Search

Background: Degenerative changes at the sesamoid-metatarsal joints (SMJs) may be a source of pain following hallux valgus surgery. The aims of this study were to describe degenerative changes at the SMJs on weightbearing computed tomography (WBCT) scans and, secondarily, investigate their association with 1-year patient-reported outcome scores following a modified Lapidus procedure for hallux valgus. We hypothesized that reduced joint space in the SMJs would correlate with worse patient-reported outcomes. Methods: Fifty-seven hallux valgus patients who underwent a modified Lapidus procedure had preoperative and minimum 5-month postoperative WBCT scans, and preoperative and at least 1-year postoperative PROMIS physical function (PF), pain interference, and pain intensity scores were included. Degenerative changes at the SMJs were measured using distance mapping between the sesamoids and first metatarsal head on preoperative and postoperative WBCT scans. The minimum and average distances between the first metatarsal head and tibial sesamoid (tibial-SMJ) for each patient preoperatively and postoperatively were measured. Sesamoid station was measured on WBCT scans using a 0 to 3 grading system. Linear regression was used to investigate the correlations between minimum preoperative and postoperative tibial-SMJ distances and 1-year postoperative PROMIS scores. Results: The median minimum and average tibial-SMJ distances increased from 0.82 mm (interquartile range [IQR] 0.40-1.03 mm) and 1.62 mm (IQR 1.37-1.75 mm) preoperative to 1.09 mm (IQR 0.96-1.23 mm) and 1.73 mm (IQR 1.60-1.91 mm) postoperative (P

Introduction/Purpose: In an ever-changing healthcare landscape, patient-reported outcomes (PROs) are becoming more important for reimbursement and evaluating the success of surgical procedures. Unfortunately, it is unclear which PROs correlate best with clinical improvement. The patient acceptable symptom state (PASS) asks the patient whether or not their outcome is acceptable at a particular post-operative time point. Recently, the use of this metric has gained traction within the foot and ankle literature. To our knowledge, this is the first study that aims to establish PASS thresholds for Patient-Reported Outcome Measurement Information System (PROMIS) scores in patients who underwent operative intervention for hallux rigidus. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 174 patients treated for hallux rigidus between February 2019 and March 2021 with at least 2-year post-operative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures that were completed. Two-years post-operatively, patients answered two PASS anchor questions (Satisfaction, Delighted-Terrible scale) with Likert- scale responses, which was collected along with pre-operative and 2-year post-operative PROMIS scores via the registry. After patient’s answers to the Satisfaction and Delighted-Terrible scales were recategorized into binary responses, PASS thresholds were determined using the maximum Youden Index and a 95% confidence interval was quantified using 2000 bootstrapped iterations. Differences in patient and surgical characteristics between patients who met or did not meet the PASS threshold were compared using independent samples t-test and Pearson chi square. Statistical significance was established at an alpha of 0.05. Results: There was excellent association between PASS thresholds and the PROMIS domains of Physical Function (48.6, AUC=0.82) and Pain Interference (52.1, AUC =0.86). Overall, 125/174 (71.8%) and 105/174 (60.3%) patients met the threshold for Physical Function (PF) and Pain Interference (PI), respectively. For the PF and PI domains, age, BMI, method of cheilectomy and use of Akin/Moberg osteotomy did not impact a patient’s likelihood of meeting the PASS threshold. For the PF domain and the PI domain stratified by the Delighted-Terrible scale, women were more likely to meet the PASS threshold than men (63.2% vs. 36.8%, p = 0.057 and 73% vs. 45%, p =0.023, respectively). Lastly, patients with a higher pre-operative PF score had a higher chance of meeting the PASS threshold (p < 0.001). Conclusion: Following operative intervention to treat hallux rigidus, pre-operative PROMIS scores were strongly associated with a patient’s likelihood of meeting the PASS threshold. After surgical intervention for hallux rigidus, less than 75% of the patients felt their outcome was acceptable; however, the PASS threshold for PF was lower than population average, so it may not be necessary for patients to reach normal physical function levels post-operatively in order to have an acceptable outcome.

Introduction/Purpose: Surgical interventions to correct hallux valgus have been shown to improve patient reported outcomes (PROs); however, many of these instruments do not measure a patient’s subjective outcome experience. The patient acceptable symptom state (PASS) is defined as the symptom threshold that a patient must reach to be satisfied with the outcome of their surgery. PASS thresholds have been defined for hallux valgus correction using American Orthopaedic Foot & Ankle Society (AOFAS) scores; however, no studies have used a validated PRO metric. This is the first study that aims to establish PASS thresholds for Patient-Reported Outcome Measurement Information System (PROMIS) scores in patients following operative intervention for hallux valgus. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 291 patients treated for hallux valgus with or without second hammertoe correction between February 2019 and March 2021 with at least 2-year post-operative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures completed. Two-years post-operatively, patients answered two PASS anchor questions (Satisfaction, Delighted-Terrible scale) with Likert-scale responses, which was collected along with pre-operative and 2-year post-operative PROMIS scores via the registry. After patient’s answers to the Satisfaction and Delighted-Terrible scales were recategorized into binary responses; PASS thresholds were determined using the maximum Youden Index and a 95% confidence interval was quantified using 2000 bootstrapped iterations. Differences in patient and surgical characteristics between patients who met or did not meet the PASS threshold were compared using independent samples t-test and Pearson chi square. Results: There was excellent association between PASS thresholds and the PROMIS domains of Physical Function (50.3, AUC=0.86) and Pain Interference (51.5, AUC=0.86). Overall, 204/291 and 205/291 patients met the threshold for Physical Function (PF) and Pain Interference (PI), respectively. For both PROMIS domains, a lower BMI was associated with a higher likelihood of meeting the PASS threshold (p=0.002 for PF, p=0.032 for PI). For the PF domain, Lapidus patients were more likely to meet the PASS threshold (p=0.05), and patients with first MTP fusion were less likely to meet the PASS threshold (p=0.004). Meeting the PASS threshold wasn’t impacted by the concomitant correction of a second hammertoe. Lastly, patients with a higher pre-operative PF score had a greater chance of meeting the PASS threshold (p < 0.001). Conclusion: This is the first study to define a PASS threshold for hallux valgus correction using PROMIS scores, a validated outcomes measure. Pre-operative PROMIS scores, patient BMI, and the type of procedure performed impacted a patient’s likelihood of meeting the PASS threshold. These results may be helpful in counseling and educating patients on their chances of obtaining a satisfactory result following hallux valgus correction.

Introduction/Purpose: Although reconstruction of the flexible progressive collapsing foot deformity (PCFD) has been shown to improve patient-reported outcomes (PROs), there is limited data describing postoperative success as defined by patient satisfaction following surgery. Distinct from the minimal clinically important difference (MCID), the patient acceptable symptom state (PASS) is a novel PRO measurement that represents the symptom threshold beyond which patients are satisfied with their postoperative outcome. The primary aim of this study was to use Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores in combination with anchor questions to define PASS thresholds following reconstruction of the flexible PCFD. A secondary aim was to analyze how patient-specific variables and certain PCFD reconstruction procedures may impact the probability of reaching PASS thresholds. Methods: Using data collected from a foot and ankle orthopedic registry at a large academic institution, 109 patients who underwent reconstruction of a flexible PCFD between February 2019 and March 2021, had preoperative and 2-year postoperative PROMIS PF and PI scores, and 2-year postoperative responses to two PASS anchor questions (the delighted-terrible scale and the satisfied scale) were included in the study. Patients who underwent either a double or triple arthrodesis were excluded. Patient responses to the anchor questions were dichotomized and receiver operating characteristic (ROC) curve analyses were performed. Using the Youden Index to balance sensitivity and specificity and maximize the area under the curve (AUC), PASS thresholds with 95% confidence intervals were quantified using 2000 bootstrapped iterations. Lastly, multivariable logistic regressions were performed to analyze the influence of patient demographics, preoperative PROMIS scores, and certain PCFD reconstruction procedures on the probability of reaching the PASS thresholds. Results: The PASS threshold for PROMIS PF was found to be 42.6 using both the delighted-terrible and the satisfied scale and 73.4% of patients (80/109) reached the threshold (both AUCs: 0.91) (Table 1). The PASS thresholds for PROMIS PI defined using the delighted-terrible scale and the satisfied scale were 54.5 (AUC: 0.90) and 57.5 (AUC: 0.91), respectively, with 72.5% of patients (79/109) and 81.7% of patients (89/109) meeting the respective thresholds. Neither patient demographics nor specific PCFD reconstruction procedures affected the probability of meeting the PASS thresholds. However, a lower preoperative PROMIS PF score or a higher preoperative PROMIS PI score significantly decreased the probability of achieving the PASS thresholds. Conclusion: Following reconstruction of the flexible PCFD, PASS thresholds for the PROMIS PF and PI domains were found to be lower and higher, respectively, than population norms. This suggests that patients may be satisfied with the outcome of their surgery despite not returning to the population mean. The probability of achieving the PASS thresholds was influenced by both preoperative PROMIS PF and PI scores but not by patient demographics or certain PCFD reconstruction procedures. In addition to guiding future outcomes research, these results may help foot and ankle surgeons optimize treatment for the flexible PCFD and better manage patient expectations.

Introduction/Purpose: While hallux valgus (HV) is understood to be a triplanar deformity of the first metatarsal, less is known about the contribution of the sesamoid-metatarsal joint (SMJ) to pain and function. Osteoarthritis of the SMJ is frequently present in HV feet, with an incidence rate ranging from 32% to 81%. Following surgical correction, approximately 10% of HV patients remain dissatisfied, but factors affecting postoperative outcomes are poorly understood. The primary aim of our study was to describe the relationship between degenerative changes at the SMJ as measured on weightbearing CT (WBCT) scans and 1-year patient-reported outcome scores following a modified Lapidus procedure for correction of HV. We hypothesized that decreased joint space at the SMJ would affect postoperative patient-reported outcomes. Methods: This study included 48 consecutive patients who underwent a modified Lapidus procedure for HV, had preoperative and at least 5-month postoperative WBCT scans, and had preoperative PROMIS scores and at least 1-year postoperative PROMIS Physical Function (PF), Pain Interference, and Pain Intensity scores. For each patient, the first metatarsal and sesamoids on pre- and postoperative WBCT scans were segmented using Disior Bonelogic software and uploaded to Geomagic Design X to perform distancing mapping. The minimum and average distances between the first metatarsal head and medial sesamoid (medial-SMJ) for each patient pre- and postoperatively were calculated. Sesamoid subluxation was measured on WBCT scans using the grading system from 0 to 3 (Yildirim et al.). A simple linear regression model was used to investigate the correlations between minimum preoperative and postoperative medial-SMJ distances and 1-year postoperative PROMIS scores in patients with postoperative reduction of the sesamoids (grade 0). Results: Preoperatively, the mean minimum and average medial-SMJ distances were 0.76 ± 0.37 mm and 1.54 ± 0.33 mm, respectively. Postoperatively, the mean minimum and average medial-SMJ distances were 1.08 ± 0.25 mm and 1.73 ± 0.24 mm, respectively. Thirty-five of 48 patients had a complete reduction of the sesamoids. Lower preoperative minimum distances at the medial-SMJ were significantly correlated with worse 1-year PROMIS PF scores (r=0.405, P=0.016) (Figure 1). Similarly, lower preoperative minimum distances at the medial-SMJ were significantly correlated with worse 1-year PROMIS Pain Intensity scores (r=-0.350, P=0.039) but did not reach significance for 1-year PROMIS Pain Interference scores (r=-0.286, P=0.095). The postoperative minimum medial-SMJ distance was not correlated with 1-year PROMIS PF, Pain Interference, and Pain Intensity scores. Conclusion: In HV patients undergoing a modified Lapidus procedure with postoperatively reduced sesamoids, decreased joint space at the medial sesamoid-metatarsal head articulation was associated with worse 1-year postoperative function as measured by PROMIS PF scores and worse 1-year postoperative pain as measured by PROMIS Pain Intensity scores. In contrast, postoperative degenerative changes at the SMJ were not found to be associated with patient-reported outcomes. Our results suggest that pre-existing SMJ arthritic changes may affect postoperative outcomes and may be a source of dissatisfaction following HV surgery despite appropriate correction of the deformity. Figure 1. Preoperative medial sesamoid to the first metatarsal head minimum distance relative to 1-year PROMIS Physical Function, Pain Intensity, and Pain Interference scores. A simple linear regression demonstrates a significant association between preoperative medial sesamoid –metatarsal head minimum joint distance and 1-year PROMIS Physical Function (r=0.405, P=0.016) and Pain Intensity (r=‒0.305, P=0.039) scores.