Scott J. Ellis

Stress fractures about the tibia, foot, and ankle.

&NA; In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High‐risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high‐level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.

Validation of Foot and Ankle Outcome Score for Hallux Valgus

Background: Patient-reported outcome questionnaires such as the Foot and Ankle Outcome Score (FAOS) are useful in evaluating results after orthopedic interventions. However, despite being frequently used in the literature, its validity has not been established for forefoot disorders. Our study aimed to validate the FAOS for use in assessing outcomes of hallux valgus surgery. Methods: From 2006 to 2009, 195 patients with nonarthritic hallux valgus were included in the construct validity portion of the study. Patients had a SF-36 and a FAOS completed. Forty additional patients, both preoperative and postoperative, were given questionnaires to assess the relevance of each of the FAOS questions as it pertained to their bunions. Patients were also given the FAOS 1 month after the first to assess FAOS reliability. Responsiveness of the FAOS was included with 40 patients who had both preoperative and postoperative FAOS scores. Results: Four out of five FAOS subscales demonstrated acceptable correlation with the SF-36. The FAOS symptoms subscale showed the least correlation with SF-36, demonstrating the foot-specific nature of the questions. Both preoperative and postoperative patients rated the FAOS quality of life questions as the most relevant. All five subscales achieved acceptable test-retest reliability. The FAOS sports and recreation subscale was the least responsive. Conclusion: Patient-based assessments have become increasingly important in evaluating treatment effectiveness. This study has shown that the FAOS has acceptable construct validity, reliability, and responsiveness in hallux valgus patients and is a useful patient-based tool in assessing these patients.

New radiographic parameters assessing forefoot abduction in the adult acquired flatfoot deformity.

Background: Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls. Materials and Methods: Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb (n = 32) or Stage IIa (n = 8) deformity. A third group of patients without flatfoot served as control (n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance. Results: The mean intrarater and interrater ICCs for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle (r = 0.86) and uncoverage percent (r = 0.76). The IA was higher in the IIb versus IIa patients (p = 0.007) and in the IIb group versus control (p < 0.001). The ID demonstrated excellent reliability (ICCs of 0.83 and 0.83), but correlated poorly with the two other abduction parameters (r = −0.59 and −0.49) and failed to differentiate between the three groups (p = 0.0528). Conclusion: This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity. Level of Evidence: III, Retrospective Comparative Study

Psychometric Comparison of the PROMIS Physical Function CAT With the FAAM and FFI for Measuring Patient-Reported Outcomes

Background: Selecting optimal patient-reported outcome (PRO) instruments is critical to improving the quality of health care. The purpose of this study was to compare the reliability, responsiveness, and efficiency of three PRO measures: the Foot and Ankle Ability Measure–Activity of Daily Living subscale (FAAM_ADL), the Foot Function Index 5-point verbal rating scale (FFI-5pt), and the PROMIS Physical Function computerized adaptive test (PF CAT). Methods: Data were aggregated from 10 clinical sites in the AOFAS’s National Orthopaedic Foot and Ankle Research (OFAR) Network from 311 patients who underwent elective surgery for a disorder of the foot or ankle. Patients were administered the FAAM_ADL, FFI-5pt, and PF CAT at their preoperative visit and at 6 months after surgery. Reliabilities were evaluated using a Rasch model. Responsiveness was calculated using paired samples t test and efficiency was recorded as number of seconds to complete the instrument. Results: Similar reliabilities were found for the three instruments. Item reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were all .99. Pearson reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were .95, .93, and .96, respectively. On average, patients completed the FAAM_ADL in 179 seconds, the FFI-5pt in 194 seconds, and the PF CAT in 44 seconds, (P < .001). The PF CAT and FAAM_ADL showed significant improvement (P = .01 and P = .001, respectively) in patients’ physical function after treatment; the FFI-5pt did not show improvement. Conclusions: Overall, the PF CAT performed best in terms of reliability, responsiveness, and efficiency in this broad sample of foot and ankle patients. It can be a potential replacement for the conventional PRO measures, but further validation is needed in conjunction with the PROMIS Pain instruments. Level of Evidence: Level I, prospective comparative outcome study.

Validation of the Foot and Ankle Outcome Score in adult acquired flatfoot deformity.

Introduction: The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score has been under recent scrutiny. The Foot and Ankle Outcome Score (FAOS) is an alternative subjective survey, assessing outcomes in 5 subscales. It is validated for lateral ankle instability and hallux valgus patients. The aim of our study was to validate the FAOS for assessing outcomes in flexible adult acquired flatfoot deformity (AAFD). Methods: Patients from the authors’ institution diagnosed with flexible AAFD from 2006 to 2011 were eligible for the study. In all, 126 patients who completed the FAOS and the Short-Form 12 (SF-12) on the same visit were included in the construct validity component. Correlation was deemed moderate if the Spearman’s correlation coefficient was .4 to .7. Content validity was assessed in 63 patients by a questionnaire that asked patients to rate the relevance of each FAOS question, with a score of 2 or greater considered acceptable. Reliability was measured using intraclass correlation coefficients (ICCs) in 41 patients who completed a second FAOS survey. In 49 patients, preoperative and postoperative FAOS scores were compared to determine responsiveness. Results: All of the FAOS subscales demonstrated moderate correlation with 2 physical health related SF-12 domains. Mental health related domains showed poor correlation. Content validity was high for the Quality of Life (QoL; mean 2.26) and Sports/Recreation subscales (mean 2.12). All subscales exhibited very good test–retest reliability, with ICCs of .7 and above. Symptoms, QoL, pain, and daily activities (ADLs) were responsive to change in postoperative patients (P < .05). Conclusion: This study has validated the FAOS for AAFD with acceptable construct and content validity, reliability, and responsiveness. Given its previous validation for patients with ankle instability and hallux valgus, the additional findings in this study support its use as an alternative to less reliable outcome surveys. Level of Evidence: Level II, prospective comparative study.

Plantar pressures in patients with and without lateral foot pain after lateral column lengthening.

BACKGROUND Lateral column lengthening, a commonly used adjuvant for the reconstruction of adult flatfoot deformity, can lead to postoperative complaints of lateral plantar pain or discomfort. We hypothesized that patients with such symptoms would have increased lateral plantar pressures when compared with matched controls without these symptoms. METHODS Ten subjects who had undergone lateral column lengthening and were experiencing pain or discomfort in the plantar-lateral aspect of the foot were selected. Controls who had undergone lateral column lengthening but who were not experiencing such symptoms were matched for age, sex, accessory reconstructive procedures, and time from surgery. At the time of the present study, the patients had been followed for at least two years after the reconstruction and had had removal of hardware. Radiographs of each foot were assessed before and after surgery. The patients completed the Short Form-36 (SF-36) and Foot and Ankle Outcome Score surveys, and standing plantar pressure measurements were obtained. Average mean pressure, peak pressure, and maximum force were assessed at twelve anatomic regions and the two groups were compared. RESULTS There were no significant preoperative differences between the two groups in terms of radiographic parameters. Patients with pain had significantly lower SF-36 Physical Health Summary scores (p < 0.05), SF-36 Physical Function Subscale scores (p < 0.05), and average Foot and Ankle Outcome Scores (p < 0.05). Patients with pain had significantly higher lateral midfoot average mean pressure (p < 0.05), peak pressure (p < 0.05), and maximum force (p < 0.05). No differences were found in the hindfoot or forefoot regions. CONCLUSIONS Patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased plantar pressure values in the lateral aspect of the midfoot. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors.

Deltoid Ligament Reconstruction with Peroneus Longus Autograft in Flatfoot Deformity

Background: Stage IV posterior tibial tendon insufficiency is characterized by the presence of valgus talar tilt in the setting of a flatfoot deformity which results from attenuation of the deltoid ligament. Correcting valgus tilt at the time of flatfoot reconstruction may prevent future collapse and the need for joint sacrificing procedures. The purpose of this study was to report the intermediate-term results of patients who underwent deltoid ligament reconstruction using a peroneus longus tendon transfer. Materials and Methods: Five patients (mean age, 67 years ± 5.3 years) who underwent flatfoot reconstruction along with deltoid ligament reconstruction using a peroneus longus autograft were evaluated at a mean of 8.9 ± 1.7 years after surgery. The FAOS, SF-36v2, and VAS surveys were administered. The correction of valgus talar tilt was determined with weightbearing radiographs of the ankle. Ankle range of motion along with standing hindfoot alignment was assessed. Results: The postoperative average FAOS and SF-36v2 were 68.3 (range, 55.2 to 85.0) and 75.7 (range, 40 to 92), respectively. The valgus talar tilt improved from 7.7 degrees preoperatively to 2.1 degrees postoperatively. Mean ankle range of motion was 47 degrees (range, 40 degrees to 55 degrees). Mean hindfoot alignment was 4 degrees valgus (range, 1 degree varus to 8 degrees valgus). Conclusion: Deltoid ligament reconstruction using a peroneus longus tendon transfer was a useful technique for reducing tibiotalar tilt in the setting of stage IV flatfoot deformity. Correction and function were maintained at intermediate-term followup. Level of Evidence: IV, Retrospective Case Series

Assessment of Lateral Hindfoot Pain in Acquired Flatfoot Deformity Using Weightbearing Multiplanar Imaging

Background: The etiology of lateral hindfoot pain in flatfoot deformity can be difficult to assess on plain radiographs. We hypothesized that multiplanar measurements obtained in a fully upright, weightbearing position would reliably demonstrate an increase in lateral hindfoot arthrosis and/or impingement in a cohort of flatfoot patients with lateral hindfoot pain compared to a cohort without pain. Materials and Methods: Ten consecutive patients with flexible flatfoot deformity and lateral hindfoot pain (mean age, 55.5 ± 13.9) were compared to 10 consecutive patients with flexible deformity but no pain (mean age, 61.0 ± 8.6). Conventional radiographs and weight-bearing multiplanar images were performed on all patients before surgical reconstruction. Flatfoot, hindfoot impingement, and arthrosis parameters were interpreted in a blinded fashion by two musculoskeletal radiologists. Interrater reliability was determined with intraclass correlation coefficients (ICC). All parameters were compared between groups with a Wilcoxon rank sum test (p < 0.05). Results: A significant increase in posterior facet subtalar arthrosis (p = 0.006) and combined anterior and posterior facet subtalar arthrosis (p = 0.022) was evident in the pain group. Calcaneofibular impingement and calcaneocuboid arthritis were increased in the pain group, but did not reach significance (p = 0.057 and p = 0.067 respectively). The multiplanar imaging parameters demonstrated good (ICC = 0.60 to 0.73) to excellent (ICC ≥ 0.74) reliability for most impingement and arthrosis parameters and for many of the standard flatfoot parameters. Conclusion: The results indicate that weightbearing, multiplanar imaging provides a reliable means of assessing lateral pain in patients with flexible flatfoot deformity. Level of Evidence: III, Case Control Series

Achilles tendon rupture in women.

Background: The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature. Methods: The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases–9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted. Results: A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant (P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture (P = .005). Conclusion: Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture. Level of Evidence: Level III, retrospective comparative series.

Reconstruction of the spring ligament using a peroneus longus autograft tendon transfer.

Background: The spring (calcaneonavicular) ligament provides one of the main static supports of the medial arch of the foot. The purpose of this study was to retrospectively assess the results of patients having undergone reconstruction of the spring ligament using a peroneus longus tendon autograft left at its distal attachment and passed through the navicular followed by either a calcaneal or tibial drill hole, a technique not previously reported. Materials and Methods: Thirteen consecutive patients (14 feet) (mean age, 63.5 ± 12.3 years) undergoing flatfoot surgery with spring ligament reconstruction for cases in which lateral column lengthening failed to correct talonavicular deformity were reviewed. The AOFAS, FAOS, and SF-36 were assessed along with standard weight-bearing radiographs at a followup visit at a mean of 8.9 ± 1.8 years after surgery. Hindfoot alignment and eversion strength were measured. Results: The AOFAS ankle-hindfoot score increased from 43.1 to 90.3 (p 0.001). The postoperative FAOS pain subscale and overall SF-36 were 83.7 (range, 67.9 to 100), and 77.3 (range 37.8 to 95.6) respectively. The AP first tarsometatarsal angle (p = 0.015), talonavicular coverage angle (p = 0.003), lateral calcaneal pitch (p = 0.002), and lateral talonavicular angle (p = 0.017) improved significantly and were within normal ranges postoperatively. The mean hindfoot alignment measured 2.7 degrees of valgus. All but one patient had normal (5/5) eversion strength. Conclusion: Reconstruction of the spring ligament resulted in few complications and might be considered as an alternative to arthrodesis in patients with ruptures of the spring ligament and deformity that does not correct fully with bony procedures alone. Level of Evidence: IV, Retrospective Case Series