Elizabeth A. Cody

Correlation of Talar Anatomy and Subtalar Joint Alignment on Weightbearing Computed Tomography With Radiographic Flatfoot Parameters

Background: Underlying bony deformity may be related to development of adult-acquired flatfoot deformity (AAFD). Multiplanar weightbearing (MP-WB) computed tomography can be used to identify subtalar deformity which may contribute to valgus hindfoot alignment. On coronal MP-WB images, 2 angles reliably evaluate the subtalar joint axis: the angle between the inferior facet of the talus and the horizontal (inftal-hor) and the angle between the inferior and superior facets of the talus (inftal-suptal). Although these angles have been shown to differ significantly between flatfoot patients and controls, no study has investigated their relationships with other components of AAFD. We hypothesized that these angles would correlate strongly with commonly used radiographic measures of AAFD. Methods: Forty-five patients with stage II AAFD and 17 control patients underwent MP-WB imaging and standard weightbearing radiographs. MP-WB measurements were correlated with standard radiographic measurements of AAFD. Differences between AAFD and control patients were assessed using independent samples t tests and Mann-Whitney U tests. To assess correlations between each MP-WB measurement and radiographic measurement, factorial generalized linear models (GLMs) were constructed. Results: Patients with AAFD differed from the controls in all measured angles (P ≤ .001 for each). After accounting for differences between flatfoot and control patients, inftal-hor was not significantly correlated with any of the radiographic angles. Inftal-suptal, however, correlated with the AP coverage angle, AP talar–first metatarsal angle, calcaneal pitch, Meary’s angle, medial column height, and hindfoot alignment after accounting for differences between flatfoot patients and controls. Meary’s angle alone explained 48% of the variation in inftal-suptal angles. Conclusion: As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. It is possible that this information could be used to identify patients likely to have progression of deformity and may ultimately guide the approach to operative reconstruction. Level of Evidence: Level III, case-control study.

Effects on the Tarsal Tunnel Following Malerba Z-type Osteotomy Compared to Standard Lateralizing Calcaneal Osteotomy

Background: Tarsal tunnel syndrome is a known complication of lateralizing calcaneal osteotomy. A Malerba Z-type osteotomy may preserve more tarsal tunnel volume (TTV) and decrease risk of neurovascular injury. We investigated 2 effects on the tarsal tunnel of the Malerba osteotomy compared to a standard lateralizing osteotomy using a cadaveric model: (1) the effect on TTV as measured by magnetic resonance imaging (MRI) and (2) the proximity of the osteotomy saw cuts to the tibial nerve. Methods: Ten above-knee paired cadaveric specimens underwent MRI of the ankle to obtain a baseline measurement of TTV. One foot in each pair received a standard lateralizing calcaneal osteotomy, with the other foot receiving a Malerba osteotomy. MRIs were performed after each of 3 increasing amounts of lateral displacement, which were accompanied by increasing amounts of wedge resection in the Malerba osteotomy group. TTV was measured on MRI using previously described and validated parameters. Differences in TTV with osteotomy type, displacement, and their interaction were assessed with generalized estimating equations. After all MRIs were completed, each specimen was dissected and the nearest distance of tibial nerve branches to the osteotomy site was measured. Results: Baseline TTV averaged 13u2009229 ± 2354 mm3 and did not differ between groups (P = .386). TTV decreased on average by 7% after the first translation, 14% after the second, and 27% after the third (P < .005 for each). The magnitude of the decrease in TTV did not differ between those specimens with standard osteotomies versus those with Malerba osteotomies (P = .578). At least one of the major branches of the tibial nerve crossed the osteotomy site in 5 of 5 specimens that received the Malerba osteotomy versus 2 of 5 that received a standard osteotomy. Conclusion: Regardless of osteotomy type, lateralizing calcaneal osteotomy decreased TTV. In all specimens, the osteotomy was at the level of branches of the tibial nerve. Clinical Relevance: Our results demonstrate that lateralizing calcaneal osteotomies must be performed with care to avoid excessive lateral translation as well as direct nerve injury on the nonvisualized medial side of the calcaneus.

Patient Factors Associated With Higher Expectations From Foot and Ankle Surgery.

Background: Few authors have investigated patients’ expectations from foot and ankle surgery. In this study, we aimed to examine relationships between patients’ preoperative expectations and their demographic and clinical characteristics. We hypothesized that patients with more disability and those with anxiety or depressive symptoms would have greater expectations. Methods: All adult patients scheduled for elective foot or ankle surgery by 1 of 6 orthopaedic foot and ankle surgeons were screened for inclusion over 8 months. Preoperatively, all patients completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey in addition to the Foot & Ankle Outcome Score (FAOS), Short Form (SF)–12, Patient Health Questionnaire (PHQ)–8, Generalized Anxiety Disorder 7-item scale (GAD-7), and pain visual analog scale (VAS). The expectations survey contained 23 expectations categories, each with 5 answer choices ranging from “I do not have this expectation” to “complete improvement” expected. It was scored from 0 to 100, with higher scores indicating more expectations. Differences in expectations relating to numerous patient demographic and clinical variables were assessed. In total, 352 patients with an average age of 55 ± 15 (range, 18-86) years were enrolled. Results: Expectations scores were not related to age (P = .36). On average, women expected to achieve complete improvement more often than men (P = .011). Variables that were significantly associated with higher expectations scores (P < .05) included nonwhite race, use of a cane or other assistive device, and greater medical comorbidity. Worse function and quality of life (as assessed by all FAOS subscales and the SF-12 physical and mental components), more depressive and anxiety symptoms, and higher pain VAS scores were associated with higher expectations scores and more expectations (P < .01 for all). Conclusions: The results of this study may help inform surgeons’ preoperative discussions with their patients regarding realistic expectations from surgery. Generally, patients with worse function and more disability had higher expectations from surgery. Addressing these patients’ expectations preoperatively may help improve their ultimate satisfaction with surgery. Level of Evidence: Level II, cross sectional study.

Development of an Expectations Survey for Patients Undergoing Foot and Ankle Surgery

Background: Many authors have reported on patient satisfaction from foot and ankle surgery, but rarely on expectations, which may vary widely between patients and strongly affect satisfaction. In this study, we aimed to develop a patient-derived survey on expectations from foot and ankle surgery. Methods: We developed and tested our survey using a 3-phase process. Patients with a wide spectrum of foot and ankle diagnoses were enrolled. In phase 1, patients were interviewed preoperatively with open-ended questions about their expectations from surgery. Major concepts were grouped into categories that were used to form a draft survey. In phase 2, the survey was administered to preoperative patients on 2 occasions to establish test-retest reliability. In phase 3, the final survey items were selected based on weighted kappa values for response concordance and clinical relevance. Results: In phase 1, 94 preoperative patients volunteered 655 expectations. Twenty-nine representative categories were discerned by qualitative analysis and became the draft survey. In phase 2, another 60 patients completed the draft survey twice preoperatively. In phase 3, 23 items were retained for the final survey. For retained items, the average weighted kappa value was 0.54. An overall score was calculated based on the amount of improvement expected for each item on the survey and ranged from zero to 100, with higher scores indicating more expectations. For patients in phase 2, mean scores for both administrations were 65 and 66 and approximated normal distributions. The intraclass correlation coefficient between scores was 0.78. Conclusion: We developed a patient-derived survey specific to foot and ankle surgery that is valid, reliable, applicable to diverse diagnoses, and includes physical and psychological expectations. The survey generates an overall score that is easy to calculate and interpret, and thus offers a practical and comprehensive way to record patients’ expectations. We believe this survey may be used preoperatively by surgeons to help guide patients’ expectations and facilitate shared decision making. Level of Evidence: Level II, cross-sectional study.

Relationship of Radiographic and Clinical Parameters With Hallux Valgus and Second Ray Pathology

Background: Hallux valgus is frequently associated with additional forefoot pathologies, including hammertoes and midfoot osteoarthritis (OA). However, the pathogenesis of these concurrent pathologies remains to be elucidated. We sought to determine whether there is a relationship between demographic and radiographic parameters and the incidence of secondary pathologies in the setting of a bunion, with an emphasis on second tarsometatarsal (TMT) OA and hammertoes. Methods: A total of 153 patients (172 feet) who underwent reconstruction for hallux valgus were divided into 3 groups: (1) bunion only (61 patients), (2) bunion with hammertoe without second TMT joint OA (78 patients), and (3) bunion with second TMT joint OA (14 patients). Preoperative age, sex, and body mass index (BMI) as well as hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsus adductus angle (MAA), ratio of second to first metatarsal length, and Meary’s angle were recorded. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) tests were used to assess differences in continuous variables. Post hoc tests were conducted with the Bonferroni technique. Associations between discrete variables and the study groups were analyzed using χ2 tests. Following the univariate analysis, multinomial logistic regression models were built to determine potential risk factors for hammertoe or TMT OA group placement. Results: Patients in the hammertoe and TMT OA groups were significantly older than patients in the bunion only group (P < .001 for both pairwise comparisons) and had significantly higher BMIs (P = .024 and P < .001, respectively). Patients in the TMT OA group had a significantly higher mean HVA than patients in the bunion-only group (P = .004) and a significantly higher mean MAA relative to both other study groups (P ≤ .001 for both comparisons). IMA, Meary’s angle, and the ratio of second to first metatarsal length did not differ significantly between groups. In the multivariate analysis, hammertoe group assignment was predicted only by age and HVA, while midfoot OA group assignment was predicted by age, HVA, BMI, and MAA. Conclusion: Our data show that older age and increased HVA were predictors of both second ray pathologies studied. Higher BMI and MAA were predictive only of TMT joint OA. These data may help identify patients with hallux valgus who are at greater risk for developing secondary pathologies. Level of Evidence: Level III, retrospective comparative series.

The Quality of Open-Access Video-Based Orthopaedic Instructional Content for the Shoulder Physical Exam is Inconsistent

BackgroundThe internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open-access video content designed for provider use.Questions/PurposesThe primary goal of the study was to determine the accuracy of internet-based instructional videos featuring the shoulder physical examination.MethodsAn assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a surrogate for the “best-case scenario” due to its widely accepted components that are stable over time. Three search terms (“shoulder,” “examination,” and “shoulder exam”) were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopaedic surgeons. Quality and accuracy were assessed in accordance with previously published standards.ResultsOf the 39 video tutorials reviewed, 61% were rated as fair or poor. Specific maneuvers such as the Hawkins test, O’Brien sign, and Neer impingement test were accurately demonstrated in 50, 36, and 27% of videos, respectively. Inter-rater reliability was excellent (mean kappa 0.80, range 0.79–0.81).ConclusionOur results suggest that information presented in open-access video tutorials featuring the physical examination of the shoulder is inconsistent. Trainee exposure to such potentially inaccurate information may have a significant impact on trainee education.

Influence of Diagnosis and Other Factors on Patients’ Expectations of Foot and Ankle Surgery

Background: Many patient factors have been associated with higher or lower expectations of orthopedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients’ preoperative expectations of elective foot and ankle surgery. Methods: Two hundred seventy-eight patients undergoing elective foot or ankle surgery for 1 of 7 common diagnoses were enrolled in a prospective cohort study. Preoperative expectations were assessed with the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed the Foot & Ankle Outcome Score, Short Form 12, pain visual analog scale, and questionnaires for depressive and anxiety symptoms. Demographic and clinical data were collected. Patient factors and diagnosis were analyzed using multivariate regression analysis to identify independent predictors of higher expectations and determine the effect of diagnosis relative to other patient factors on expectations. Results: The multivariate regression analysis adjusting for demographics and other clinical characteristics showed that diagnosis contributed the most to the model, accounting for 10.5% of the variation in expectations survey scores. Patients with mid- or hindfoot arthritis (P < .001), hallux valgus (P = .001), or hallux rigidus (P = .005) had lower scores (lower expectations) than those with ankle instability or osteochondral lesion. In the model, female sex (P = .001), non-Caucasian race (P = .031), and lower scores on the Foot & Ankle Outcome Score daily activities subscale (P = .024) were associated with higher scores. Conclusions: Diagnosis of ankle instability or osteochondral lesion, female sex, non-Caucasian race, and lower Foot & Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively. Level of Evidence: Level II, cross-sectional study.

Measuring Joint Flexibility in Hallux Rigidus Using a Novel Flexibility Jig

Background: The flexibility of the first metatarsophalangeal (MTP) joint in patients with hallux rigidus (HR) has not been studied. Compared to measuring range of motion alone, measures of joint flexibility provide additional information that may prove useful in the assessment of HR. The purpose of this study was to assess the flexibility of the hallux MTP joint in patients with HR compared to controls using a novel flexibility device. Methods: Fifteen patients with Coughlin stage II or III HR and 20 healthy controls were recruited prospectively. Using a custom flexibility jig, each of 2 raters performed a series of seated and standing tests on each subject. Dorsiflexion angle and applied torque were plotted against each other to generate 5 different parameters of flexibility. Differences between (1) HR patients and controls and (2) the sitting and standing testing positions were assessed with t tests. Intrarater test-retest reliability, remove-replace reliability, and interrater reliability were assessed with intraclass correlation coefficients (ICCs). Results: Patients in the HR group were older than patients in the control group (P < .001) and had lower maximum dorsiflexion (P < .001). HR patients were less flexible as measured by 3 of the 5 flexibility parameters: early flexibility (first 25% of motion; P = .027), laxity angle (P < .001), and torque angle (P = .002). After controlling for age, only laxity angle differed significantly between HR patients and controls (P < .001). Generally, patients were more flexible when seated compared to standing, with this effect being more marked in HR patients. All parameters had good or excellent intra- and interrater reliability (ICC ≥ 0.60). Conclusions: Hallux MTP joint flexibility was reliably assessed in HR patients using a flexibility device. Patients with HR had decreased flexibility of the hallux MTP joint compared to control patients. Level of Evidence: Level II, prospective comparative study.

Outcomes of Total Ankle Arthroplasty in Moderate and Severe Valgus Deformity

Introduction. Failure to correct coronal deformity at the time of total ankle arthroplasty (TAA) can lead to early implant failure. We aimed to determine clinical, radiographic, and patient-reported outcomes of patients with moderate to severe valgus deformity who underwent TAA for end-stage ankle arthritis. Methods. Patients with a valgus deformity of at least 10° who underwent TAA were retrospectively reviewed. The coronal tibiotalar angle was assessed on radiographs preoperatively, at 1 year, and at final follow-up. The visual analog scale (VAS) for pain, Short Form-36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scale, and Short Musculoskeletal Function Assessment (SMFA) scores were assessed preoperatively and at final follow-up. Results. Mean preoperative valgus deformity was 15.5 ± 5.0°, and was corrected to a mean of 1.2 ± 2.6° of valgus postoperatively. VAS, SF-36, AOFAS, and SMFA scores improved significantly (P < .001 for all). There was no significant change in tibiotalar angle between 1 year and final follow-up in either group. Reoperation and revision rates did not differ between groups. Conclusion. Correction of coronal alignment was achieved and maintained in patients with both moderate and severe preoperative valgus malalignment. Outcome scores significantly improved for all patients. Levels of Evidence: Therapeutic, Level IV

Total Ankle Arthroplasty with Simultaneous Versus Secondary Hindfoot Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) for ankle arthritis leads to a more normal gait pattern compared to ankle arthrodesis, prompting many to hypothesize that TAA slows development of adjacent joint arthrosis. However, following TAA, patients may also develop hindfoot pain, deformity and dysfunction, ultimately requiring arthrodesis procedures. Many patients with AA also have subtalar and/or talonavicular arthrosis. In these cases, simultaneous TAA and hindfoot arthrodesis may be performed. Previous studies have found that TAA in conjunction with hindfoot arthrodesis procedures led to inferior outcomes compared to isolated TAA. The purpose of this analysis was to compare the functional outcomes of simultaneous vs. subsequent hindfoot arthrodesis procedures and to describe the change, if any, in outcome scores following a subsequent hindfoot arthrodesis procedure. Methods: After receiving Institutional Review Board approval, the TAA database at our institution was reviewed for all TAA performed between 1998 and 2015. All patients who received a TAA and either a simultaneous or subsequent hindfoot arthrodesis with at least two years of clinical follow up were included in the analysis. All surgeries were performed by one of three fellowship-trained orthopaedic foot and ankle surgeons with extensive experience in TAA and associated hindfoot arthrodesis procedures. Outcome measures included preoperative and 2-year postoperative visual analog scale (VAS) scores, Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36 and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores. Results: 64 patients met the inclusion criteria. 39 patients underwent TAA with simultaneous hindfoot arthrodesis (Sim) and 25 underwent a subsequent arthrodesis procedure (Sub) an average 22.2 months following TAA. 20 patients underwent double arthrodesis (11 Sub) and 44 patients underwent subtalar fusion (14 Sub). There were no differences in preoperative questionnaire scores between the two groups. Both the Sim and Sub groups experienced significant improvement in their postoperative VAS, SMFA, SF-36 and AOFAS scores. Postoperative VAS and SMFA bother scores were significantly lower for the Sim group (p<0.05). In the Sub group, there was no difference in outcome scores before and after the fusion procedure. Demographics and questionnaire scores are shown in the Table. Conclusion: These results support previous findings demonstrating significant functional improvement and decrease in pain scores following TAA and associated fusion procedures. However, these results also suggest that simultaneous fusion procedures may provide better reduction in pain when compared to sequential procedures. In addition, for patients who underwent subsequent fusion, the improvement experienced in terms of pain and function tends to be maintained postoperatively.