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Category: Other Introduction/Purpose: The importance of collecting outcomes information was promoted by Ernest Codman in the early 1900's. He stated the importance of 'Following every patient treated long enough to determine whether or not the treatment has been successful, then inquire-if so or if not- WHY?', ' He stressed the importance of evaluating outcomes for each patient as an individual and not from groups of patients. Since that time numerous outcomes measures have been validated and are in current use. The purpose of this study was to review all publications in Foot and Ankle International from 2019-2020 which included outcomes data. Then to determine if these principles (use of individual versus group data and WHY treatment was successful or not) were followed. Methods: All articles published in Foot and Ankle International during 2019-2020 were reviewed. Articles which included patient outcomes data were selected for further review. This review then included assessment of outcomes measure(s) used, organization of outcomes data, utilization of this data by the study, analysis of individual versus group data, and any assessment of WHY the outcomes scores had improved or not. Results: Eighty-five publications were selected. Eleven different outcomes measurement tools were used. All were reportedy validated tools except for the AOFAS scoring system. Every study reported outcomes data as group means (some with standard deviations, some with range of scores). These studies then compared group means (of different treatment groups or preop vs post op). No specific individual patient outcomes data was provided. There was no specific assessment of WHY scores improved or not. There was also no analysis of individual questions from these outcomes tools (e.g. can you put on your own shoes?–if patient answered 'no' there was no further explanation of why this response was selected). When the range of scores were provided it was common to have scores on the low end of the scale before and after treatment with overall conclusion of improvement based on group means but no assessment of why individual patients improved or not. Conclusion: Outcomes measures are generally considered to be part of the 'standard of care'. They may be considered important by third party payers, used in evaluation treatment options, and are usually necessary for publication. However trhis data is being underutilized. It is commonly reported as group means +/- range or standard deviations with provides little information about the individuals in a group or groups. Even with methodologies to minimize Type I or II errors evaluation of group means can obscure significant progress, lack of progress, or decline by individual patients. Methods to more effectively utilize outcomes measures are needed.

Category: Midfoot/Forefoot Introduction/Purpose: The goal of surgery for hallux limitus is to relieve pain, correct the dorsal joint impingement and improve ROM, especially MTP joint dorsiflexion. Obtaining increased dorsiflexion can be achieved by bone resection (cheilectomy), ostetomy of the proximal phalanx (Moberg), and soft tissue releases (plantar plate release, capsulotomy, ligament recession). In stiff joints of the hand collateral ligament recession is commonly done to improve motion. The purpose of this study was to evaluate the effect of MTPj collateral ligament recession (in addition to cheilectomy) in improving the range of motion achieved during surgery. Methods: Twenty consecutive patients undergoing surgical treatment for hallux limitus were studied. A dorsal approach was used and the extensor tendons protected. The dorsal capsule was opened and a cheilectomy was done removing about 25% of the dorsal metatarsal head. The joint was manually distracted and the gap measured with a spacer. Dorsiflexion of the MTP joint was measured. (Historically our goal was to obtain at least 75 degrees of dorsiflexion-more motion achieved by resecting more bone). Recession of the medial and lateral collateral ligaments was then done. Prominent medial or lateral condylar processes were smoothed with a rasp. Dorsiflexion of the MTP joint was again measured. No release of the plantar structures was done. The capsule and skin were closed in standard manner and final motion measured before applying a foot dressing. Results: The average introperative MTP joint dorsiflexion ROM obtained by chelectomy alone was 65 degrees (range 45 to 90). This motion was measured related to the plantar surface of the foot. The ROM after cheilectomy and collateral ligament recession was 85 degrees or more in all patients. Collateral ligament recession permitted the joint to be distracted (increased 'joint space') and facilitated the conversion of the MTP joint from a gliding to a hinge joint (the mechanical goal of cheilectomy). Also noted was that less bone needed to be resected from the metatarsal head to obtain the desired correction. After resection of any osteophytes from the dorsal proximal phalanx - this surface needed to rest about 5 mm dorsal to the residual surface (after cheilectomy) of the metatarsal head for optimum recovery of motion. This technique now used in all patients (> 150) with same intraoperative findings. Conclusion: For surgical treatment of hallux limitus cheilectomy plus collateral ligament recession resulted in greater intra- operative dorsiflexion of the MTP joint than cheilectomy alone. Less bone resection from the dorsal metatarsal head was also needed to obtain 85+ degrees of intraoperative correction. Intraoperative ROM is the baseline correction and is related to the surgical techniques used. Maintaining ROM after surgery is very dependent on the patient and the intensity of their rehabilitation commitment-so the last clinical follow up ROM did vary from 30 to 90+ degrees.