Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

BACKGROUND

Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation.

METHODS

New foot and ankle patients completed PROMIS physical function (PF), pain interference (PI), and depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). Responses to the CG-CAHPS questions and PAM were compared between the 2 groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored.

RESULTS

After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses nor PAM scores between the 2 groups (P > .05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate "top box" scores for the understanding domain of the CG-CAHPS question (OR 0.51, P < .001) and had decreased odds of high patient activation compared to control subjects (OR 0.67; P = .005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (P = .09).

CONCLUSION

Highly rated foot and ankle surgeons who show and discuss PROM results may not improve patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROM discussions are most beneficial and how best to present PROMs data, as we suspect that how the information was presented-and not the use of PROMs-resulted in our findings. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level III, case-control study.

Impingement in Insertional Achilles Tendinopathy Occurs Across a Larger Range of Ankle Angles and Is Associated With Increased Tendon Thickness

BACKGROUND

Insertional Achilles tendinopathy (IAT) is characterized by tendon degeneration and thickening near the tendon-bone insertion.¹¹ Calcaneal impingement is believed to contribute to the pathogenesis of IAT.⁵ However, it is unclear how increased tendon thickness in individuals with IAT influences impingement. This study aimed to compare Achilles tendon impingement in individuals with and without IAT.

METHODS

Eight healthy adults and 12 adults with clinically diagnosed symptomatic IAT performed a passive flexion exercise during which ankle flexion angle, anterior-posterior (A-P) thickness, and an ultrasonographic image sequence of the Achilles tendon insertion were acquired. The angle of ankle plantarflexion at which the calcaneus first impinges the Achilles tendon, defined as the impingement onset angle, was identified by (1) a anonymized observer (visual inspection method) and (2) a computational image deformation-based approach (curvature method).

RESULTS

Although the 2 methods provided different impingement onset angles, the measurements were strongly correlated (R² = 0.751, P < .05). The impingement onset angle and the thickness of the Achilles tendon insertion were greater in subjects with clinically diagnosed IAT (P = .0048, P = .0047). Furthermore, impingement onset angle proved to have a moderate correlation with anterior-posterior thickness (R² = 0.454, P < .05).

CONCLUSION

Our findings demonstrated that increased tendon thickness in IAT patients is associated with larger impingement onset angles, raising the range of ankle angles over which the tendon is exposed to impingement.

CLINICAL RELEVANCE

Increased susceptibility to impingement may exacerbate or perpetuate the pathology, highlighting the need for clinical strategies to reduce impingement in IAT patients.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

BACKGROUND

Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).

METHODS

PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.

RESULTS

Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.

CONCLUSION

The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.

LEVEL OF EVIDENCE

Level IV, case series.

Tensile mechanical changes in the Achilles tendon due to Insertional Achilles tendinopathy

Insertional Achilles tendinopathy (IAT) is a painful condition that is challenging to treat non-operatively. Although previous studies have characterized the gross histological features, in vivo strain patterns and transverse compressive mechanical properties of tissue affected by IAT, it is not known how IAT impacts the tensile mechanical properties of the Achilles tendon insertion along the axial/longitudinal direction (i.e., along the predominant direction of loading). To address this knowledge gap, the objectives of this study were to 1) apply ex vivo mechanical testing, nonlinear elastic analysis and quasilinear viscoelastic (QLV) analysis to compare the axial tensile mechanical properties of the Achilles tendon insertion in individuals with and without IAT; and 2) use biochemical analysis and second harmonic generation (SHG) imaging to assess structural and compositional changes induced by IAT in order to help explain IAT-associated tensile mechanical changes. Tissue from the Achilles tendon insertion was acquired from healthy donors and from patients undergoing debridement surgery for IAT. Tissue specimens were mechanically tested using a uniaxial tensile (stress relaxation) test applied in the axial direction. A subset of the donor specimens was used for SHG imaging and biochemical analysis. Linear and non-linear elastic analyses of the stress relaxation tests showed no significant tensile mechanical changes in IAT specimens compared to healthy controls. However, SHG analysis showed that fibrillar collagen was significantly more disorganized in IAT tissue as compared with healthy controls, and biochemical analysis showed that sulfated glycosaminoglycan (sGAG) content and water content were higher in IAT specimens. Collectively, these findings suggest that conservative interventions for IAT should target restoration of ultrastructural organization, reduced GAG content, and reduced resistance to transverse compressive strain.

Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection

BACKGROUND

Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers.

METHODS

We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded.

RESULTS

Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average.

DISCUSSION

In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation.

LEVEL OF EVIDENCE

IV, Case Series.

A Comparative Analysis of Clinical Outcomes in Noninsertional Versus Insertional Tendinopathy Using PROMIS

Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.

PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients

BACKGROUND:

The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF).

METHODS:

Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria.

RESULTS:

PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code.

CONCLUSION:

PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management.

LEVEL OF EVIDENCE:

Level II, prognostic.

Incidence and Radiographic Predictors of Valgus Tibiotalar Tilt After Hindfoot Fusion

BACKGROUND

The development of valgus tibiotalar tilt following hindfoot arthrodesis is rarely discussed in the literature. The purpose of this study was to determine the incidence of valgus tibiotalar tilt and to evaluate if there were any radiographic predictors for the development of valgus tibiotalar tilt.

METHODS

Patients who underwent hindfoot fusion between January 1, 2004 and December 31, 2013 were identified. Charts were reviewed for demographic information and operative details. Preoperative and postoperative radiographs were reviewed for the development of tibiotalar tilt, and standardized measurements and angles were calculated. A total of 187 patients were included. There were 106 (56.7%) females and 81 (43.3%) males. The average age was 52 years (range, 11-82 years). The most common indication for surgery was adult-acquired flatfoot deformity (n = 92, 49.2%), followed by arthritis (n = 83, 44.4%). The most common procedure was triple arthrodesis (n = 101, 54%). Twenty-seven patients demonstrated tibiotalar tilt preoperatively.

RESULTS

A total of 51 patients (27.3%) developed valgus tibiotalar tilt postoperatively at an average of 3.6 months after surgery. We found that an increase in the preoperative Meary (lateral talar-first metatarsal) angle (hazard ratio, 1.039; 95% confidence interval, 1.002-1.077; P < .05) was associated with the development of tibiotalar tilt. An increase in the postoperative Meary angle (hazard ratio, 1.052; 95% confidence interval, 0.999-1.108; P = .0528) approached significance for the development of tibiotalar tilt.

CONCLUSION

The development of valgus tibiotalar tilt following hindfoot fusion was a notable phenomenon, occurring in 27% of our patient population. The preoperative Meary angle was the only radiographic measurement that was significantly associated with the development of valgus tibiotalar tilt, although the postoperative Meary angle approached significance. These findings should encourage surgeons to be aware of patients with large deformities and of their propensity to develop a valgus deformity about the ankle.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion

The purposes of this case-control study (N = 20) were to examine the effects of insertional Achilles tendinopathy (IAT) and tendon region on tendon strain in patients with IAT compared to a control group without tendinopathy. An ultrasound transducer was positioned over the Achilles tendon insertion during dorsiflexion tasks, which included standing and partial squat. A non-rigid image registration-based algorithm was used to estimate transverse compressive and axial tensile strains of the tendon from radiofrequency ultrasound images, which was segmented into two regions (superficial tendon and deep). For transverse compressive strain, two-way mixed effects ANOVAs demonstrated that there were interaction effects between group and tendon region for both dorsiflexion tasks (Heel lowering, p = 0.004; Partial squat, p = 0.008). For axial tensile strain, the IAT group demonstrated a main effect of lower tensile strain than the control group (Standing, p = 0.001; Partial squat, p = 0.033). There was also a main effect of greater tensile strain in the superficial region of the tendon compared to the deep during standing (p = 0.002), but not during partial squat (p = 0.603). Reduced transverse compressive and axial tensile strains in the IAT group indicate altered mechanical properties specific to the region of IAT pathology. Additionally, patterns of compressive strain are consistent with the theory of calcaneal impingement contributing to IAT pathology. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:910-915, 2017.

Utility of Ultrasound for Imaging Osteophytes in Patients With Insertional Achilles Tendinopathy

OBJECTIVES

To examine (1) the validity of ultrasound imaging to measure osteophytes and (2) the association between osteophytes and insertional Achilles tendinopathy (IAT).

DESIGN

Case-control study.

SETTING

Academic medical center.

PARTICIPANTS

Persons with chronic unilateral IAT (n=20; mean age, 58.7±8.3y; 10 [50%] women) and age- and sex-matched controls (n=20; mean age, 57.4±9.8y; 10 [50%] women) participated in this case-control study (N=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Symptom severity was assessed using the Foot and Ankle Ability Measure, the Victorian Institute of Sport Assessment-Achilles questionnaire, and the numerical rating scale. Length of osteophytes was measured bilaterally in both groups using ultrasound imaging, as well as on the symptomatic side of the IAT group using radiography. The intraclass correlation coefficient was used to examine the agreement between ultrasound and radiograph measures. McNemar, Wilcoxon signed-rank, and Fisher exact tests were used to compare the frequency and length of osteophytes between sides and groups. Pearson correlation was used to examine the association between osteophyte length and symptom severity.

RESULTS

There was good agreement (intraclass correlation coefficient, ≥.75) between ultrasound and radiograph osteophyte measures. There were no statistically significant differences (P>.05) in the frequency of osteophytes between sides or groups. Osteophytes were larger on the symptomatic side of the IAT group than on the asymptomatic side (P=.01) and on the left side of controls (P=.03). There was no association between osteophyte length and symptom severity.

CONCLUSIONS

Ultrasound imaging is a valid measure of osteophyte length, which is associated with IAT. Although a larger osteophyte indicates tendinopathy, it does not indicate more severe IAT symptoms.

Mechanical changes in the Achilles tendon due to insertional Achilles tendinopathy

Insertional Achilles tendinopathy (IAT) is a painful and debilitating condition that responds poorly to non-surgical interventions. It is thought that this disease may originate from compression of the Achilles tendon due to calcaneal impingement. Thus, compressive mechanical changes associated with IAT may elucidate its etiology and offer clues to guide effective treatment. However, the mechanical properties of IAT tissue have not been characterized. Therefore, the objective of this study was to measure the mechanical properties of excised IAT tissue and compare with healthy cadaveric control tissue. Tissue from the Achilles tendon insertion was acquired from healthy donors and from patients undergoing debridement surgery for IAT. Several tissue specimens from each donor were then mechanically tested under cyclic unconfined compression and the acquired data was analyzed to determine the distribution of mechanical properties for each donor. While the median mechanical properties of tissue excised from IAT tendons were not significantly different than healthy tissue, the distribution of mechanical properties within each donor was dramatically altered. In particular, healthy tendons contained more low modulus (compliant) and high transition strain specimens than IAT tendons, as evidenced by a significantly lower 25th percentile secant modulus and higher 75th percentile transition strain. Furthermore, these parameters were significantly correlated with symptom severity. Finally, it was found that preconditioning and slow loading both reduced the secant modulus of healthy and IAT specimens, suggesting that slow, controlled ankle dorsiflexion prior to activity may help IAT patients manage disease-associated pain.

Total and distributed plantar loading in subjects with stage II tibialis posterior tendon dysfunction during terminal stance

BACKGROUND

In subjects with stage II tibialis posterior tendon dysfunction (TPTD), the function of the tibialis posterior muscle is altered and may be associated with a change in total and distributed loading.

METHODS

Thirty subjects with a diagnosis of stage II TPTD and 15 matched control subjects volunteered to participate in a study to examine the total and distributed plantar loading under the foot during the terminal stance phase of gait. Plantar loading, measured as the subject walked barefoot, was assessed using instrumented flexible insoles. A secondary analysis was done to explore the contribution of flatfoot kinematics to plantar loading patterns.

RESULTS

Overall, there was reduced total plantar loading in subjects with stage II TPTD compared with controls. Accounting for differences in total loading, the presence of clinically measured weakness in subjects with TPTD was associated with reduced lateral forefoot loading. Medial longitudinal arch height was significantly correlated with loading patterns but explained only 21% of the variance in observed loading patterns.

CONCLUSION

Subjects with TPTD who are strong exhibited loading patterns similar to controls. Changes in total and distributed loading during terminal stance suggest there are altered ankle mechanics at push-off during the functional task of gait.

CLINICAL RELEVANCE

Strength, in the presence of TPTD, may be important to stabilize the midfoot during gait and might be important in rehabilitation protocols.

Distraction arthroplasty

Few joint-preserving surgical options exist for the patient who has ankle arthritis refractory to conservative measures. Therefore, continuous effort is afforded to the development of additional treatment options for such patients. Distraction arthroplasty has been proposed as one of these options for the patient in whom fusion or joint replacement is not appropriate. Although the mechanism of action remains unknown, the reports of several researchers support the potential beneficial effects that can be obtained from joint distraction arthroplasty in the severely osteoarthritic ankle. Furthermore, the studies published to date suggest that these effects may not only persist for years but also improve as time progresses during the first several years after treatment. Although additional laboratory studies are needed to understand the biochemical and biomechanical effects of distraction, additional prospective clinical studies are also needed to further understand its efficacy and appropriate patient population. The data thus far suggests that joint distraction arthroplasty may be a viable alternative treatment to arthrodesis and replacement for the young patient who has a congruent, painful, mobile, arthritic ankle joint.

Ankle pain and peroneal tendon pathology

Chronic ankle pain can be due to multiple causes. A thorough review of the patient's history with a physical examination concentrating on anatomic structures surrounding the ankle is imperative. The most common of causes have been presented. The addition of provocative testing and radiographic examinations can aid in elucidating the pathology. After treatment of the injury, attention to training technique, shoe and insert usage as well as individual gait abnormalities are integrated into global patient education to decrease the incidence of injury recurrence.

Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft

BACKGROUND

The purpose of this study was to evaluate our protocol with the modified skin incision without bone graft in the treatment of intra-articular calcaneal fractures in a consecutive series.

METHODS

Thirty-three displaced intra-articular calcaneal fractures operatively treated by a single surgeon were evaluated. Each fracture was managed according to a standardized protocol that included an oblique lateral incision and stable internal fixation, without supplemental bone graft. Fractures were classified according to two accepted criteria. Patients were evaluated with serial clinical and radiographic examinations. Final evaluation was made after at least a 2-year follow-up and was determined by the use of a functional outcome assessment questionnaire.

RESULTS

Anatomic or near anatomic reductions were obtained in 97% of cases. All fractures healed without loss of initial reduction or collapse. Excellent or good results were achieved in 88% of non-worker's compensation patients and 27% of worker's compensation patients. Fractures with anatomic reductions were more likely to achieve a good or excellent result. Ninety-two percent of patients returned to the workforce. Complications included one superficial wound infection and five cases of peroneal tendinitis requiring hardware removal. One patient underwent subtalar fusion secondary to painful posttraumatic arthritis.

CONCLUSIONS

The open reduction and internal fixation using our standardized protocol is an effective method of treatment for intra-articular calcaneal fractures.

Subtalar arthrodesis for complications of intra-articular calcaneal fractures

Eighty six subtalar arthrodeses performed between 1985 and 1996 for complications associated with intra-articular calcaneal fractures were retrospectively evaluated. Patients were divided into three Groups: (I) 59 patients with calcaneal malunions (II) 13 patients with failed open reduction and internal fixation, and (III) eight patients undergoing open reductions and primary fusion for highly comminuted fractures. In each scenario, internal fixation was achieved with cancellous lag screws. Bone graft material consisted of either autogenous iliac crest graft, local graft obtained from the lateral wall exostectomy of the malunion, or freeze-dried cancellous allograft. Fusions in Groups II and III were performed in situ. Fusions in Group I were performed either in situ or utilizing a variety of reconstructive procedures depending upon the type of malunion encountered. Eighty three of the 86 fusion attempts were successful following the initial operations for a union rate of 96%. Fusion rates were similar regardless of the graft material used. Complications included four varus malunions, four cases of osteomyelitis, and two cases of reflex sympathetic dystrophy. A statistically significant shorter hospital stay was found for patients not undergoing iliac crest bone graft procedures. Eighty patients with at least two year follow up achieved a mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of 75.0. Scores were similar for all three groups and for the various types of reconstructive procedures used. No correlation was found between postoperative talar declination angle and the AOFAS ankle-hindfoot score. Worker's compensation patients tended to have a poorer clinical outcome.