Sriniwasan B. Mani

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.

Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution. All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments.

Crossed-Screws Provide Greater Tarsometatarsal Fusion Stability Compared to Compression Plates

Background. Hallux valgus is a common deformity that is often treated with a fusion of the first tarsometatarsal (TMT) joint. Crossed-screws are currently the accepted standard but advances in plate systems present opportunities for improved clinical outcomes; however, in vitro testing should be performed prior to clinical implementation. The purpose of this study was to determine whether a locking plate with surgeon-mediated compression provides similar fusion stability compared to crossed-screws and if bone density or joint size are related to construct success. Methods. Ten matched-pair cadaveric specimens received first TMT fusions with either crossed-screws or a compression plate and were loaded for 1000 cycles to assess the amount of joint motion measured as plantar gapping. Bone density was quantified using computed tomography images of each specimen, and joint height was measured with calipers. Results. Crossed-screws provided 3 times greater resistance to plantar gapping compared to compression plates after 1000 cycles. Bone density and joint size did not affect resistance to plantar gapping for either construct. Conclusion. Lag screws or a plantarly applied plate are needed to maximize TMT fusion stability prior to osseous union. Dorsomedially applied plates are also effective when paired with a lag screw placed across the TMT joint. These constructs do not appear to depend on bone density or joint size, suggesting that patients with osteoporosis are viable candidates. Clinical Relevance. The results of this study suggest that traditional, lagged cross-screws provide greater stability to that of a dorsally place compression plate and may lead to better rates of union. Levels of Evidence: Therapeutic, Level V: Cadaveric Study

Epidemiology of Total Ankle Arthroplasty: Trends in New York State

The rate of total ankle arthroplasty (TAA) is increasing in the United States as its popularity and indications expand. There currently is no national joint registry available to monitor outcomes, and few studies have addressed the challenges faced with TAA. The purpose of this study was to evaluate the incidence, complications, and survival rates associated with TAA using a large statewide administrative discharge database. Individuals who underwent primary TAA from 1997 to 2010 were identified in the Statewide Planning and Research Cooperative System database from the New York State Department of Health. The age, sex, comorbidities, state of residence, primary diagnosis, and readmissions within 90 days were analyzed for patients with an ICD-9-CM procedure code of 81.56 (TAA). Failure of a TAA implant was defined as revision, tibiotalar arthrodesis, amputation, or implant removal. During the 14-year period, 420 patients underwent 444 TAAs (mean patient age of 61 years, 59% women, mean Charlson-Deyo comorbidity score of 0.45, and 86% New York State residents). The primary diagnosis was 37.4% osteoarthritis, 34.3% traumatic arthritis, and 15.5% rheumatoid arthritis. Surgery for failure was associated only with a younger age (56.5 vs 62 years, P=.005). The rate of subsequent failure procedures following TAAs performed in New York State was 13.8%. The incidence of TAAs is steadily increasing. The overall survival rate in New York State is better than rates reported in other national registries, but it is not yet comparable to those of hip and knee replacements. [Orthopedics. 2016; 39(3):170-176.].

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.

Maternal Syphilis: Variations in Prenatal Screening, Treatment, and Diagnosis of Congenital Syphilis

Syphilis is a sexually transmitted infection that, if left untreated, can impact fetal development. In this systematic review of syphilis in pregnancy, we attempt to better understand worldwide discrepancies regarding its diagnosis and management. OVID MEDLINE and PubMed databases were searched for keywords and 74 relevant articles were identified. Twenty-nine articles were ultimately included in our review. In the literature spanning from 1944—2014, we identified several variations in maternal syphilis screening and treatment, as well as a spectrum of gestational outcomes. Even following the publication of universal guidelines by the World Health Organization, the Centers for Disease Control and Prevention, and scientific investigators, practice patterns have continued to vary. Greater adherence to these guidelines could improve the quality of research in this area and promote earlier detection and thus prevention of maternal and congenital syphilis.


Measuring Joint Flexibility in Hallux Rigidus Using a Novel First Metatarsophalangeal Joint Flexibility Jig

Category: Midfoot/Forefoot Introduction/Purpose: Range of motion measurements of the first metatarsophalangeal joint (MTPJ) are an essential component in assessing and classifying hallux rigidus (HR). However, they provide little information about joint function and are limited by variability in technique. As an alternative, measuring joint flexibility can characterize intrinsic properties of the joint—aside from simply maximum dorsiflexion and plantarflexion—that may prove more clinically meaningful. No prior study has assessed hallux MTPJ flexibility in patients with HR. The purpose of this study was therefore to assess the reliability of a custom flexibility device and to compare flexibility between HR patients and controls. Methods: Fifteen patients with Coughlin stage II or III HR indicated for cheilectomy and 20 healthy controls were recruited prospectively. Each of two raters performed a series of seated and standing tests on each subject with the device. Dorsiflexion angle and applied torque were plotted against each other to generate a flexibility curve. “Early flexibility” and “late flexibility” were defined as the slope of the curve in the first 25% and last 25% of motion, respectively. From these two parameters, three additional parameters were calculated: laxity angle, laxity torque, and torque angle (Figure). Differences between (1) HR patients and controls and (2) sitting and standing testing positions were assessed with t-tests. Intra-rater test-retest reliability, remove- replace reliability, and inter-rater reliability were assessed with intraclass correlation coefficients (ICCs). Results: Patients in the HR group were older than patients in the control group (p < 0.001) and had significantly lower maximum dorsiflexion (p < 0.001). HR patients were less flexible as measured by three of the five flexibility parameters: early flexibility (p = 0.027), laxity angle (p < 0.001), and torque angle (p = 0.002). After controlling for age on seated measurements, only laxity angle and maximum dorsiflexion differed significantly between HR patients and controls (p < 0.001). Generally, patients were more flexible in the seated position than in the standing position, with this effect being more marked in HR patients. All parameters had good or excellent intra- and inter-rater reliability (ICC = 0.60). Conclusion: This is the first study to demonstrate a reliable method of measuring first MTPJ flexibility in patients with HR. We found that flexibility, even early in the arc of motion, is impaired in patients with HR. Moreover, significant differences between sitting and standing measurements suggest that soft tissue tension may be a major contributor to this finding. We do not know yet how flexibility of the joint relates to symptomatology, or if the surgeries performed for HR affect flexibility. Further research will be required to determine the clinical utility of these measurements.

Correction of Multiplanar Lesser Metatarsophalangeal Joint Deformity Using an Extensor Digitorum Brevis Reconstruction

Varus or valgus deformity, with or without dorsal angulation, is commonly seen in the lesser toes about the metarsophalangeal joint. This occurs from failure of either the plantar plate, the collateral ligaments, or both. The deformity can present concomitantly with other forefoot pathology, such as hallux valgus. Although numerous corrective procedures have been described, static reconstruction using the extensor digitorum brevis appears to provide strong, accurate correction. Outcomes have been studied specifically in second toe pathology with positive results, supporting the use of this procedure in the other lesser toes as well.

Lateral Column Lengthening and How to Achieve Good Correction

Lateral column lengthening (LCL) is a procedure that has been used for many years to address flatfoot deformity. However, it is associated with several risks including overcorrection and excessive stiffness. LCL is often preferred over hindfoot fusions as it preserves motion. Herein, LCL, by way of using the stepcut osteotomy, is described in detail. Use of operative guidance tools, such as trial metal wedges and a hindfoot alignment radiographic assessment can significantly improve correction of the deformity, leading to more successful outcomes. Auxiliary procedures that may be combined with LCL such as medial slide calcaneal osteotomy and spring ligament reconstruction are discussed as well.

Detection of In Vivo Foot and Ankle Implants by Walkthrough Metal Detectors

Background: Heightened security concerns have made metal detectors a standard security measure in many locations. While prior studies have investigated the detection rates of various hip and knee implants, none have looked specifically at the detection of foot and ankle implants in an in vivo model. Our goals were to identify which commonly used foot and ankle implants would be detected by walkthrough metal detectors both in vivo and ex vivo. Methods: Over a 7-month period, 153 weightbearing patients with foot and ankle hardware were recruited to walk through a standard airport metal detector at 3 different program settings (buildings, airports, and airports enhanced) with a base sensitivity of 165 (arbitrary units), as currently used by the Transportation Security Administration. The number of implants, location and type, as well as the presence of concomitant hardware outside of the foot and ankle were recorded. To determine the detection rate of common foot and ankle implants ex vivo, different hardware sets were walked through the detector at all 3 program settings. Results: Seventeen patients were found to have detectable hardware at the buildings, airports, and airports enhanced settings. An additional 3 patients had hardware only detected at the airports enhanced setting. All 20 of these patients had concomitant metal implants outside of the foot and ankle from other orthopaedic procedures. All patients with foot and ankle implants alone passed through undetected. Seven hardware sets were detected ex vivo at the airports enhanced setting. Conclusion: Our results indicate that patients with foot and ankle implants alone are unlikely to be detected by walkthrough metal detectors at standard airport settings. When additional hardware is present from orthopaedic procedures outside of the foot and ankle, metal detection rates were higher. We believe that these results are important for surgeons in order to educate patients on how they might be affected when walking through a metal detector such as while traveling. Level of Evidence: Level II, prospective comparative study.