Search

Purpose: To develop and assess the Bed Bridge Test's (BBT) feasibility, safety, and clinimetric properties and evaluate functional capacity in hospitalised patients. Materials and methods: This feasibility and measurement study examined four BBT versions, including the timed-limited at 30 and 60 s and repetition-limited at 5 and 10 times, in hospitalised patients in a university hospital in Brazil. Ninety-two functionally stable patients with respiratory, gastrointestinal, or post-surgical conditions participated. Participants completed the BBT versions in a random order. BBT concurrent criterion validity was evaluated using the Short Physical Performance Battery (SPPB), Sit-to-Stand (STS) test, and Functional Status Score (FSS). Results: The participants were 51 ± 17 years old, 60% female, and 66% with clinical conditions. All participants completed the BBT versions without adverse events. Test–retest reliability was good–excellent (intraclass correlation coefficient >0.87) for all BBT versions, with acceptable agreement parameters and minimal detectable changes. The time-limited versions of the BBT might be affected by a ceiling effect. Floor effects were minimal for all BBT versions. BBT showed moderate associations with SPPB and STS and weak associations with FSS. Conclusions: The BBT is feasible and has promising measurement properties. IMPLICATIONS FOR REHABILITATION: The Bed Bridge Test (BBT) offers a valuable solution for healthcare professionals by addressing the limitations of existing functional tests, providing a straightforward assessment of functional capacity for both the patient and the assessor. The BBT has demonstrated excellent feasibility and safety, as all eligible participants completed its various versions without adverse events, indicating its potential utility across diverse patient populations. The BBT exhibits good to excellent reliability, indicating its reproducibility in clinical settings. The BBT has validated its effectiveness by exhibiting robust correlations with established functional tests such as the Short Physical Performance Battery (SPPB) and Sit-to-Stand (STS) test. [ABSTRACT FROM AUTHOR]

Children with disabilities need comprehensive intervention spanning health, education, and social systems from infancy through adulthood, with ongoing assessment of outcomes. While assistive technology is crucial, it must be complemented by inclusive learning options and other systemic interventions. Bronfenbrenner's Ecological Systems Theory guides this approach. A project in South Africa's Northern Cape Province utilized Acumen's Lean Data methodology for monitoring and evaluation. This methodology emphasizes rapid, technology-enabled data collection to inform stakeholders effectively. The project focused on disability awareness, referral systems, assistive technology provision, and early childhood development, adapting programs for various stakeholders and virtual delivery during COVID-19 lockdowns. Results underscored the interconnectedness of assistive technology with broader inclusion efforts and the importance of adaptability and continuous assessment. Further research is recommended to explore the project's role in fostering disability inclusion comprehensively. This ecosystemic approach highlights the necessity of holistic intervention and ongoing evaluation for sustainable social transformation and inclusion. [ABSTRACT FROM AUTHOR]

Background: Magnetic resonance imaging (MRI) of the thigh is used in diagnosis of idiopathic inflammatory myositis (IIM) diagnosis due to its high sensitivity in detecting muscle oedema and to localize the site for muscle biopsy. At the same time, dual energy absorptiometry (DXA) is an accepted method in clinical practice to measure muscle mass and change in body composition. In this longitudinal study of patients with active IIM we sought to correlate muscle findings on serial thigh MRI and body composition assessed using DXA with six-month clinical outcomes, we also studied correlation of thigh MRI scores with body composition parameters. Methods: A single-centre prospective study involving 20 active IIM patients. Clinical outcomes, muscle enzymes, MRI of the thigh scores and body composition were periodically assessed over 6 months. Results: Muscle oedema score significantly decreased from baseline (median 17.7) to 3 months (0.7) and 6 months (0) (p < 0.001). Fatty infiltration increased significantly from baseline (8.8) to 3 months (13.3; p < 0.001) and remained stable. Muscle atrophy score did not change significantly from baseline to 3 or 3 to 6 months. Body composition indices showed significant changes over 6 months, with increases in both lean mass indices and adiposity measures (p < 0.05). Muscle oedema score significantly correlated with manual muscle testing-8 (MMT-8) at baseline (r = −0.64). At 6 months MMT-8 showed a significant negative correlation with muscle atrophy (r = −0.562) and fatty infiltration (r = −0.478) but not with muscle oedema. Multivariate regression model revealed muscle oedema scores at 3 months (p = 0.03) and baseline muscle atrophy (p = 0.02) as significant predictors of MMT-8 at 6 months. Conclusion: Thigh MRI correlated with clinical outcomes both cross-sectionally and longitudinally. Higher baseline muscle atrophy and fatty infiltration, and higher muscle oedema at 3 months predict suboptimal clinical outcomes at 6 months. Intramuscular fatty infiltration scores on thigh MRI did not correlate with lower limb fat indices but correlated with overall fat indices on DXA scan. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the relationship of thigh MRI (t-MRI) with manual muscle testing-8 (MMT-8), muscle enzymes and autoantibodies. To determine the causal and mediating factors resulting in poor recovery of MMT-8 in inflammatory myositis (IIM). Methods This was a single-centre retrospective study in IIM patients. t-MRI was semi-quantitatively scored for muscle oedema, fascial oedema, muscle atrophy and fatty infiltration. Spearman correlation of t-MRI scores was done with muscle enzymes at baseline, and MMT-8 at baseline and on follow-up. Causal mediation analysis was performed with age, sex, symptom duration, autoantibodies, diabetes and BMI as independent variables, follow-up MMT-8 as dependent and t-MRI scores as mediating variables. Results Baseline evaluation was done on 59 and follow-up on 38 patients. Median follow-up of the cohort was 31 (10–57) months. Baseline MMT-8 negatively correlated with muscle oedema (r = –0755), fascial oedema (r = –0.443) and muscle atrophy (r = –0.343). Creatinine kinase (r = 0.422) and aspartate transaminase (r = 0.480) positively correlated with muscle oedema. Follow-up MMT-8 correlated negatively with baseline atrophy (r = –0.497) and fatty infiltration (r = –0.531). On follow-up, MMT-8 males had positive total effect (estimate (95%CI)) via atrophy [2.93 (0.44, 4.89)] and fatty infiltration [2.08 (0.54, 3.71)]. Antisynthetase antibody had a positive total effect via fatty infiltration [4.50 (0.37, 7.59)]. Age had a negative total effect via atrophy [–0.09 (0.19, –0.01)] and fatty infiltration [–0.07 (–0.15, –0.01)]. Disease duration had a negative total effect via fatty infiltration [–0.18 (–0.27, –0.02)]. Conclusion Baseline fatty infiltration and muscle atrophy resulting from older age, female sex, longer disease duration and absent anti-synthetase antibodies, partly mediate muscle recovery in IIM. [ABSTRACT FROM AUTHOR]

Surgery is an effective modality to reduce pain and increase range of motion (ROM) in TMJ disorders. The aim of this study was to determine which comorbidities and risk factors affect outcomes and progression to total joint replacement (TJR). A retrospective cohort study of patients who underwent TJR between 2000- 2018 at MGH was conducted. Primary outcome was successful vs unsuccessful surgery. Success was defined as pain score ≤ 4 and ROM ≥ 30 mm; failure was defined as lack of either or both. Secondary outcome was differences between patients undergoing TJR only (group A) and those undergoing multiple surgeries progressing to TJR (group B). 99 patients (82 females, 17 males) were included. Mean follow-up was 4.1 years; mean age at first surgery was 34.2 (range 14–71) years. Unsuccessful outcomes were associated with high preoperative pain, low preoperative ROM, and higher number of surgeries. Male sex favored successful outcome. 75.0% group A and 47.6% group B had successful outcome. Group B had more females, higher postoperative pain, lower postoperative ROM, and used more opioids compared to group A. High preoperative pain, low preoperative ROM, and more surgeries were associated with poorer outcomes and frequent opioid use. [ABSTRACT FROM AUTHOR]

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The traditional scarf osteotomy (TSO) has limited ability to correct the first metatarsal pronation. A novel modification which we refer to as a "dovetailed notch Scarf osteotomy" (DNSO) has been developed to enhance the ability to correct coronal plane pronation. The study aimed to observe and compare TSO to DNSO in the treatment of moderate to severe hallux valgus deformity. Methods: This retrospective study included 78 feet that had a TSO and 105 feet that had a DNSO.Minimum follow-up was 24 months.Weightbearing CT (WBCT) and weightbearing anterior-posterior (AP) radiographs were taken preoperatively and at the last follow-up. We measured the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular surface angle (DMAA) on AP radoigrpahs and first metatarsal coronal pronation angle (α angle), tibial sesamoid coronal grading (TSCG), and first metatarsal length (FML) on WBCT. Clinical assessment was done using Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS), Foot and Ankle Ability Measure (FAAM), and the 36-Item Short Form Health Survey (SF-36). The occurrence of postoperative complications was also documented. Results: The DNSO group exhibited a significantly higher correction amount of α angle and IMA (14.3±9.9° and 10.3±4.6°) than the TSO group (8.6±5.9 °and 5.4±5.9°) during the final follow-up assessment (P<.05).The DNSO group (10.1±6.9°and 4.8±3.1°) demonstrated significantly smaller α angle and IMA compared to the TSO group (15.3±5.7°and 9.1±5.0°) at 24 months post-surgery (P<.05). (P<.05).The postoperative FAAM-ADL and SF-36-PF scores were significantly higher in the DNSO group (97.2±3.3 and 95.7±4.4 points) compared to the TSO group (92.3±3.3 and 87.7±8.7 points) (P<.05). Additionally, hallux varus occurred in one case in the DNSO group, while four cases were observed in the TSO group. Conclusion: Two osteotomy methods can effectively correct moderate to severe hallux valgus deformity. Compared with the TSO, the DNSO has stronger correction ability. The most crucial aspect lies in its controllability when correcting first metatarsal pronation, as well as its exceptional performance in addressing IMA. [ABSTRACT FROM AUTHOR]

Category: Lesser Toes; Other Introduction/Purpose: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, and osteotomy and excision arthroplasty. The aim of the study is to describe a new technique for treatment of Freiberg's disease of lesser metatarsals and document the one and five-year functional outcomes. Methods: A retrospective analysis of ten patients who had Freiberg's infraction of the lesser toe metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC membrane was carried out. The patients were followed up to five years and the outcome measures were scored using The Manchester-Oxford Foot Questionnaire (MOxFQ) and Visual Analogue Pain Score (VAS), Figure 1. Results: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45±100) which improved to 42.5 (95%CI- 2.5±82.5) at one year. The mean baseline VAS improved from 47.3(95%CI- 14.3±80.3) to 30.3 (95%CI- 2.1±58.5) at one year. The mean MOxFQ and VAS at five years was 7 (95%CI-0.8±13.2) and 3.6(95%CI-1.3±6.2) respectively. Conclusion: Open debridement of the Freiberg's disease combined with microfracture of the defect, bone grafting and application of AMIC membrane gives good functional outcomes. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Ankle Introduction/Purpose: Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims. Consequently, medical malpractice lawsuits can impose significant economic and psychological burden on orthopedic surgeons. This study aims to investigate malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. Methods: The Westlaw legal database was queried for all cases involving hindfoot arthrodesis using the terms "malpractice" and either "ankle fusion," "arthrodesis," "subtalar fusion," "tibiotalar fusion," "tibiotalocalcaneal fusion," "TTC fusion," or "tibiofibular fusion" from 1987 to present day. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Results: Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (± 456,179). The most commonly alleged category of negligence was procedural/intraoperative error (75%) followed by post-surgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Conclusion: This study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality. Given the frequency of hindfoot arthrodesis performed, it is imperative for orthopedic surgeons to prioritize surgical goals, patient expectations, and complication profiles to reduce the risk of malpractice litigation and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux rigidus is a degenerative condition of first metatarso-phalangeal joint, affecting people at all ages, but more commonly above 50 years of age. Multiple options are available to alleviate pain and improve movements of big toe. These include cheilectomy with Moberg osteotomy, silastic implants, ceramic and metal arthroplasties, hemiarthroplasties with Co-Cr and titanium implants with varying success. The aim of our study is to evaluate the midterm outcome of synthetic cartilage implant (SCI - Cartiva) arthroplasty for hallux rigidus. Methods: There were a total of 70 patients who underwent SCI interpositional arthroplasty. The five-year functional scores for all patients were collected and analysed. The functional evaluation was done using Manchester-Oxford Foot Questionnaire (MOxFQ). The general health was assessed by EQ-5D which included EQVAS. The data was obtained from hospital digital database Medway and Amplitude clinical outcomes. This was analysed by an independent assessor who was not involved in the patients' care. The complications and revision rates were also documented. Results: Mean age at the time of operation was 63.4 years (range 42–84 years). The mean follow-up was 62.6 months. At five years follow up, 90% of the patients were satisfied with the outcome. The average preoperative MOxFQ score improved from 36.8 to 19.3 at one year after surgery. The EQ-5D scores improved from preoperative average of 9.4 to 4.4 at one year. The preoperative EQVAS was 75 and 85 at one year. At five years follow up the average MOxFQ score was 17.6, EQ-5D - 4.8 and EQVAS - 80. None of the patients had any infection. Three patients out of 70 had revision to first MTP fusion due to ongoing pain. Figure 1 shows the survival curve of the SCI implant at five years. Conclusion: Long term outcomes of Cartiva demonstrate clinical efficacy of this synthetic implant. The implant is durable, safe and is a viable treatment option to decrease pain, improve function and maintain motion for advanced hallux rigidus. [ABSTRACT FROM AUTHOR]

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: With the rising prevalence of cannabis consumption among individuals undergoing foot and ankle procedures, there is a critical need for a comprehensive investigation into the impact of cannabis use on post-operative outcomes. The shifting societal attitudes towards cannabis, coupled with legislative changes promoting increased accessibility, underscore the urgency of understanding the implications for both patients and surgeons. This study aims to address this gap in knowledge and provide insights that can guide pre-operative evaluations and post-operative care planning. Methods: Utilizing data from PearlDiver, patients who underwent interphalangeal fusion, arthrodesis, arthroscopy, total ankle arthroplasty, ankle fracture repair, lateral ankle ligament reconstruction, calcaneal tendon repair, bunionectomy and calcaneal osteotomy were identified. These patients with prior history of cannabis use were propensity-matched with a cohort without prior history of cannabis use based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Both cohorts were evaluated for 90-day occurrence of medical complications using univariate analysis. Results: In this study, we matched 59,797 patients with a history of cannabis use undergoing foot or ankle procedures with 239,086 without such history. Those with prior cannabis use showed significantly elevated rates of medical conditions compared to controls: pneumonia (6.1% vs. 2.2%, p <.001), deep vein thrombosis (1.5% vs. 0.8%, p <.001), pulmonary embolism (0.4% vs. 0.2%, p <.001), myocardial infarction (1.6% vs. 0.5%, p <.001), stroke (1.8% vs. 0.8%, p <.001), surgical site infections (4.0% vs. 2.2%, p <.001), acute kidney injury (6.8% vs. 3.0%, p <.001), urinary tract infections (9.0% vs. 3.5%, p <.001), sepsis (4.6% vs. 2.0%, p <.001), and hypoglycemia (1.2% vs. 0.5%, p <.001). Conclusion: This study highlights a compelling correlation between prior cannabis use and heightened risks of medical complications post foot and ankle surgeries. The findings emphasize the imperative for healthcare professionals to include cannabis use history in pre-operative assessments and post-operative care planning. Acknowledging the evolving landscape of cannabis use among surgical patients, further research is essential to refine clinical approaches and enhance patient outcomes in this context. [ABSTRACT FROM AUTHOR]

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand the impacts of sustained cannabis use on one's health. Previous literature has shown the potential for cannabidiol products to aid in the improvement of some osteoarthritic symptoms. However, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes for end stage osteoarthritis management, including procedures such as foot and ankle arthrodesis. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of foot or ankle arthrodesis. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. CPT codes were used to identify patients who underwent arthrodesis of the ankle, subtalar, talonavicular, calcaneocuboid, naviculo-cuneiform, midtarsal, tarsometatarsal, metatarsophalangeal, or interphalangeal joints. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 192,162 patients undergoing foot or ankle arthrodesis, 6,387 had a documented history of cannabis use. Compared to controls, the cannabis cohort was significantly younger (mean age 44.1 vs. 56.5; p< 0.001), exhibited a higher comorbidity burden (mean CCI 1.59 vs. 1.38; p< 0.001), and had a greater proportion of male patients (48.2% vs. 31.9%; p< 0.001). Post-matching for age, CCI, and sex, cannabis users demonstrated a significantly higher incidence of medical complications within 90 days of their index ankle fracture ORIF procedure. Notably, cannabis users exhibited elevated rates of various complications, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia compared to matched controls (all p< 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of foot or ankle arthrodesis. These results may help better inform physicians and patients about the increased postoperative risks cannabis users may face, which may lead to the implementation of tailored perioperative care. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to understand the risk-benefit ratio between the therapeutic effects of cannabidiol for arthritic pain relief, and the adverse outcomes that may result following surgical intervention. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: Although female students comprise over half of U.S. undergraduate and medical school enrollment, representation among residents and practicing surgeons in orthopaedics remains disproportionately low at 15% and 6%, respectively. The decline in residency may stem from a lack of early exposure to female mentors. This study investigates female representation in speaker roles at American Orthopaedic Foot & Ankle Society (AOFAS) meetings over time. Methods: The annual AOFAS meeting programs for 2012, 2017, and 2022 were reviewed by three independent raters. Each speaker, moderator, and panelist was classified based on sex and role; 15% of the data was cross-checked and evaluated using Fleiss Multirater Kappa validation. Sessions discussing surgical or biomedical topics were categorized as "technical", and all other sessions (i.e., welcome sessions) were categorized as "nontechnical." Individual-year odds ratios (ORs) and confidence intervals (CIs) evaluating sex versus session status, as well as sex versus speaker role, are provided. Combined results controlling for year were calculated using the Cochran-Mantel-Haenszel method. Results: A total of 403 speaking sessions were analyzed; 12% of sessions were led by female speakers. On average, female speakers were significantly more likely than males to assume nontechnical speaking roles across the three years combined (OR 3.84; 95% CI, 1.43 to 10.33). Female speakers led 12.7% of the 381 technical sessions. Females also comprised 9.8% and 16.7% of moderator and panelist roles, respectively. Conclusion: Although our study reveals an increasing trend in female speakers, panelists, and moderators from 2012 to 2022, these data demonstrate a persistent lack of sex diversity at AOFAS annual meetings, especially within technical sessions and moderator roles. Increasing female representation at conferences while fostering mentorship opportunities for medical students may serve as a valuable opportunity to address disparities between males and females within orthopaedics. Female Representation in Speaker Roles at AOFAS and Session Category Odds Ratios [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Although Evan's lateral column lengthening (LCL) calcaneal osteotomy is the standard joint-sparing surgical option to correct the forefoot abduction in Johnson and Strom Grade IIB progressive collapsing flatfoot deformity (PCFD), studies evaluating the choice of filling (autograft or allograft) for the osteotomy site on outcomes reveal heterogeneous results. The purpose of this study is to compare the results of graft choice on bony union, subsequent clinical outcomes and complication rates after LCL osteotomy. Methods: This was a retrospective study of 34 patients who underwent Evan's LCL divided into 2 cohorts dependent on the type of graft used for the opening osteotomy (Group A used tricortical autograft harvested from the iliac crest, n = 24; Group B used tricortical allograft soaked in the patient's own bone marrow aspirate concentrate, n = 10). Patient demographics, time to union, postoperative complications, and patient-reported outcome measures were compared among groups using univariable analyses. Minimum follow-up was 24 months. Results: Both groups demonstrated significant improvement in Visual Analogue Scale (VAS) of the midfoot and hindfoot, American Orthopaedic Foot & Ankle Society (AOFAS)-Mid and AOFAS-Hind scores at 6 months (P < 0.05) and continued experiencing improvement at 24 months postoperatively (P < 0.05). Nevertheless, there was no statistically significant difference in clinical outcomes or time to union between autograft and allograft when performing Evan's LCL. In terms of complications, neither group experienced any non-union, though all who experienced surgical complications were from group A - 3 patients suffered peroneal tendinopathy, 1 patient experienced Achilles tendinopathy, 2 patients underwent removal of implants and 1 patient had chronic pain due to irritation to the plantar nerve. Conclusion: Significant and early improvement in clinical outcomes were observed in both groups with 100% union rates. Though Group A (iliac crest autograft) had higher rates of complications, it did not fare worse on patient-reported outcome measures when performing Evan's LCL. Future studies involving larger sample sizes with standardized definitions for radiographic union will be critical to further elucidate graft-related impacts on outcomes after LCL. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Comparative studies examining Fixed-Bearing (FB) and Mobile-Bearing (MB) Total Ankle Replacement (TAR) designs have demonstrated similar results and successful long-term outcomes for both. To date there has been no study directly comparing FB and MB designs of the same prosthesis. We present the first randomised prospective trial comparing patient satisfaction, functional outcomes and radiographic results of the Salto Talaris Fixed-Bearing and the Salto Mobile-Bearing Total Ankle Replacement in the treatment of end-stage ankle arthritis. Methods: A total of 106 adult patients with end-stage ankle arthritis were enrolled in the study between November 2014 and October 2021 with similar demographic comparison. Prospective patient-reported outcomes and standardised weightbearing ankle radiographs were performed preoperatively, at 6 weeks, 6 months and 12 months post-operatively, followed by yearly intervals. Foot Function Index, Revised Foot Function Index, 12-Item Short Form Survey and Total Ankle Joint Replacement Questionnaire were used for patient reported scoring. All surgeries were performed by a single non-design orthopaedic foot and ankle specialist with experience in over 200 Salto and Salto Talaris TAR prior to the study. Radiographs were examined independently by two clinicians. Complete patient data and radiographs were available for 101 patients with an average follow up of 3 years. Results: Both groups demonstrated statistically significant improvement from preoperative evaluation to most recent follow up with no statistically significant difference between the two groups in all outcome measures. Radiographic incidence of subchondral cyst formation was 17.4% and 49.1% for FB and MB, respectively. Talar subsidence occurred in 8.7% and 18.2% of FB and MB, respectively. Implant subluxation was observed in 1.8% of MB TAR. Two patients required revision, one from each cohort reflecting a revision rate of 2.2% for FB and 1.8% for MB TAR. Conclusion: Our study demonstrates a higher than previously reported rate of subchondral cyst formation in the MB TAR and comparatively higher talar subsidence in the MB TAR vs FB however this did not correlate with clinical outcome measures which were favourable for both groups. [ABSTRACT FROM AUTHOR]

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: It is often challenging to determine the exact cause of nerve injury following peripheral nerve block (PNB). The etiology of pathologic sequelae is likely multifactorial and may be influenced by the type of PNB, choice of local anesthetic and adjuvant, level of conscious sedation during PNB administration, and use of ultrasound guidance or nerve stimulation. This study examines the incidence of postoperative neurologic complications following use of PNB in foot and ankle surgery. The primary goal is to identify the PNB with the greatest neurologic complication rate as reported in the literature and to characterize the symptomatology of these deficits. Additionally, this study will investigate possible risk factors related to block administration. Methods: A bibliography search was conducted in MEDLINE, PubMed, and Cochrane from 2012 to 2023. Included studies were those that analyzed neurologic complications following use of peripheral nerve block in foot and ankle surgery. Studies that included pediatric or pregnant populations were excluded, along with those that involved orthopedic surgeries other than foot and ankle. The Methodological Index for Non-Randomized Studies (MINORS) scale was used to evaluate risk of bias. The primary outcome was complication rate, which included neurologic complications, defined as sensory or motor nerve dysfunction or unresolved pain beyond what would be expected in the postoperative course. Secondary outcome measures included choice of local anesthetic, use of adjuvant, patient position, and level of patient sedation during block administration. Results: Of 6,014 total patients, 794 reported neurologic complications (13.2%). 97% of deficits were sensory (770 of 794), 1.8% were motor (14 of 794), and 1.3% were mixed (10 of 794). Popliteal block had a complication rate of 12.2% (400 of 3,273), the highest of any solitary block; of these patients, 7 developed complex regional pain syndrome and 3 developed reflex sympathetic dystrophy. Complication rates for bupivacaine and ropivacaine were 8.8% (243 of 2,778) and 24.1% (330 of 1,367), respectively. Motor complications were greater with bupivacaine (3 of 243) than ropivacaine (1 of 330); these included foot drop, transient paresis, and flexor hallucis tendon weakness. Lastly, comparison of adjuvants yielded complication rates of 24.3% with epinephrine (89 of 267) and 15.5% with corticosteroids (277 of 1,784). Conclusion: While most neurologic complications involve transient paresthesia followed by spontaneous resolution, some patients develop long-lasting symptoms resulting in chronic pain and motor compromise. Implementation of a screening protocol to identify at-risk patients should be considered given the prevalence of comorbid mood disorders in those with complex regional pain syndrome (CRPS) and evidence of altered nerve physiology in patients with diabetic neuropathy. Continuation of current risk mitigation strategies is paramount. However, there is still a gap in knowledge regarding the effect of previous neurologic dysfunction, such as Bell's Palsy and Guillain-Barre Syndrome, and whether this predisposes to further nerve injury. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Other Introduction/Purpose: For most patients suffering from plantar fasciitis, nonoperative management can alleviate their symptoms. In a small subset of patients these modalities are unsuccessful, and invasive procedures can be recommended. With current studies supporting the use of this procedure with good short-term results and a low complication rate, we hypothesize that an isolated gastrocnemius recession for plantar fasciitis will demonstrate good midterm results. Methods: Eighty-eight patients underwent a gastrocnemius recession for isolated, recalcitrant plantar fasciitis between September 2014-June 2017, and were identified using procedural codes. Patients were then contacted via phone to obtain answers to Foot and Ankle Ability Measurement, and AAOS foot and ankle outcome scores. Patients were also asked questions about if they were satisfied with the procedure, would repeat the procedure, or would recommend it to a friend. Results: Fifty-two patients were contacted, nine declined participation. The group included 33 females and 10 males, 23 left and right feet (3 bilateral). Investigator follow up occurred at a mean time of 5.0±1.3 years. The average FAAM scores by category were ADL 92.0±15.0, daily function 91.0±19.8. On the FAAM rating of current function 30 rated themselves as normal, 8 near normal. The average AAOS foot and ankle scores were 93.9±11.4 (normative standard 50.9±9.8), shoe comfort 83.5±25.8 (normative standard 53.4±8.8). 41 patients rated themselves as satisfied with the procedure (95%), 40 would do it again (93%) and 39 would recommend the procedure to a friend with recalcitrant symptoms (91%). One patient required a revision gastrocnemius recession with relief of symptoms. No other complications were noted. Conclusion: he use of an isolated gastrocnemius recession for recalcitrant plantar fasciitis demonstrates a high rate of patient satisfaction and function in the midterm at 5 years. This study supports the use of this procedure in patients who fail non-operative regimens. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle replacement (TAR) is increasingly performed on patients across a wide age spectrum, though historically it has been reserved for older patients (>60). In this study, we seek to determine how age influences patient outcomes. Methods: This is a retrospective, comparative cohort study of consecutive patients that underwent TAR from 2004-2021. Patients were categorized into three age groups: < 55, 56-70, and >70. We evaluated surgical complications and patient-reported outcome measures, including Ankle Osteoarthritis Pain & Disability Scores (AOS) and Short Form-36 Health Survey (SF-36). Analysis of covariance was performed, adjusting for patient factors. Results: We reviewed 812 consecutive TARs from a single-centre with 407 (50.1%) male and mean BMI of 29.8±5.78. The median follow up was 64.0 months (IQR,76.0). Patients ≤55 had worse pain preoperatively than both older patient groups (p=0.03) and worse mental health (p< 0.001), however, this difference was not observed in postoperative AOS pain (p=0.15) or SF-36 MCS scores (p=0.87). Patients >70 had worse physical health than patients 56-70 (p=0.02) and less change in pre- to postoperative SF-36 PCS scores (p=0.02). Patients from all groups improved similarly according to the AOS pain (p=0.15) and disability (p=0.12). Conclusion: These results show that TAR patients younger than 55 have worse pain and mental health preoperatively but have similar long-term clinical outcomes to patients 56 and older. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: Previous literature has noted that a higher proportion of females than males matched into all orthopaedic surgery fellowships from 2010-2014. However, this has not been investigated specifically in regards to foot and ankle fellowships or with more recent match data. Therefore, the purpose of this study was to evaluate the trends in applicant gender for orthopaedic surgery foot and ankle fellowships over the last 11 years and to evaluate the differences in match rates between male and female applicants. Methods: San Francisco Match from 2013 to 2023 was analyzed. There were 986 applicants for foot and ankle fellowships from 2013-2023. There were 395 (40.1%) international medical graduates who were excluded from this analysis, leaving 591 applicants in the study cohort. There were 126 female applicants (21.3%) and 465 Male applicants (78.7%). The gender, number of applicants, and number of matched applicants into orthopaedic foot and ankle fellowship was reviewed. In addition, trends regarding number of applicants and match rates based on gender were evaluated. Results: Female applicants ranged from a low of 6 in 2013 to a high of 14 in 2023, (mean 11.5+/- 2.8) with no statistically significant change (r=0.4, p=0.097). Match rate for female applicants increased from a low of 76.9% (10 of 13) in 2017 to 100.0% (14 of 14) in 2022, (mean 92.1% +/- 8.7%), with no statistically significant change (r=0.45, p=0.07). Male applicants ranged from a low of 32 in 2023 to a high of 58 in 2014 (mean 42.3 +/- 8.0), with a significant decrease (r=-0.89, p=0.00004). Match rate for male applicants ranged from a low of 86.5% (45 of 52) in 2013 to a high of 100.0% (32 of 32) in 2023 (mean 95.1% +/- 4.9%), with a significant increase (r=0.95, p=0.000002). Conclusion: Since 2013, there has been no statistical significant change in the number of female applicants and female applicant match rate for orthopaedic foot and ankle fellowship. The number of male applicants experienced a significant decrease over the study period, with a significant increase in match rate. Although male applicants had a slightly higher match rate than female applicants, there was no statistical significant difference. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: In recent years, there has been an increase in doctors of osteopathic medicine (DO) applying for orthopaedic residency, which has led to an increase in osteopathic residents applying for fellowships. The purpose of this study was to evaluate the change in degree type of applicants to foot and ankle fellowships over the last 12 years and to evaluate the differences in match rates between osteopathic and allopathic applicants. Methods: SF Match data from 2012 to 2023 was analyzed. There were 1082 applicants for adult foot and ankle fellowships from 2012-2023. There were 74 osteopathic applicants (11.4%) and 573 allopathic applicants (88.6%). There were 435 (40.2%) international medical graduates who were excluded from this analysis. The degree type, number of applicants, and number of matched applicants into orthopaedic foot and ankle fellowship was reviewed. Trends regarding number of applicants and match rates based on applicant degree were evaluated. Results: Osteopathic applicants ranged from a low of 2 in 2018 to a high of 11 in 2016, (mean 6.2 +/- 2.6), with no statistically significant change (r=-0.12, p=0.34). Match rate for osteopathic applicants increased from 75.0% (6 of 8) in 2013 to 100.0% (5 of 5) in 2023, (mean 91.2% +/- 9.9%), with a significant increase (r=0.72, p=0.003). Allopathic applicants ranged from a low of 37 in 2022 to a high of 63 in 2014 (mean 47.8 +/- 6.9), with a significant decrease (r=-0.7, p=0.003). Match rate for allopathic applicants ranged from a low of 88.0% (44 of 50) in 2013 to a high of 100.0% (37 of 37) in 2022, (mean 94.5% +/- 4.5%), with a significant increase over the study period (r=0.79, p=0.0007). Conclusion: Since 2012, there has been no statistically significant change in the number of osteopathic applicants for foot and ankle fellowship. While both osteopathic and allopathic applicants experienced a significant increase in match rates, there was no significant difference in match rates. [ABSTRACT FROM AUTHOR]

Category: Sports; Other Introduction/Purpose: Orthopaedic surgeons routinely utilize Patient Reported Outcome Measures (PROMs) to evaluate surgical and nonsurgical treatment outcomes. PROMs can be cumbersome to both patients and surgeons with issues of noncompliance. With the rise of wearable fitness devices and smartphone applications, alternative methods are being explored for a more efficient and objective measurement of outcomes. There is a lack of studies directly comparing PROMs with patient wearable outcome (PWO) methods. This study aims to compare PWOs to PROMs and determine the feasibility of using PWOs as an outcome measurement tool in orthopaedics. The findings of this study could have implications for surgeons to integrate phone application-based technology into orthopaedic care in conjunction with PROMs and the potential to be used independently of PROMs to measure outcomes. Methods: This study is a non-randomized prospective cohort study with a known foot and ankle orthopaedic condition presenting to an orthopaedic clinic. Subjects with any foot and ankle condition over the age of 16 were asked to participate. Standard PROM surveys were administered at enrollment and then at 1 month, 2 month, and 3 month time periods. Surveys utilized were the Foot and Ankle Ability Measure Computerized Adaptive Testing (FAAM CAT), PROMIS physical function, mobility and pain interference scores, and Visual Analog Scale (VAS). A mobile phone application was then installed in subjects' smartphones that utilized past and future health data including step counts and distance traveled. Statistical analysis was performed to correlate PWOs with PROMs. Results: Our study analyzed 19 participants aged 17 to 77, who complied with the treatment protocol. There were strong positive correlations in step counts across consecutive months, notably from 1-month to 2-month (r = 0.913,95% CI: 0.783 to 0.966) and 1-month to 3-month (r = 0.852, 95% CI: 0.648 to 0.942), indicating consistent physical activity. However, the relationship between activity levels (measured by step counts) and pain perception (Pain-VAS scores) proved complex, with variable moderate correlations (3-month Pain-VAS Score vs 3-month Steps, r= 0.416, 95% CI: −0.245to 0.813) suggesting that higher activity might be associated with greater pain at different time points. Conclusion: This study highlights the potential value of integrating objective physical activity data from wearable devices with PROMs for a more holistic assessment. The variable moderate correlations discovered underscores the challenge of correlating pain directly with physical activity. Despite objective measurements of activity consistency, patient-reported scores on factors like daily living and sport were nuanced, underscoring the complex interplay between physical functioning and subjective experience of pain. A balanced approach considering both objective and subjective data is needed to enhance treatment strategies and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Category: Bunion Introduction/Purpose: The purpose of this study was to determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the Visual Analogue Scale (VAS) and Foot and Ankle Ability Measure (FAAM) Scores after Hallux Valgus surgery. Methods: A retrospective review of prospective collected data was performed in patients undergoing hallux valgus surgery at a single institution from January 2021 through December 2022. Patient-reported outcome measures (PROMs) were collected pre-operatively and 1 year post-operatively. The specific PROMs utilized were the FAAM- Activities of Daily Living (FAAM-ADL), Single Assessment Numeric Evaluation (SANE), and VAS scale. The study measured change in PROMs from before surgery to one year after surgery to determine delta. Two methods were used to calculate MCID and PASS thresholds: A distribution-based approach and an anchor-based approach using responses to a one-year postoperative satisfaction question. The analysis identified optimal cut-off points that maximized sensitivity and specificity based on the Youden index. The percentage of patients reaching these optimal MCID and PASS thresholds was also determined. Results: Overall, 86% (136/158) completed baseline PROMs, and 72.7% (99/136) completed 1-year PROMs. The distribution-based MCID for FAAM-ADL, FAAM-ADL-SANE,, and VAS were calculated to be 10.8, 14.1, and 1.2 respectively. The rate of patients who achieved MCID thresholds was 54% for FAAM-ADL, 42% for FAAM-ADL-SANE, and 95.8% for VAS. The PASS threshold for FAAM-ADL, FAAM-ADL-SANE, and VAS were ≥78.5, ≥85, and ≤ 2, respectively. The rate of patients who achieved PASS thresholds was 77.5% for FAAM-ADL, 71.4% for FAAM-ADL-SANE, and 68.7% for VAS. Conclusion: This study identified useful values for the MCID and PASS thresholds at 1-year follow-up for patient undergoing hallux valgus surgery of FAAM-ADL, FAAM-ADL-SANE, and VAS scores. [ABSTRACT FROM AUTHOR]

Category: Ankle; Ankle Arthritis Introduction/Purpose: Obesity is an ongoing public health epidemic with wide-ranging implications for orthopaedic surgery. Bariatric surgery has been shown to be an effective method for weight reduction. This retrospective cohort study aimed to compare rates of reoperation between patients who underwent primary ankle arthrodesis (AA) and those who underwent total ankle arthroplasty (TAA) after undergoing bariatric surgery. Methods: Utilizing data from PearlDiver, patients who received primary AA or TAA with prior history of bariatric surgery to a cohort without prior bariatric surgery were retrospectively analyzed for reoperations. Both cohorts were propensity-matched based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Indications for reoperation included revision, prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Kaplan-Meier survival analysis and hazard ratios were calculated for five years after the procedure. Results: Of the 801 patients with prior history of bariatric surgery, 519 (65%) underwent AA, while 282 (35%) underwent TAA. At 5 years post-operatively, patients who had undergone AA showed a higher incidence of adjacent joint fusion if they had prior history of bariatric surgery (Hazard ratio: 1.79, 95% Confidence Interval: 1.23 - 2.61, P-value < 0.001). No differences in reoperation rates were observed for PJI, hardware removal and ORIF. At 5 years, patients who had undergone TAA with history of bariatric surgery showed no difference in the incidence of revision, PJI, hardware removal, ORIF and adjacent joint fusion as compared to patients who underwent TAA with no history of bariatric surgery. Conclusion: Our findings suggest that patients undergoing primary TAA displayed comparable reoperation rates regardless of prior bariatric surgery history over a five-year post-procedure period. In contrast, patients undergoing primary AA exhibited an increased risk of adjacent joint fusions if they had history of bariatric surgery, although the rates of reoperation due to PJI, ORIF, and hardware removal remained comparable. Notably, our results do not position a prior history of bariatric surgery as a significant determinant in reoperation rates. These insights offer valuable guidance for orthopedic surgeons navigating the complexities of surgical interventions in the context of bariatric surgery. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on an online review website. Methods: We conducted a retrospective analysis of negative one-star reviews on Vitals.com with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described. Results: Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients. Conclusion: Complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. Summary of Background Data: Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to assess currently reported complication, satisfaction, and other outcome rates. Results: Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. Conclusions: This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have assembled a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to high-quality research where improvement efforts should be focused. [ABSTRACT FROM AUTHOR]

The aim of the present study was to compare scores from the English and the Spanish versions of two well-known measures of psychological distress using a within-subject approach. This method involved bilingual participants completing both measures in four conditions. For two groups of people, measures were offered in the same language both times and for the other two groups, each language version was offered, the order differing between the groups. The measures were the Clinical Outcomes in Routine Evaluation-Outcome Measure and the Schwartz Outcome Scale-10, both originally created in English and then translated to Spanish. In total, 109 bilingual participants (69.7% women) completed the measures in two occasions and were randomly allocated to the four conditions (English-English, English-Spanish, Spanish-English and Spanish-Spanish). Linear mixed effects models were performed to provide a formal null hypothesis test of the effect of language, order of completion and their interaction for each measure. The results indicate that for the total score of the Clinical Outcomes in Routine Evaluation-Outcome Measure just language had a significant effect, but no significant effects were found for completion order or the language by order interaction. For the Schwartz Outcome Scale-10 scores, none of these effects were statistically significant. This method offers some clear advantages over the more prevalent psychometric methods of testing score comparability across measure translations.

The aim of the present study was to compare scores from the English and the Spanish versions of two well-known measures of psychological distress using a within-subject approach. This method involved bilingual participants completing both measures in four conditions. For two groups of people, measures were offered in the same language both times and for the other two groups, each language version was offered, the order differing between the groups. The measures were the Clinical Outcomes in Routine Evaluation-Outcome Measure and the Schwartz Outcome Scale-10, both originally created in English and then translated to Spanish. In total, 109 bilingual participants (69.7% women) completed the measures in two occasions and were randomly allocated to the four conditions (English-English, English-Spanish, Spanish-English and Spanish-Spanish). Linear mixed effects models were performed to provide a formal null hypothesis test of the effect of language, order of completion and their interaction for each measure. The results indicate that for the total score of the Clinical Outcomes in Routine Evaluation-Outcome Measure just language had a significant effect, but no significant effects were found for completion order or the language by order interaction. For the Schwartz Outcome Scale-10 scores, none of these effects were statistically significant. This method offers some clear advantages over the more prevalent psychometric methods of testing score comparability across measure translations. [ABSTRACT FROM AUTHOR]

Background Generic and disease specific health-related quality of life scales have been found to be non-responsive to changes in medications in polypharmacy patients. The Taiwanese medication-related quality of life (MRQoL) scale aims to measure the effect of medication use on patients' quality of life. Objective To evaluate the psychometric properties of the Danish translation of MRQoL in a population of patients with polypharmacy. Setting Polypharmacy patients waiting for services at a community pharmacy or hospital in Denmark. Method The original MRQoL included 14 items. It was forward-translated into Danish and backward-translated into Chinese according to a modified translation protocol proposed by Sousa and Rojjanasrirrat et al. The translation was pre-tested, adjusted, and administered to polypharmacy patients. The factor structure was examined using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency reliability was evaluated, and criterion validity assessed using the beliefs about medicines questionnaire (BMQ) and SF-12v2. Known-group validity was carried out on age, number of medicines and setting. Main outcome measure Validity of the Danish version of the MRQoL-scale. Results 164 patients completed the questionnaire. EFA of all 14 items resulted in a two-factor structure, accounting for 72.8% of the total variance. The two factors were named "Energy/Concentration" (7 items) and "Feelings/Social" (7 items). Items correlating over 0.80 were removed leaving 11 items (Model 1). This model was further reduced to 8 items (Model 2) based on Cronbach's alpha. CFA confirmed the two-factor structure of both models. Model 2 fitted data without having to define covariations between error terms. Both factors showed high internal consistency reliability (Cronbachs' alpha 0.901-0.932). Ceiling effects were detected for both factors. Criterion validity was demonstrated via its significant correlations with SF-12vs2 subscales (Spearman's rho 0.340-0.353) and BMQ Concern (Spearman's rho - 0.451 to - 0.347). There was a statistically significant difference in relation to total scores of the MRQoL for age and number of drugs taken, indicating known-group validity. Conclusion The Danish translation of the MRQoL instrument showed measurement properties indicating a well-defined two-factor structure with high internal reliability, concurrent criterion validity, and known group validity. However, challenges remain with ceiling effects and efforts should be put into further development of the instrument. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: Optimising clinical practice requires emphasis on patient-orientated care and therefore patient reported outcome measures (PROMs) play a key role in shaping evidence-based clinical guidelines. As such, it is crucial that we use appropriate, valid and reliable PROMs to quantify outcomes in orthopaedic research. A previous systematic review evaluating evidence published between 2002-2011 identified 139 different PROMs used in the foot and ankle literature and found the most common PROM was The American Orthopaedic Foot and Ankle Society (AOFAS) score. However, in 2011, AOFAS issued a position statement outlining the lack of reliability and validity of the AOFAS score, describing it as a 'less than ideal' measure. This systematic review aims to provide an updated analysis of the PROMS used in the foot and ankle literature. Methods: This systematic review was performed according to PRIMSA guidelines. An electronic title/abstract screen of every article published between January 2012- December 2022 in Foot and ankle international, Clinical Orthopaedics and Related Research, Knee Surgery Sports Traumatology and Arthroscopy, The Bone and Joint Journal and The American Journal of Sports Medicine was performed by two reviewers. Articles with a foot and ankle focus were selected for full text screening and papers reporting at least one PROM were included in the final review. The following data was extracted from each article: journal of publication, month/year of publication, pathology/intervention described, PROMS reported and use of the minimally clinically important difference (MCID) to evaluate post intervention changes in PROMs. The number of studies using each individual PROM was calculated and a subgroup analysis was performed to investigate variation in PROM selection according to year of publication, journal of publication and the condition being investigated. Results: A total of 3,174 foot and ankle articles were identified, of which 1,168 (36.8%) articles reporting at least one PROM were included. The most common PROM was the AOFAS score, reported in 50.3% of studies, followed by visual analogue scale (VAS) pain score (44.4%) and 36-item short form survey (SF-36) (15.3%). Use of the AOFAS score declined across the review period. Between 2012-2016 AOFAS was the most common PROM, whilst VAS pain was most common in four of the last six years. Although some variation in PROMs according to clinical pathology exists, AOFAS score is featured in the top 3 most common PROMs for every analysed condition. Only 8/1,168 (0.7%) articles reported the number of patients achieving a minimally clinically important difference (MCID) post-intervention. Conclusion: Whilst use of the AOFAS score declined over the review period, it remains the most common PROM overall across all included journals and many conditions. There exists a lack of consensus regarding the most suitable alternative PROMs, with multiple validated instruments including FAOS, FAAM and FFI used inconsistently with relatively low frequency. There is a heavy reliance on statistical significance to evaluate and compare post-intervention PROM changes. However, it is important to quantify PROMs according to the patient perspective. Reporting the proportion of patients achieving MCID will allow clinicians to interpret PROMs and develop management guidelines in a patient-focused manner. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Surgeons' response to the nationwide opioid epidemic has included using alternatives to narcotic pain medications. Regional anesthesia has provided options to reduce narcotic consumption after surgery. Liposomal Bupivacaine (LB) is not FDA approved for use in nerve blocks in the lower extremity, though it is approved for more dangerous blocks (interscalene for example) in the upper extremity. The literature on LB in foot and ankle surgery has been limited to local infiltration and no major study has explored its efficacy when used in lower extremity peripheral nerve blocks. In this study, we compare local LB infiltration with LB used in peripheral nerve blocks in the lower extremity and compare both of these techniques with the current standard of care, a non-LB peripheral nerve block. Methods: All patients undergoing surgery in a single surgeon foot and ankle practice were enrolled in this IRB approved, prospective, randomized controlled study. Patients having surgery between January 2022 – January 2023 were randomized to one of three study arms: Group 1 Anesthesia administered ultrasound guided nerve block with local anesthetic only, Group 2 Anesthesia administered ultrasound guided nerve block with LB/local only mix, or Group 3 Surgeon administered infiltrative field block with LB/local mix. The primary outcomes collected included the amount of narcotic pain medication required in the PACU, oral morphine equivalents (OME) up to postoperative day 4 and after postoperative day 4, subjective duration of nerve block, and patient reported outcomes (PROMIS Pain Interference/Depression/Physical Function). Collection was obtained via chart review from hospital EMR, and phone calls made to patients during specific time intervals after surgery. Analysis was performed utilizing GraphPad Prism (Ver 9.0, GraphPad Software, San Diego CA USA). Results: After exclusion of 110 patients, 248 patients met inclusion criteria. Ninety-eight underwent perineural popliteal or popliteal adductor block with LB/local mix, 70 underwent popliteal or popliteal adductor block with local only (Group 2), 80 underwent surgeon administered local field block with LB/local mix (Group 3). Median PACU morphine equivalents required for pain control were significantly lower in Groups 1 and 2 (0 OME) compared to local field block (7.5 OME) (p < 0.05). Median OME utilized up to POD 4 and median OME utilized after POD 4 were both significantly lower in the LB/local mix perineural block group (p < 0.05) compared to Groups 2 and 3. Duration of block effect was significantly higher in the LB/local mix group compared to Groups 2 and 3 (p < 0.05). Conclusion: Preoperative perineural blocks containing a mix of LB and local anesthetic significantly reduce PACU, early postoperative, and mid postoperative narcotic use of patients undergoing outpatient foot and ankle surgery. The duration of effect of perineural block is significantly extended with addition of LB to the block mixture. Consideration should be given to the use of LB blocks in foot and ankle surgical procedures to reduce patient postoperative narcotic requirements. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Other Introduction/Purpose: Utilization rates of total ankle arthroplasty (TAA) have greatly increased in recent years. For patients with rheumatoid arthritis (RA) undergoing TAA, conflicting data have been reported regarding risk of complications and patient reported outcome (PRO) improvement when compared to patients with osteoarthritis. The purpose of this study is to compare complication rates and PROs of patients with RA to patients with osteoarthritis and posttraumatic arthritis. Methods: This was a retrospective study of 1,071 primary TAA performed at a single institution between 2001 and 2020. Minimum follow-up was two years. Patients were stratified by indication for TAA (osteoarthritis, n=372; posttraumatic arthritis, n=642; RA, n=57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1). Results: Compared to the osteoarthritis and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest ASA score (p < 0.001). Univariate analysis showed no statistically significant difference for infection rates among groups (p=1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2/57, 3.5%, p< 0.001). Multivariable regression analysis showed no increased risk of implant failure for the RA cohort (p=0.23). For the SMFA, SF-36, AOFAS-hindfoot, FAOS-symptoms, and FAOS-ADL the RA group reported the worst scores at final follow-up (p < 0.001). However, the RA cohort demonstrated the largest improvements from preoperative to postoperative scores on the FADI, SF-36, and the symptoms and ADL subscales of the FAOS (p=0.04, 0.01, 0.03, 0.03). Conclusion: In the largest single institution study to date, patients with RA had the worst PRO scores compared to the osteoarthritis and posttraumatic arthritis groups. However, they experienced significantly higher improvements in functional outcomes from their preoperative baseline. Large patient samples with mid- to long-term follow up such as a presented in this series are imperative to fully understand the risk-benefit of TAA in various patient cohorts. [ABSTRACT FROM AUTHOR]

Abstract Background Our objective in this study was to examine whether stakeholders further endorse the core domain set proposed by the Outcome Measures in Rheumatology Trials (OMERACT) total joint replacement (TJR) working group. Methods We emailed a survey to 3810 hip/knee arthroplasty patients and 49 arthroplasty surgeons at a high-volume arthroplasty center to rate the importance of each core domain (i.e., pain, function, patient satisfaction, revision surgery, adverse events, and death) and two additional domains (i.e., cost and participation). Ratings were on a 1–9 scale, with 1–3 indicating limited or no importance for patients, 4–6 being important but not critical, and 7–9 being critical. We calculated median (IQR) values and compared ratings by sex, age, and participant type using the Wilcoxon rank-sum test. Results The questionnaire was completed by 1295 patients (34%) and 21 surgeons (43%). Patient nonresponders were similar to responders in age (≥55 years, 85.7% vs. 88.6%), sex (female, 57.5% vs. 57.3%), and joint procedure (total hip replacement, 56.9% vs. 63.2%). Overall, all core domains and one noncore domain (i.e., participation) were confirmed as “critical” by both stakeholder groups. Cost was rated as only “important” but not “critical” by surgeons. A completed consensus for all the core domains persisted even when we stratified by sex, age, arthritis type, and the affected joint (knee vs. hip). We received suggestions for additional critical domains from 217 patients and 5 surgeons, prompting the inclusion of 2 research agenda items. Conclusions Our study confirmed a consensus rating of the OMERACT TJR core domain set as critical for patients. This broad endorsement should encourage the identification of candidate outcome instruments to further develop a TJR core measurement set that can harmonize reporting in TJR clinical trials.

Objective: The evaluation of the disease severity in hip osteoarthritis (OA) patients being currently based on subjective instruments. It would be of interest to develop more objective instruments, for example based on gait analysis. The aims of this study were to explore if pelvis-thorax coordination parameters could be valuable instrument outcomes to achieve this evaluation by assessing their reliability, discriminant capacity and responsiveness.Methods: Three groups of subjects; healthy, hip OA patients with severe disease (defined as indication to surgery), hip OA patients with less severe disease (no indication to surgery) were included. Hip OA patients with severe disease were evaluated before and 6 months after surgery. Subjects had to perform a gait analysis at comfortable speed, and pelvis-thorax coordination was evaluated. The correlations with clinical and structural parameters, as well as reliability, discriminant capacities and responsiveness, were assessed.Results: The pelvis-thorax coordination in the coronal plane during walking was correlated to clinical and to structural severity in hip OA patients (R2 = 0.13). The coronal plane coordination allowed to discriminate healthy subjects from all hip OA patients (sensibility = 0.86; specificity = 0.59). Moreover, when comparing OA patients only, coronal plane coordination allows to discriminate patients with indication of surgery from those with no indication of surgery (sensibility = 0.72; specificity = 0.72). Moreover, the pelvis-thorax coordination demonstrated an excellent reliability and a good responsiveness.Conclusion: Changes in the pelvis-thorax coordination might refer to different mechanisms, from analgesia to motor control plasticity, and might be a possible explanation for the weak correlation between structure and symptoms in hip OA patients. Moreover, such parameter might be used as an objective outcome in hip OA clinical trials.Clinical Trials Registration:www.ClinicalTrials.gov, identifier: NCT02042586 and NCT01907503.

Introduction: Total ankle replacement is indicated for end-stage ankle osteoarthritis. Periprosthetic radiolucency, from separation between the bone and implant, is suggested to be indicative of potential prosthesis failure risk. Anchoring implants with cement may mitigate this. This study aimed to compare rates of periprosthetic radiolucency between patients with cement-affixed and cementless implants., Methods: A retrospective analysis was performed on 28 patients who underwent total ankle replacement with the INFINITY Total Ankle System (Wright Medical, Memphis, Tennessee) implant between January 2016 and May 2022. Anteroposterior, mortise, and lateral ankle X-rays were reviewed by 2 independent reviewers for tibiotalar angle, talar tilt, and periprosthetic radiolucency. The Wilcoxon rank-sum test and chi-square test were performed., Results: The incidence of periprosthetic radiolucency at the most recent follow-up did not significantly differ between cement and cementless groups (57.1% in both groups, P = 1.0). Follow-up tibiotalar and talar tilt angles were not significantly different (P > .51 for all comparisons)., Conclusions: Patients with cemented implants had a similar incidence of periprosthetic radiolucency compared with patients with cementless prostheses. Understanding of long-term clinical outcomes will help inform optimal operative approaches for ankle prostheses., Levels of Evidence: Therapeutic, Level III, Retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective. The Psoriatic Arthritis (PsA) Core Domain Set for randomized controlled trials and longitudinal observational studies has recently been updated. The joint counts are central to the measurement of the peripheral arthritis component of the musculoskeletal (MSK) disease activity domain. We report the Outcome Measures in Rheumatology (OMERACT) 2018 meeting's approaches to seek endorsement of the 66/68 swollen and tender joint count (SJC66/TJC68) for inclusion in the PsA Core Outcome Measurement Set (COS). Methods. Using the OMERACT Filter 2.1 Instrument Selection Process, the SJC66/TJC68 was assessed for (1) domain match, (2) feasibility, (3) numerical sense (construct validity), and (4) discrimination (test retest reliability, longitudinal construct validity, sensitivity in clinical trials, and thresholds of meaning). A protocol was designed to assess the measurement properties of the SJC66/TJC68 joint count. The results were summarized in a Summary of Measurement Properties table developed by OMERACT. OMERACT members discussed and voted on whether the strength of the evidence supported that the SJC66/TJC68 had passed the OMERACT Filter as an outcome measurement instrument for the PsA COS. Results. OMERACT delegates endorsed the use of the SJC66/TJC68 for the measurement of the peripheral arthritis component of the MSK disease activity domain. Among patient research partners, 100% voted for a "green" endorsement, whereas among the group of other stakeholders, 88% voted for a "green" endorsement. Conclusion. The SJC66/TJC68 is the first fully endorsed outcome measurement instrument using the OMERACT Filter 2.1 and the first instrument fully endorsed within the PsA COS. [ABSTRACT FROM AUTHOR]

Emergency departments (EDs) may already be invalidating environments for patients diagnosed with a personality disorder, with negative attitudes from staff perpetuating patients' feelings of dismissal and rejection. Despite a higher prevalence of patients with personality disorder in health services, including EDs, than the general population, there is a lack of literature on how achieving ED targets may affect this patient group. This article expands on Harden's concept of destructive goal pursuit in relation to the four- hour target and uses the literature to illustrate how pressures to meet the target may distort clinical priorities and result in adverse clinical outcomes for patients. It makes recommendations for practice including using short-stay units in which patients can be treated outside of the target wait time and introducing mental health triage in EDs to improve delivery of psychosocial assessments. [ABSTRACT FROM AUTHOR]

• Handheld dynamometer may be considered valid for scapular protraction strength test. • The best correlation with the gold standard occurs with subjects tested seated. • Handheld dynamometer tends to overestimate the peak force. Handheld dynamometers (HHD) provide quick and low-cost assessments of muscle strength and their use has been increasing in clinical practice. There is no available data related to the validity of HHD for this measurement. To verify the concurrent validity of scapular protraction measurements using an HHD. Individuals with traumatic anterior glenohumeral instability were allocated in Instability Group (n = 20), healthy swimmers were allocated in Athletes Group (n = 19) and healthy subjects were allocated in Sedentary Group (n = 21). Concurrent validity was verified by the Pearson correlation test between HHD and isokinetic measurements. The agreement between instruments was verified by Bland–Altman plots, for each of the two HHD positions. A moderate correlation was observed between seated (r = 0.59) and lying supine HHD (r = 0.54) and isokinetic dynamometer measurements for the all groups. Separated group analysis exhibited a strong correlation between seated HHD and isokinetic dynamometer measurements in the Instability Group (r = 0.80), Sedentary Group (r = 0.79) and Athletes Group (r = 0.76). The Bland–Altman plot showed greater agreement in the seated position than the lying supine position when comparing measurements with the HHD and isokinetic in both the general sample and separated groups. The HHD may be considered a valid tool for assessing scapular protraction muscle strength among healthy athletes, non-athletes and subjects with shoulder instability. We recommend to assess subjects in the seated position and to be aware that the HHD tends to overestimate the peak force, compared with the gold-standard isokinetic dynamometer. [ABSTRACT FROM AUTHOR]

Aim There is a lack of literature on what patients with myeloma think about patient-reported outcome measures (PROMs). The aim of this study was to examine the views of patients and their family members about commonly used PROMs in myeloma to help guide future development and use. Method Two groups of patients were asked to review a selection of validated PROMs used in care of people with myeloma according to their perceived relevance to their lives, ease of completion, language and comprehensiveness. The PROMs selected for review were the EQ5D-5L, HADS, FACT-G and the MyPOS. Findings Participants believed that PROMs had a validating effect on their concerns. They preferred the language and content of the MyPOS and FACT-G to the EQ5D-5L and HADS, and considered that the former two had greater relevance to their illness experience. Conclusion Patients with myeloma believe PROMs are important but underused in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Noninferiority trials are becoming more common. Their design often requires investigators to "trade" a secondary benefit for efficacy. Use of mortality as an outcome of interest leads to important ethical conflicts whereby researchers must establish a minimal clinically important difference for mortality, a process which has the potential to result in problematic conclusions.Objective: We sought to investigate the frequency of the use of mortality as an outcome in noninferiority trials, as well as to determine the average pre-specified noninferiority ("delta") values.Design: We searched MEDLINE for reports of parallel-group randomized controlled noninferiority trials published in five high-impact general medical journals.Main Outcome Measures: Data abstracted from articles including trial design parameters, results, and interpretation of results based on CONSORT recommendations.Results: One hundred seventy-three manuscripts reporting 196 noninferiority comparisons were included in our analysis. Of these, over a third (67 trials) used mortality either as their sole endpoint (11 trials) or as part of a composite endpoint (56 trials). Nine trials were consort A, 21 trials consort B, 19 trials consort C, 12 were consort F, 4 consort G, and 2 were consort H. Four analyses showed statistically significant more deaths in the new treatment arm, while meeting consort criteria as "inconclusive" (consort G), (Behringer et al. in Lancet. 385(9976):1418-1427, 2015; Kaul et al. in N Engl J Med. 373(18):1709-1719, 2015; Bwakura-Dangarembizi et al. in N Engl J Med. 370(1):41-53, 2014) and thirteen trials utilizing mortality as an endpoint and had an absolute increase of > 3%, and six had an absolute increase of > 5%.Conclusions: The use of mortality as an outcome in noninferiority trials is not rare and scenarios where the new treatment is statistically worse, but a conclusion of noninferiority or inconclusive do occur. We highlight these issues and propose simple steps to reduce the risk of ethically dubious conclusions. [ABSTRACT FROM AUTHOR]

nternational Classification of Functioning, Disability, and Health (ICF, WHO, 2001) is a constructive framework for quality assessment and treatment in Logopedics (Speech Language Therapy). The current research study makes an attempt to introduce this standard into logopedical practice and applied research to measure the quality of life of persons with fluency disorders, such as stuttering. The quality of life is a modern multidimensional construct that covers health-medical, psychological, social and economic factors. Good level of communication and stabilized fluency is of key importance to improve the quality of life of persons who stutter. The purpose of the study was to show a model of assessment, treatment and evaluation of the efficacy of the non-avoidance approach in adult stuttering therapy. According to the results of the Index of disability, 47% of the people with multiple sclerosis have limited independence in providing daily activities leading up to 31% of the examinees with rare participation in the everyday social activities, the result obtained by the Frenchay Index of activities. We can conclude that the Index of disability is higher with older respondents and it is often followed by a drop of the daily activity frequency. Methods: CharlesVan Riper’s non-avoidance approach for an intensive therapy. Participants were 15 adults who stutter with an average age 25.2 years. Results: Specific significant decreasing of the two main parameters: index of dysfluencies immediately after the intensive therapy as well as duration of disfluences in seconds. The changes in speech fluency before and after the intensive therapy as well as 3 years after this therapy were obtained regarding the duration of disfluencies and index of dysfluency. Conclusion: The present model of an intensive non-avoidance therapy format for adults with stuttering disorders was successfully applied for the Bulgarian conditions. Improved fluency is an important factor for quality of life improvement of persons with stuttering disorder.

Introduction. Two of the largest countries in the world, still developing nations, China and Indonesia, have now created national credit systems for continuing medical education (CME). A third, India, has tried but succeeded only on a state-by-state basis. This study tracks the development of CME/continuing professional development (CPD) credit systems in these three major Asian countries, analyses the related administrative backgrounds and points to strengths and weaknesses of each system in terms of serving the goals of CME/CPD in impacting medical care systems. Methods. The authors researched national- and state-level government records to identify legal and regulatory data affecting CME in China, India and Indonesia. Information on current and future activities was gained from media reports. Results. In all three countries, CME/CPD systems evaluate physician continuing competence by counting credits or credit hours. Central health authorities in China and Indonesia have established national systems applying to all health professionals. In Indonesia, CME/CPD is mandatory for re-licensure; in China, it is necessary for career advancement and re-registration. An effort to develop mandatory CME requirements in India, for physicians only, failed because the central agency underwent a major overhaul. Nevertheless, 9 of 28 states in India have developed systems, all tied to re-registration. Discussion. A comparison of systems in the three countries shows that little attention has been paid to physician performance improvement or improved patient health outcomes. Needs assessments and outcomes measures are not regularly carried out. We did not find any evidence of programmes to train administrators or faculty in CME/CPD principles, with the possible exception of Indonesia. Suggestions are offered to CME system leaders and providers to help their counterparts in developing nations.

Objectives The Musculoskeletal Health Questionnaire (MSK-HQ) is a recently developed Patient Reported Outcome Measure for use across patients with musculoskeletal conditions. This study provides a validation of the MSK-HQ examining construct validity and reliability in inflammatory arthritis. Methods 287 adults with inflammatory arthritis completed the MSK-HQ and other Patient Reported Outcome Measures at baseline and after 3 months. Construct validity was assessed using item response theory methods. Concurrent validity was considered in relation to the HAQ and EuroQol-5D in all patients, as well as the RA Impact of Disease (RAID), PsA Impact of Disease scales, and AS Quality of Life Questionnaire (ASQoL) in disease subtypes. Results The MSK-HQ was approximately normally distributed with no evidence of floor or ceiling effects. A unidimensional structure was confirmed. Two items were less weakly related to the latent musculoskeletal health variable, providing some evidence of multidimensionality. Reliability was high (α = 0.93). The total score correlated highly with the HAQ (r = −0.81) and EuroQol-5D index (r = 0.80) in all patients, RAID in RA patients (r = −0.88), PsA Impact of Disease in PsA patients (r = −0.88), and ASQoL in AS patients (r = −0.86). Test-retest reliability was high (r ICC = 0.73). Conclusion This study provides evidence for the validity and reliability of the MSK-HQ in people with inflammatory arthritis. The major advantage of the MSK-HQ is that it is not disease specific and has high content validity in rheumatological conditions. The MSK-HQ score will be of value in clinical rheumatology practice, providing a measure that can be used across disease areas. [ABSTRACT FROM AUTHOR]

This article argues that the use of performance information may change according to economic circumstances. In a fiscal crisis, policy-makers likely demand less documentation of service quality, but under longer-term term austerity they can use performance information, including outcomes measures, to target and reallocate scarce resources across organizational boundaries. The argument is tested in an analysis of six Danish municipalities after the financial crisis. In these cases, performance information was used in new ways. For instance, outcomes measures were linked to overall strategies and used in the budgeting process to promote the reallocation of resources towards more effective services. [ABSTRACT FROM AUTHOR]

UK emergency departments (EDs) are high-pressure environments focused on delivering care in the most efficient way to patients with a range of health problems. For many people EDs are the front door of the NHS and are a focus of significant media and political interest. People who attend EDs are often anxious and a main element of their concern is waiting time for treatment. In UK EDs the four-hour target is a main NHS target and a cornerstone of evaluating ED performance. There is ongoing debate about whether spending additional time in EDs affects patient care and outcomes, with some research showing increased mortality associated with longer stays and some showing no effect on mortality. Evidence suggests that patients are spending longer in UK EDs and it is possible that those who remain longer than four hours could have worse outcomes. This article identifies the effects of prolonged ED length of stay through a systematic literature review of data published since implementation of the four-hour target to measure the relationship between breaching the target and morbidity and mortality. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The treatment of relapsed, resistant, or neglected clubfoot presents a challenge — some patients may not respond to the traditional Ponseti method. Studies involving gradual distraction using external fixators for treatment of these cases have been performed, but no systematic review has been conducted on the subject. Methods: A comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science according to PRISMA guidelines. Only articles that pertained to the treatment of pediatric patients with clubfoot using external fixation and contained three or more human subjects were included. Reviews, professional opinions, and studies with non-human subjects were excluded. Results: Of 6,469 articles generated from the initial search, 25 met inclusion criteria. 609 total feet (490 total patients) were included, and 533 of these feet (445 patients) were treated with external fixation. The mean age of patients was 8.5 [2-18] years with a mean follow-up length of 40.9 [5-126] months. 21 (84%) studies used the Ilizarov apparatus, two used Joshi's external stabilization system, and one used the Taylor spatial frame. The most reported primary scoring systems were the 60-point International Clubfoot Study Group (ICFSG) score (20%), Dimeglio classification (12%), Pirani score (8%), and Reinker and Carpenter scales (8%). All but one study found significantly improved primary outcomes for the majority of respective patients. Conclusion: External fixation, which may or may not include open surgery, is a promising intervention for neglected or relapsed clubfoot. However, encouraging more standardized outcome measurements would allow for more thorough comparisons between studies. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited data concerning the "learning curve" in Total Ankle Replacement (TAR). This study aimed to examine surgeons' revision rates over time to determine the number of cases after which revision rates plateaued. Methods: Primary TAR procedures for any diagnosis performed by surgeons whose first procedure was recorded by the AOANJRR since January 2008 were analysed. The time to first revision for procedures performed by surgeons with < 15, 15-29, 30-49, and ≥50 prior TAR procedures was summarised using Kaplan-Meier estimates of implant survivorship. Hazard ratios (HR) were obtained from Cox proportional hazards models adjusting for age, gender and the operating surgeon's number of prior TAR cases, with the latter modelled using restricted cubic splines. Further adjustment for insert mobility was also performed. Results: There were 2,637 TAR procedures performed by 128 eligible surgeons. Procedures performed by surgeons with < 15 prior cases had a cumulative percent revision (CPR) of 15% at 8 years, compared to 11.8% for procedures where the surgeon had previously performed ≥50 TARs. Procedures where the surgeon had 15 prior cases had approximately 1.5 times the hazard of revision of procedures where the surgeon had ≥50 prior cases (HR = 1.57, p = 0.042). The revision rate of procedures in which the surgeon had performed 25 prior cases did not differ significantly compared to those with ≥50 prior cases (HR = 1.24, p = 0.143). Similar results were obtained when adjusting for insert mobility, although estimated revision rates did not differ significantly with number of procedures. Conclusion: The first 15 TAR undertaken by a surgeon have a significantly higher rate of revision compared to those after 50 TAR. This difference reduces after 25 TAR. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: Determining the success of a clinical intervention can be challenging even with modern patient-reported outcomes. Traditionally studies have used the Minimum Clinically Important Difference (MCID), the smallest difference in an outcome that is felt to have clinical significance. More recently some authors have emphasized the alternative model of the Patient Acceptable Symptomatic State (PASS), the threshold of a PRO defining where patients consider their overall status to be acceptable. PASS scores have not yet seen wide use in the foot and ankle literature, but may add insight to surgical outcomes beyond simply measuring the minimal changes implied by the MCID. Methods: The most universal patient-reported outcome in the foot and ankle literature is the simple Visual Analog Pain Scale (VAS), in which a patient rates their pain along an analog scale between 0 to 10 cm. Articles in Foot and Ankle International from December 2020 to August 2022 that reported VAS pain scores and variance following an intervention were included. Although specific PASS thresholds for VAS scores in many conditions in the foot and ankle have not been determined analytically, values ranging from 2.0 to 3.0 are typical for orthopaedic conditions, corresponding to the intuitive statement "I would like my pain to be less than 2 or 3 out of 10." A PASS threshold of 2.0 has been used previously in the foot and ankle literature. The studies were therefore analyzed against PASS thresholds for the VAS of 2.0, 2.5, and 3.0. Results: Twenty-one studies were included. Five had multiple internal groups, yielding a total of 27 total sets of VAS scores.All 27 (100%) showed improvements well beyond the MCID and were considered successful. 17 (81%) of the 21 studies subjectively described their intervention as "reliable", "good", "effective" or "satisfactory". Despite this, 8 (38%) of the 21 studies reported final mean VAS scores for all internal groups above a PASS threshold of 2.0. An analytically calculated weighted average final VAS pain score for all studies was 1.78 +/-1.89. Based upon this, the expected percentages of patients included in FAI studies whose results failed to meet VAS PASS thresholds were 45% for a threshold of 2.0, 35% for a threshold of 2.5, and 26% for a threshold of 3.0. Conclusion: Studies in the foot and ankle literature almost universally report positive results, both subjectively in their discussions and by statistically demonstrating improvement of patient-reported outcomes beyond the MCID. PASS threshold analysis yields a much less positive interpretation and emphasizes the number of negative outliers in the population who do not find their outcome acceptable. A fuller picture of the outcome of foot and ankle procedures and overall patient satisfaction can be gained from reporting both changes in the mean and comparing final outcomes to PASS thresholds. [ABSTRACT FROM AUTHOR]