not been previously reported.

METHOD

NHS and private patients having undergone forefoot surgery were sent a further PSQ-10 satisfaction questionnaire after the standard 6-month PSQ-10 had been completed. The main outcome measure reflected a change in the score between the original and repeat PSQ-10 response. Internal consistency was measured by correlation between baseline questions for a subset of patients who were sent the second questionnaire within 6 months of the first.

RESULTS

Of a total cohort of 204 patients, no significant differences were seen in overall scores. 46% showed increased satisfaction at the stage of the repeat questionnaire, with 41% a decline in score and 13% no change. Neurectomy patients improved the most with time and digital surgery was associated with the greatest decline in score. Significant correlations were demonstrated between all baseline questions for the test-retest cohort (13 patients).

CONCLUSION

Time does not significantly influence patient satisfaction after discharge. There was satisfactory consistency between PSQ-10 responses. Further investigation into digital procedure outcomes is required.

Revision tibiotalar arthrodesis

BACKGROUND

Contemporary recommendations for primary and revision ankle arthrodesis favor internal compression techniques involving the use of screw and/or plate fixation. While tibiotalocalcaneal arthrodesis with internal fixation may be a suitable method of salvage for the treatment of a failed tibiotalar arthrodesis in selected patients, ring external fixation has been reported as an alternative. We reviewed our experience with revision tibiotalar arthrodesis, with a focus on ring external fixation.

METHODS

Forty-five consecutive patients underwent revision tibiotalar arthrodesis with use of repeat internal fixation (eleven patients), ring external fixation (twenty-two patients), or tibiotalocalcaneal arthrodesis (twelve patients). Union rates were assessed radiographically, and functional outcome was determined with use of preoperative and postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scores.

RESULTS

All forty-five patients were available for follow-up at an average of 50.3 months. The average ankle-hindfoot score improved from 31.1 points preoperatively to 65.8 points at the time of the most recent follow-up. At the time of the most recent follow-up, the union rate was 88.9% (forty of forty-five). Fusion was achieved with revision tibiotalar arthrodesis in thirty-six (80%) of forty-five patients, including eight of the eleven patients in the repeat internal fixation group, nineteen of the twenty-two patients in the ring external fixation group, and nine of the twelve patients in the tibiotalocalcaneal arthrodesis group. Re-revision led to union in four of five patients. The overall union rate for ring external fixation, including revision and re-revision tibiotalar arthrodeses, was 84.6% (twenty-two of twenty-six). The five patients with persistent nonunion following revision ankle arthrodesis opted for transtibial amputation.

CONCLUSIONS

Revision tibiotalar arthrodesis leads to satisfactory limb salvage in a majority of patients. Ring external fixation may facilitate clinically acceptable limb salvage in complex cases when methods of internal fixation are limited or even contraindicated.

Treatment of displaced intra-articular calcaneal fractures with triangular tube-to-bar external fixation: long-term clinical follow-up and radiographic analysis

Sixty-six feet (62 patients) with displaced intra-articular calcaneal fractures underwent manual reduction and distraction with the use of a triangular tube-to-bar external fixation device and were retrospectively reviewed at a minimum of 1-year post-operative. Final radiographic follow-up revealed complete consolidation in all fractures, maintenance of reduction, and limited degenerative osteoarthrosis about the subtalar joint. Our results indicate that with proper application and attention to detail, restoration of calcaneal morphology using triangular tube-to-bar external fixation should be considered a viable alternative in the treatment of displaced intra-articular fractures of the calcaneus.

Clinical outcome scoring of intra-articular calcaneal fractures

Outcome reporting of intra-articular calcaneal fractures is inconsistent. This study aimed to identify the most cited outcome scores in the literature and to analyze their reliability and validity. A systematic literature search identified 34 different outcome scores. The most cited outcome score was the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, followed by the Maryland Foot Score (MFS) and the Creighton-Nebraska score (CN). Reliability (internal consistency) and validity (content, construct, and criterion) were determined for the 3 outcome scoring systems. Internal consistency (Cronbach's alpha, reliability) was similar for the Maryland Foot Score (alpha=0.82) and American Orthopedic Foot and Ankle Society hindfoot score (alpha=0.78), but lower for the Creighton-Nebraska (alpha = 0.61). Floor and ceiling effects were good for all 3 scores. The individual items within these outcome scores showing best content validity were pain, return to work, subtalar range of motion, walking distance, ankle range of motion, and gait abnormalities or limping. Construct validity was good for all individual items except sagittal motion, stability at physical exam, and shoe size. The 3 outcome scores showed high correlation with patient satisfaction as measured with a visual analog scale (VAS, criterion validity) and indication for an arthrodesis. In conclusion, pending consensus, we would recommend choosing between the widely accepted, reliable and valid AOFAS hindfoot and the Maryland Foot Score as the scoring systems of choice.

LEVEL OF CLINICAL EVIDENCE

2.

A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot

BACKGROUND

This study compared the effects of lateral column lengthening and medial translational calcaneal osteotomy on pedal realignment and degeneration of adjacent hindfoot joints noted on radiographs.

METHODS

Forty patients who had either a lateral column lengthening (25 feet) or calcaneal osteotomy (17 feet) to reconstruct a flatfoot were retrospectively reviewed as two groups. Six parameters of foot alignment were measured from weightbearing preoperative, early postoperative, and latest followup radiographs. The magnitude of realignment achieved initially and preserved at latest followup was determined for each group. The talonavicular and subtalar joints were graded for radiographic evidence of arthritis before the reconstruction and at latest followup. Demographic information, complication rate, and reoperation associated with each group also were determined by chart review.

RESULTS

The group that received a lateral column lengthening demonstrated a greater initial realignment than the group treated with a calcaneal osteotomy. The lengthening group also demonstrated greater realignment than the osteotomized group when they were compared at their respective latest followup. The lengthening group had a higher number of adjacent joints with progression of arthritis. The rate of nonunion was higher with a lateral column lengthening; however, the rate of reoperation after an osteotomy was more than twice that observed after a lateral column lengthening.

CONCLUSIONS

The lateral column lengthening group achieved greater realignment initially and maintained correction better over time than the calcaneal osteotomy group while having a lower reoperation rate despite a higher incidence of nonunion and radiographic progression of adjacent joint arthritis.

Treatment of severe, painful pes planovalgus deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft

BACKGROUND

This study tested the hypothesis that modification of the standard technique of hindfoot arthrodesis with the use of a wedge-shaped tricortical allograft would improve the amount of correction of pes planovalgus deformity. The results were compared to previous reports.

METHODS

Between 1998 and 2005, the senior author (LBC) performed 13 hindfoot arthrodeses on 12 patients using an allograft to improve correction of the deformity for severe, painful pes planovalgus deformity. The average patient age was 55 (range 27 to 77) years. There were seven women and five men. The indications were posterior tibial tendon dysfunction (seven feet), rheumatoid arthritis (three feet), post-traumatic arthritis and deformity (one foot), congenital pes planovalgus (one foot), and tarsal coalition (one foot).

RESULTS

Twelve of 13 feet achieved union by 12 weeks postoperatively. There was one nonunion. The average time to fusion was 12 weeks. All 12 patients were satisfied with the results of the operation. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 87 points, and the AOFAS Midfoot score was 85 points. Preoperative and postoperative radiographs were compared to evaluate correction of deformity. On lateral weightbearing views, the talo-first metatarsal angle improved from 15 to 6 degrees, and the lateral talocalcaneal angle improved from 48 to 35 degrees. On anteroposterior views, the talo-first metatarsal angle improved from 17 to 7 degrees, the talonavicular coverage decreased from 28 to 13 degrees, and the talocalcaneal angle improved from 23 to 13 degrees.

CONCLUSIONS

A simple modification of the addition of allograft to a common procedure of hindfoot arthrodesis to treat severe, painful pes planovalgus results is reliable and offers satisfactory correction.

Correlation of the AOFAS scores with a generic health QUALY score in foot and ankle surgery

BACKGROUND

The American Orthopaedic Foot and Ankle Score (AOFAS) is one scoring system used to assess and monitor the progress of patients after foot and ankle surgery. The aim of this study was to evaluate the trend of the AOFAS score over a period of time and correlate it with the QUALY score, which is a valid and reliable scoring system.

METHODS

All patients undergoing surgery by one foot and ankle surgeon between January, 2001, and July, 2003, were reviewed. The preoperative AOFAS and QUALY and postoperative scores at 3, 6 and 12 months, and yearly were collected prospectively.

RESULTS

This study includes 204 operative procedures in 159 patients. The mean age of the patients was 51.9 (range 12 to 89) years. The AOFAS scores increased from a mean of 45.5 preoperatively to 76.5 at 3 months and reached a peak of 81.5 at 6 months and then started to decrease to 79.2 at 12 months. This fall, though seemingly marginal, was significant (p < 0. 01). This trend seems to be consistent for all the procedures. The 6-month AOFAS score was found to have a higher correlation with the final QUALY score (r(2) = 0.423) than the 12-month AOFAS score (r(2) = 0.326).

CONCLUSIONS

The AOFAS score has low levels of correlation with the validated generic health QUALY score. Our study suggests that scores collected preoperatively, at 6 and 12 months after surgery, and annually there after may be best. The 3-month score may not be necessary. We recommend that a generic health score such as the QUALY score be used in conjunction with the AOFAS score to reflect outcome.