Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Adult-Acquired Flatfoot Deformity (AAFD) is a progressive hindfoot and midfoot deformity that causes pain and disability. It presents as a plano-valgus deformity from the failure of static and dynamic medial osteoligamentous stabilizers. Stage II presents as a passively correctable, flexible deformity of the foot; stage III presents as a fixed or arthritic deformity of the foot; and stage IV presents with marked deformity of the foot caused by failure of the deltoid ligament and subsequent peritalar instability. Although operative treatment of AAFD is dependent on the stage, there is little data on patient- reported and radiographic outcomes stratified by primary versus revision stage II, III, and IV reconstruction surgery. Methods: Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent AAFD reconstruction between November 2013 and January 2019 with minimum 12-month follow-up (average 23 months). Twenty patients underwent stage II reconstruction, 5 of which were revision surgeries; 19 patients underwent stage III reconstruction, 8 of which were revision surgeries; and 7 patients underwent stage IV reconstruction, all of which were primary surgeries. Radiographic correction was measured pre- and post-operatively and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percent, AP talo-first metatarsal angle, Meary’s angle, medial cuneiform height, and medial cuneiform-fifth metatarsal height. Results: For the overall cohort, PROMIS PF increased significantly from 37.6+-5.7 to 42.4+-6.8 (p=0.0014). PROMIS PI improved significantly from 64.7+-6.3 to 54.6+-9.5 (p<0.0001). PROMIS scores were not statistically different between AAFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) versus revision (-3.7) surgery (p=0.0157). Change in PROMIS PF was non- significantly greater in primary (+4.0) versus revision surgery (+2.3). All radiographic measurements improved significantly (p<0.05). In primary stage II AAFD, pre-operative PROMIS PI scores correlated with pre-operative medial cuneiform-fifth metatarsal height (r = -0.606, p = 0.0479). In addition, in primary stage II AAFD, post-operative PROMIS scores correlated with post-operative medial cuneiform height (PROMIS PF: r=0.7725, p=0.0020; PROMIS PI: r=-0.5692, p=0.0446). Conclusion: Patient-reported and radiographic outcomes improve significantly after AAFD reconstruction. There was no significant difference in PROMIS scores between AAFD stages. However, stage III patients had non-significantly lower improvements in PROMIS PF, likely due to loss of function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II AAFD, reconstructing the medial arch correlates significantly with improvement in pain and functionality. This survey of outcomes after primary and revision stage II, III, and IV reconstruction should help clinical decision making by providing data on expected surgical improvement.

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Postoperative Medial Cuneiform Position is Correlated with Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult Acquired Flatfoot Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00150 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0015

Author(s):

Matthew S. Conti ◽

Jonathan H. Garfinkel ◽

Grace C. Kunas ◽

Jonathan T. Deland ◽

Scott J. Ellis

Keyword(s):

Patient Reported Outcomes ◽

Valgus Deformity ◽

Stage Ii ◽

Daily Activities ◽

Opening Wedge ◽

First Metatarsal ◽

Medial Cuneiform ◽

Patient Reported ◽

Adult Acquired Flatfoot Deformity ◽

Sports Activities

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: During reconstruction of the stage II adult acquired flatfoot deformity (AAFD), residual supination of the midfoot is often addressed with an opening wedge medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform using the previously described cuneiform articular angle (CAA) on lateral radiographs and postoperative patient-reported outcomes using the Foot and Ankle Outcome Score (FAOS). Methods: Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included the study. The CAA, medial arch sag angle (MASA), and lateral talo-first metatarsal (Meary’s) angles were measured on postoperative weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson’s correlation analysis was used to determine if there was an association between postoperative radiographic angles and FAOS at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (CAA> or =-2 degrees) and moderate plantarflexion (CAA<-2 degrees) groups, and Wilcoxon rank-sum tests were used to identify whether there were differences in clinical outcomes between the two medial cuneiform positions. A postoperative CAA of -2 degrees was chosen because it is two standard deviations from the average postoperative CAA following a flatfoot reconstruction (Castaneda et al. FAI 2012). Results: Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms (r=.27, P=.03), daily activities (r=.29, P=.02), sports activities (r=.26, P=.048), and quality of life (r=.28, P=.02) subscales. A positive correlation indicates that higher postoperative FAOS scores are associated with a decreased amount of plantarflexion of the medial cuneiform (i.e. a more positive CAA). Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms (P=.04), daily activities (P =.04), and sports activities (P=.01) subscales (Figure 1). Graft size was correlated with postoperative CAA (r =-.30, P = .02) but not correlated with any postoperative FAOS subscale (all P values > .40). Conclusion: Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD.

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Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity

Foot & Ankle International ◽

10.1177/1071100718822839 ◽

2019 ◽

Vol 40 (5) ◽

pp. 491-498 ◽

Cited By ~ 8

Author(s):

Matthew S. Conti ◽

Jonathan H. Garfinkel ◽

Grace C. Kunas ◽

Jonathan T. Deland ◽

Scott J. Ellis

Keyword(s):

Patient Reported Outcomes ◽

Valgus Deformity ◽

Stage Ii ◽

Daily Activities ◽

Level Of Evidence ◽

Medial Cuneiform ◽

Patient Reported ◽

Adult Acquired Flatfoot Deformity ◽

Sports Activities

Background: Residual supination of the midfoot during reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) is often addressed with a medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform and patient-reported outcomes. Methods: Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included in the study. Radiographic angles were measured on weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson’s correlation analysis was used to determine if there was an association between postoperative radiographic angles and Foot and Ankle Outcome Score (FAOS) at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (cuneiform articular angle [CAA] ≥–2 degrees) and moderate plantarflexion (CAA <–2 degrees) groups to evaluate for differences in clinical outcomes. Results: Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms ( r = .27, P = .03), daily activities ( r = .29, P = .02), sports activities ( r = .26, P = .048), and quality of life ( r = .28, P = .02) subscales. Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms ( P = .04), daily activities ( P = .04), and sports activities ( P = .01) subscales. Conclusions: Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD. Level of Evidence: Level III, comparative series.

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Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011421992111 ◽

2021 ◽

Vol 6 (1) ◽

pp. 247301142199211

Author(s):

Rusheel Nayak ◽

Milap S. Patel ◽

Anish R. Kadakia

Keyword(s):

Patient Reported Outcomes ◽

Statistical Significance ◽

Stage Ii ◽

Foot Deformity ◽

Primary Stage ◽

Radiographic Outcomes ◽

Metatarsal Angle ◽

Medial Cuneiform ◽

Significant Difference ◽

Patient Reported

Background: Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes. Methods: PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo–first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform–fifth metatarsal height. Results: For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 ( P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 ( P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (–12.3) vs revision (–3.7) surgery ( P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly ( P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = –0.5692, P = .0446). Conclusion: Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality. Level of Evidence: Level II, prospective cohort study.

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Outcomes of Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity in Older Patients

Foot & Ankle International ◽

10.1177/1071100718777459 ◽

2018 ◽

Vol 39 (9) ◽

pp. 1019-1027 ◽

Cited By ~ 13

Author(s):

Matthew S. Conti ◽

Mackenzie T. Jones ◽

Oleksandr Savenkov ◽

Jonathan T. Deland ◽

Scott J. Ellis

Keyword(s):

Older Patients ◽

Patient Reported Outcomes ◽

Stage Ii ◽

Surgical Reconstruction ◽

Middle Aged ◽

Level Of Evidence ◽

Younger Patients ◽

Patient Reported ◽

Outcome Scores ◽

Adult Acquired Flatfoot Deformity

Background: Reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) often requires the use of multiple osteotomies and soft tissue procedures that may not heal well in older patients. The purpose of our study was to determine whether patients older than 65 years with stage II AAFD had inferior clinical outcomes or an increased number of subsequent surgical procedures after flatfoot reconstruction when compared with younger patients. Methods: One-hundred forty consecutive feet (70 right, 70 left) with stage II AAFD in 137 patients were divided into 3 groups based on age: younger than 45 years (young; n = 21), 45 to 65 years (middle-aged; n = 87), and 65 years and older (older; n = 32). Preoperative and postoperative Foot and Ankle Outcome Scores (FAOSs) at a minimum of 2 years were compared. Hospital records were reviewed to determine if patients underwent a subsequent procedure postoperatively. Results: Patients in the older group did not demonstrate any differences in changes in FAOS subscales compared with patients in the young and middle-aged groups (all P > .15). The older group had significant preoperative to postoperative improvements in all the FAOS subgroups ( P < .01). In addition, patients in the older group were not more likely to undergo a subsequent surgery than were the younger patients (all P > .10). Conclusions: Our study found that patients older than 65 years with stage II AAFD have improvements in patient-reported outcomes and rates of revision surgery after surgical reconstruction that were not significantly different than those of younger patients. Level of Evidence: Therapeutic Level III, comparative series.

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Contribution of First Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult Acquired Flatfoot Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00184 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0018

Author(s):

Jonathan Day ◽

Matthew S. Conti ◽

Nicholas Williams ◽

Scott J. Ellis ◽

Jonathan T. Deland ◽

...

Keyword(s):

Clinical Outcomes ◽

Patient Reported Outcomes ◽

Interobserver Reliability ◽

Deformity Correction ◽

Measurement Information ◽

Radiographic Parameters ◽

Metatarsal Angle ◽

Patient Reported ◽

Adult Acquired Flatfoot Deformity

Category: Midfoot/Forefoot; Other Introduction/Purpose: Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. The purpose of this study was to examine the role of first tarsometatarsal (1st TMT) fusion combined with subtalar fusion in correcting deformity at this joint. Methods: We retrospectively analyzed 40 patients (41 feet) who underwent 1st TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed six radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1 year follow-up. Results: The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (p <0.01). Overall, patients had statistically significant improvement in all PROMIS domains (p <0.01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes. Conclusion: Our data suggests that when addressing collapse of the medial arch in patients with AAFD, fusion of the 1st TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Based on our findings, deformity through the NC joint does not significantly impact clinical outcomes. In addition, the NCIA was established as a reliable radiographic parameter that can be used to assess NC deformity in the presence of talonavicular and/or 1st TMT fusion. [Table: see text]

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Outcomes of Reconstruction of the Stage II Adult Acquired Flatfoot Deformity in Older Patients

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00014 ◽

2018 ◽

Vol 3 (2) ◽

pp. 2473011418S0001

Author(s):

Matthew Conti ◽

Mackenzie Jones ◽

Joseph Nguyen ◽

Jonathan Deland ◽

Scott Ellis

Keyword(s):

Clinical Outcomes ◽

Older Patients ◽

Stage Ii ◽

P Value ◽

Middle Aged ◽

Younger Patients ◽

Patient Reported ◽

Adult Acquired Flatfoot Deformity ◽

The Mean ◽

Removal Of Hardware

Category: Hindfoot Introduction/Purpose: Reconstruction of the stage II adult acquired flatfoot deformity (AAFD) often requires the use of multiple osteotomies and soft-tissue procedures that may not heal well in older patients potentially leading to persistent pain, recurrent flatfoot symptoms, and the need to revise or fuse these patients at a higher rate than younger patients. Thus, some surgeons may advocate performing a double/triple arthrodesis in older patients with severe flexible deformity (Pinney and Lin, FAI 2006). No studies have investigated the clinical outcomes of flatfoot reconstructions in this population. The purpose of our study was to determine whether patients older than 65 years old with stage II AAFD had inferior clinical outcomes or an increased number of subsequent surgical procedures following flatfoot reconstruction when compared with younger patients. Methods: One-hundred and forty consecutive feet (70 right, 70 left) in 137 patients from the authors’ institution who underwent a reconstruction for stage II AAFD performed between January 2007 and March 2015 were eligible for this retrospective study (mean 57.3 years old, range 22.9 to 81.6 years old). Patients were divided into three groups based on age: less than 45 years old (young) (n=20), 45 to 65 years old (middle-aged) (n=88), and 65 years old and older (older) (n=32). Preoperative and postoperative clinical outcomes at a minimum of 2.0 years (mean 3.2 years) were compared using the using the Foot and Ankle Outcome Score (FAOS), which has been validated for AAFD. Hospital records were reviewed to determine if patients underwent a subsequent procedure. One-way ANOVA tests were used to compare the mean change in FAOS scores, and Chi-squared tests were used to compare the number of subsequent procedures for each group. Results: Older patients did not demonstrate any differences in changes in FAOS subscales compared with younger patients (all p- values>0.18) (Figure 1). The mean improvement in the FAOS pain, symptoms, daily activities, sports activities, and quality of life for the older group was 22.8 (p-value=0.50), 12.8 (p-value=0.48), 15.1 (p-value=0.19), 23.3 (p-value=0.45), and 38.1 (p-value=1.0), respectively, which was not different than the mean improvement in younger patients. Additionally, patients in the older group were not more likely to undergo a subsequent arthrodesis (p-value=0.18), revision surgery (p-value=0.65), or removal of hardware (p-value=0.15) than the younger patients. Two patients (6.3%) in the older cohort required a revision of their flatfoot reconstruction compared with nine patients (10.2%) in the middle-aged group and one patient (5.0%) in the young group. Conclusion: Our study indicates that patients over the age of 65 years old with stage II AAFD have improvements in patient- reported outcomes following surgical reconstruction that are not significantly different than younger patients. Additionally, older patients are not more likely to undergo a subsequent arthrodesis, revision procedure, or removal of hardware than patients in the younger cohorts. These results suggest that joint-preserving reconstruction of the stage II AAFD may be performed in older patients with acceptable outcomes.

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Outcomes after Tibiocalcaneonavicular Ligament Reconstruction in Stage IIB and Stage IV Adult Acquired Flatfoot Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00366 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0036

Author(s):

Rusheel Nayak ◽

Milap Patel ◽

Anish R. Kadakia

Keyword(s):

Patient Reported Outcomes ◽

Stage Iv ◽

Deltoid Ligament ◽

First Metatarsal ◽

Spring Ligament ◽

Radiographic Outcomes ◽

Radiographic Parameters ◽

Metatarsal Angle ◽

Patient Reported ◽

Adult Acquired Flatfoot Deformity

Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: The tibiocalcaneonavicular ligament (TCNL) is formed from the confluence of the superficial deltoid ligament and the superomedial spring ligament. In advanced flexible adult acquired flatfoot deformity (AAFD), progressive strain on the TCNL can lead to spring ligament tears, deltoid insufficiency, and eventual medial peritalar instability. Historically, medial peritalar instability was corrected using calcaneal osteotomy in conjunction with isolated spring or deltoid reconstruction. A recent study (Brodell et al.) demonstrated the efficacy of TCNL reconstruction in patients with medial peritalar instability. The purpose of this study is to add to this literature using patient-reported and radiographic outcomes in patients undergoing TCNL reconstruction. Patient-reported outcomes were collected using Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Methods: Sixteen patients (mean age 50.25 years; 11 female, 5 male) who underwent TCNL reconstruction were prospectively identified. TCNL reconstruction was indicated for stage IIB patients (n=13) with large spring ligament tears (>1.5cm on MRI or intraoperatively) or if osseous correction did not provide adequate talonavicular joint correction. TCNL reconstruction was indicated in stage IV patients (n=3) if deltoid reconstruction required additional medial stabilization. No patients underwent lateral column lengthening osteotomies. PROMIS scores were obtained at baseline and at minimum 12-months follow-up (average 16 months). Surgical success was determined using minimum clinically important differences (MCID), defined as improvement greater than one-half the standard deviation of each pre-operative PROMIS domain (PF: +2.9 and PI: -2.5). Pre- and post-operative radiographic parameters were measured: talonavicular uncoverage angle, talonavicular uncoverage percentage, AP talo-first metatarsal angle, Meary’s angle, and medial cuneiform height (MCH). Correlation coefficients determined the relationship between radiographic parameters and PROMIS scores. Results: PROMIS PF scores improved significantly from 38.1+-5.8 to 44.1+-7.1 (p=0.0087). PROMIS PI scores improved significantly from 62.9+-5.1 to 52.3+-8.9 (p=0.0025). Seventy-nine and 77 percent of patients had successful surgeries, as defined by MCIDs in the PROMIS PF and PI domains, respectively. Talonavicular uncoverage percentage and Meary’s angle improved significantly from 34.4+-13.4 to 26.3+-9.9 percent (p=0.0360) and 19.2+-8.8 to 15.3+-6.2 degrees (p=0.0089), respectively. Talonavicular uncoverage angle improved from 29.3+-9.6 to 23.3+-8.0 degrees (p=0.0562), AP talo-first metatarsal angle improved from 15.2+-10.2 to 10.4+-9.0 degrees (p=0.0555), and MCH improved from 13.5+-6.2 to 15.9+-4.8 millimeters (p=0.1374). Post- operative MCH correlated significantly with post-operative PROMIS PF scores (r=0.5941; p=0.0152). Change in AP talo-first metatarsal angle correlated significantly with change in PROMIS PI scores (r=0.5682; p=0.0427). No other correlations were significant. Conclusion: Patients with stage IIB and stage IV AAFD who undergo TCNL reconstructions have excellent patient-reported and radiographic outcomes. Reconstruction of the medial longitudinal arch, as measured by post-operative MCH, is associated with higher post-operative functionality. Surgical correction of midfoot abduction, as measured by change in the AP talo-first metatarsal angle after surgery, is associated with improvements in pain. In patients with medial peritalar instability, TCNL reconstruction can be a valuable technique to correct the sagittal arch, prevent excessive midfoot abduction, and improve pain and functionality.

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Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity

Foot & Ankle Specialist ◽

10.1177/1938640020951050 ◽

2020 ◽

pp. 193864002095105

Author(s):

James P. Davies ◽

Xiaoyue Ma ◽

Jonathan Garfinkel ◽

Matthew Roberts ◽

Mark Drakos ◽

...

Keyword(s):

Patient Reported Outcomes ◽

Chart Review ◽

Statistical Significance ◽

Retrospective Chart Review ◽

Stage Ii ◽

Primary Study ◽

Study Objective ◽

Subtalar Fusion ◽

Patient Reported

Background Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL. Methods Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups. Results STF patients were older ( P < .05), with higher BMIs ( P < .004). STF had significantly worse TNU ( P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively ( P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function ( P = 0.04). Conclusions STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse. Levels of Evidence: Level III: Retrospective chart review comparison study (case control)

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Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02331-7 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Rusheel Nayak ◽

Joshua Barrett ◽

Milap S. Patel ◽

Mauricio P. Barbosa ◽

Anish R. Kadakia

Keyword(s):

Patient Reported Outcomes ◽

Correlation Coefficients ◽

Metatarsal Angle ◽

Medial Cuneiform ◽

Hardware Complications ◽

Increased Risk ◽

Screw Length ◽

Patient Reported ◽

Metatarsal Fractures ◽

Metatarsus Adductus

Abstract Background Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. Methods We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. Results The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=−0.478; p=0.045). Metatarsus adductus angle (r=−0.606; p=0.008), lateral talo-1st metatarsal angle (r=−0.592; p=0.01), and medial cuneiform height (r=−0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=−0.7526; p=0.005), lateral talo-1st metatarsal angle (r=−0.7539; p=0.005), and medial cuneiform height (r=−0.627; p=0.029). Conclusion Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

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