Telemedicine Foot and Ankle Visits in the COVID-19 Era

Background: The COVID-19 pandemic created a difficult environment to provide musculoskeletal care to patients with foot and ankle pathology given the limitations placed on in-office visits. Telemedicine offered a unique avenue to reach these patients; however, the efficacy of telemedicine visits in patients with foot and ankle pathology is not well studied. We propose a telemedicine protocol that has allowed us to effectively see and treat patients with foot and ankle pathology. Methods: A 12-step standardized telemedicine protocol was created within the Foot and Ankle division that was used for seeing patients through telemedicine. Also included in this is previsit preparation and follow-up recommendations. Press Ganey surveys were retrospectively reviewed to understand patient experience with telemedicine. Results: 85.2% of patients surveyed responded with scores indicating excellent care. When comparing patients who were seen in-office and through telemedicine, 89.2% and 83.4% responded with scores indicating excellent care, respectively ( P = .37). Conclusion: Telemedicine offers an effective and convenient way to provide excellent musculoskeletal care to patients affected with foot and ankle pathology. This is the first study that evaluated a comprehensive protocol for telemedicine encounters and can be used to implement telemedicine by others using this approach. Level of Evidence: Level V, expert opinion.

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Lateral open wedge calcaneus osteotomy with bony allograft augmentation in adult acquired flatfoot deformity. Clinical and radiological results

European Journal of Orthopaedic Surgery & Traumatology ◽

10.1007/s00590-021-02888-3 ◽

2021 ◽

Author(s):

Gabriele Colo’ ◽

Mattia Alessio Mazzola ◽

Giulio Pilone ◽

Giacomo Dagnino ◽

Lamberto Felli

Keyword(s):

Range Of Motion ◽

Case Series ◽

Deformity Correction ◽

Tibialis Posterior ◽

Open Wedge ◽

Foot And Ankle ◽

Retrospective Case ◽

Level Of Evidence ◽

Adult Acquired Flatfoot Deformity

Abstract The aim of this study is to evaluate the results of patients underwent lateral open wedge calcaneus osteotomy with bony allograft augmentation combined with tibialis posterior and tibialis anterior tenodesis. Twenty-two patients underwent adult-acquired flatfoot deformity were retrospectively evaluated with a minimum 2-year follow-up. Radiographic preoperative and final comparison of tibio-calcaneal angle, talo–first metatarsal and calcaneal pitch angles have been performed. The Visual Analog Scale, American Orthopedic Foot and Ankle Score, the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure were used for subjective and functional assessment. The instrumental range of motion has been also assessed at latest follow-up evaluation and compared with preoperative value. There was a significant improvement of final mean values of clinical scores (p < 0.001). Nineteen out of 22 (86.4%) patients resulted very satisfied or satisfied for the clinical result. There was a significant improvement of the radiographic parameters (p < 0.001). There were no differences between preoperative and final values of range of motion. One failure occurred 7 years after surgery. Adult-acquired flatfoot deformity correction demonstrated good mid-term results and low recurrence and complications rate. Level of evidence Level 4, retrospective case series.

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PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

Foot & Ankle International ◽

10.1177/1071100718800304 ◽

2018 ◽

Vol 40 (1) ◽

pp. 65-73 ◽

Cited By ~ 21

Author(s):

Man Hung ◽

Judith F. Baumhauer ◽

Frank W. Licari ◽

Maren W. Voss ◽

Jerry Bounsanga ◽

...

Keyword(s):

Patient Reported Outcomes ◽

Minimum Clinically Important Difference ◽

Measurement Information ◽

Diagnostic Study ◽

Foot And Ankle ◽

Meaningful Change ◽

Level Of Evidence ◽

Patient Reported ◽

Level I

Background: Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population. Methods: Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods. Results: A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports. Conclusions: This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making. Level of Evidence: Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

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Responsiveness of the PROMIS and FAAM Instruments in Foot and Ankle Orthopedic Population

Foot & Ankle International ◽

10.1177/1071100718799758 ◽

2018 ◽

Vol 40 (1) ◽

pp. 56-64 ◽

Cited By ~ 9

Author(s):

Man Hung ◽

Judith F. Baumhauer ◽

Frank W. Licari ◽

Jerry Bounsanga ◽

Maren W. Voss ◽

...

Keyword(s):

T Test ◽

Measurement Information ◽

Foot And Ankle ◽

Level Of Evidence ◽

Paired Samples ◽

Level Ii ◽

Patient Reported ◽

Prospective Comparative Study ◽

Ability Measure

Background: Investigating the responsiveness of an instrument is important in order to provide meaningful interpretation of clinical outcomes. This study examined the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), the PROMIS Pain Interference (PI), and the Foot and Ankle Ability Measure (FAAM) Sports subscale in an orthopedic sample with foot and ankle ailments. Methods: Patients presenting to an orthopedic foot and ankle clinic during the years 2014–2017 responded to the PROMIS and FAAM instruments prior to their clinical appointments. The responsiveness of the PROMIS PF v1.2, PROMIS PI v1.1, and FAAM Sports were assessed using paired samples t test, effect size (ES), and standardized response mean (SRM) at 4 different follow-up points. A total of 785 patients with an average age of 52 years (SD = 17) were included. Results: The PROMIS PF had ESs of 0.95 to 1.22 across the 4 time points (3, >3, 6, and <6 months) and SRMs of 1.04 to 1.43. The PROMIS PI had ESs of 1.04 to 1.63 and SRMs of 1.17 to 1.23. For the FAAM Sports, the ESs were 1.25 to 1.31 and SRMs were 1.07 to 1.20. The ability to detect changes via paired samples t test provided mixed results. But in general, the patients with improvement had statistically significant improved scores, and the worsening patients had statistically significant worse scores. Conclusion: The PROMIS PF, PROMIS PI, and FAAM Sports were sensitive and responsive to changes in patient-reported health. Level of Evidence: Level II, prospective comparative study.

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Three-Stage Masquelet Technique and One-Stage Reconstruction to Treat Foot and Ankle Tuberculosis

Foot & Ankle International ◽

10.1177/1071100719890854 ◽

2019 ◽

Vol 41 (3) ◽

pp. 331-341 ◽

Cited By ~ 1

Author(s):

Wenqiang Qu ◽

Chi Wei ◽

Li Yu ◽

Yu Deng ◽

Panfeng Fu ◽

...

Keyword(s):

Pain Score ◽

Early Stage ◽

Distal Tibia ◽

Case Series ◽

Cement Spacer ◽

Foot And Ankle ◽

Aofas Score ◽

Level Of Evidence ◽

Masquelet Technique

Background: The purpose of this article was to report the feasibility and effectiveness of 3-stage Masquelet technique and 1-stage operation for different stages of foot and ankle tuberculosis (TB). Methods: Ten consecutive patients with foot and ankle TB were retrospectively analyzed between January 2014 and December 2018. Five patients were treated with the 3-stage Masquelet technique, including thorough debridement with vacuum sealing drainage, implantation of antibiotic cement spacer, and subsequent reconstruction. Five patients were treated with a 1-stage reconstruction. The American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) pain scores were recorded at the last follow-up. The follow-up was 30.3 ± 17.8 months. Results: No reactivation of TB was observed in any patients. For the 3-stage operation group, 1 patient developed a distal tibia fracture. The duration of anti-TB therapy was 12.0 ± 0.8 months. The AOFAS score increased from 39.5 ± 9.9 preoperatively to 75.3 ± 7.0 postoperatively ( P < .05). The VAS pain score decreased from 6.3 ± 1.9 to 1.5 ± 1.3 ( P < .05). For the 1-stage operation, 1 patient had wound necrosis. The duration of anti-TB therapy was 13.8 ± 1.1 months. The AOFAS score increased from 51.8 ± 15.0 to 81.8 ± 6.3 ( P < .05). The VAS pain score decreased from 5.4 ± 1.1 to 1.0 ± 0.7 ( P < .05). Conclusion: Three-stage operation was effective for foot and ankle TB with stage IV, sinus tracts or other infections, and 1-stage reconstruction was effective for early-stage TBs. Level of Evidence: Level IV, case series.

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The Virtual Foot and Ankle Physical Examination

Foot & Ankle International ◽

10.1177/1071100720941020 ◽

2020 ◽

Vol 41 (8) ◽

pp. 1017-1026

Author(s):

Stephanie K. Eble ◽

Oliver B. Hansen ◽

Scott J. Ellis ◽

Mark C. Drakos

Keyword(s):

Physical Examination ◽

Expert Opinion ◽

Orthopedic Surgery ◽

Foot And Ankle ◽

Level Of Evidence ◽

Patient Instruction ◽

Evidence Level ◽

Virtual Visits ◽

Routine Physical Examination

The COVID-19 pandemic has necessitated a rapid and drastic shift for clinicians and patients away from traditional in-person visits and toward internet-based virtual visits. The adoption of telehealth services is likely to persist in some capacity even as in-person visits resume, given the convenience and efficiency of telehealth consultations for patients and perhaps surgeons. A primary challenge of virtual visits, particularly in the field of orthopedic surgery, is the physical examination. However, for the foot and ankle, routine physical examination maneuvers can be completed virtually with little modification given proper patient instruction. We present a comprehensive virtual foot and ankle examination for telehealth visits, including instructions that can be provided to patients verbatim and a corresponding checklist for provider documentation. Level of Evidence: Level V, expert opinion.

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Treatment of Bone Marrow Edema of the Foot and Ankle With the Prostacyclin Analog Iloprost

Foot & Ankle International ◽

10.1177/1071100718778557 ◽

2018 ◽

Vol 39 (10) ◽

pp. 1183-1191 ◽

Cited By ~ 9

Author(s):

Hubert Hörterer ◽

Sebastian Felix Baumbach ◽

Johanne Gregersen ◽

Stefanie Kriegelstein ◽

Oliver Gottschalk ◽

...

Keyword(s):

Bone Marrow ◽

Outcome Measures ◽

Bone Marrow Edema ◽

Pain Treatment ◽

Short Form ◽

Foot And Ankle ◽

Level Of Evidence ◽

Prostacyclin Analog ◽

Marrow Edema

Background: Bone marrow edema (BME) of the foot and ankle is challenging to treat. One approach is intravenous Iloprost treatment, which is a vasoactive prostacyclin analog. The aim of this study was to evaluate the early and intermediate outcome of intravenous Iloprost therapy on BME of the foot and ankle and to analyze the influence of its etiology and Association Research Circulation Osseous (ARCO) stage on the outcome. Methods: This was a retrospective study with prospective follow-up. All patients treated by intravenous Iloprost for BME of the foot and ankle (ARCO I-III) at a single orthopedic reference center were included. Demographics, medical history, and MRIs were assessed prior to treatment (t0). MRIs were used to assess the BMEs’ etiology (idiopathic/ischemic/metabolic, mechanical/degenerative, traumatic) and severity (ARCO). Complications as well as changes in pain, treatment, and MRI were evaluated after 3 months (t1). The following patient-rated outcome measures (PROMs) were assessed prospectively (t2): 12-Item Short Form Health Survey (SF-12), Visual Analog Scale Foot and Ankle (VAS FA), and the Foot Function Index (FFI) (also at t0). The descriptive outcomes and the influence of the etiology and ARCO on the outcome parameters were evaluated. Out of 70 eligible patients, 42 patients (60%; 47 ± 15 years; 30% female) with a mean follow-up of 28 ± 19 months were included. Results: Twelve patients reported minor complications during Iloprost therapy. At t1, pain decreased significantly in 56%, and the amount of BME decreased in 83% of patients. Both parameters correlated moderately (r = −0.463, P = .015). The PROMs at t2 revealed moderate results. The overall FFI improved from 59 ± 21 to 30 ± 22 ( P < .001), the overall VAS FA was 68 ± 20, the SF-12 Physical Component Summary 42 ± 12 and Mental Component Summary 50 ± 9. Subgroup analysis revealed no significant influence of the etiology or ARCO stage on any outcome measure. Conclusion: Iloprost therapy for BME of the foot and ankle resulted in a 60% pain and 80% edema decrease after 3 months. After 2 years, patient-rated outcome measures showed residual impairment. Neither the etiology nor ARCO stage significantly influenced the outcome. Level of Evidence: Level III, comparative study.

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Gunshot-Related Injuries to the Foot & Ankle: Review Article

Foot & Ankle International ◽

10.1177/1071100720901712 ◽

2020 ◽

Vol 41 (4) ◽

pp. 486-496 ◽

Cited By ~ 1

Author(s):

Tyler Gonzalez ◽

Jorge Briceno ◽

Brian Velasco ◽

Philip Kaiser ◽

Derek Stenquist ◽

...

Keyword(s):

Expert Opinion ◽

Current Literature ◽

Scientific Literature ◽

Review Article ◽

The Body ◽

Foot And Ankle ◽

Level Of Evidence ◽

Evidence Level

Gunshot-related injuries remain a significant and important cause of global morbidity and cost. The foot and ankle has certain anatomic and functional considerations that make gunshot-related injuries challenging to manage. While the scientific literature regarding gunshot-related injuries is extensive, little of the existing literature focuses on the foot and ankle. While principles of management can be somewhat extrapolated from the current literature, an understanding of the body of work specific to the foot and ankle is valuable. Therefore, this review provides an overview of ballistic injuries to the foot and ankle as well as specific guidelines to aid surgeons in treating these difficult injuries. Level of Evidence: Level V, expert opinion.

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Late Presentation of a Retained Stingray Spine in the Plantar Medial Hindfoot

Foot & Ankle Orthopaedics ◽

10.1177/2473011419864020 ◽

2019 ◽

Vol 4 (3) ◽

pp. 247301141986402

Author(s):

David P. Falk ◽

Sreenivasulu Metikala ◽

Viviana Serra Lopez ◽

Matthew Stein ◽

Karim Mahmoud ◽

...

Keyword(s):

The United States ◽

Late Presentation ◽

Tarsal Tunnel ◽

Delayed Presentation ◽

Foot And Ankle ◽

Level Of Evidence ◽

Acute Injuries ◽

Operative Exploration ◽

Magnetic Resonance Imaging Mri

In the United States, approximately 2000 stingray injuries occur annually. The majority of reports on stingray injuries to the foot and ankle reflect acute injuries. Delayed presentation after stingray injury to the foot and ankle has not been reported. We present a case of a 29-year-old female who sustained a stingray injury to the left plantar medial hindfoot 14 months prior to presenting to our clinic with new-onset posteromedial ankle redness and swelling along the tarsal tunnel. Magnetic resonance imaging (MRI) revealed multiple linear foreign bodies at the quadratus plantae and tarsal tunnel. The patient underwent operative exploration with removal of multiple retained stingray spines. At her most recent follow-up at 3 months, she was able to resume her usual activities. Level of Evidence: Level V, case report.

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Charcot arthropathy of the foot and ankle

Journal of the Foot & Ankle ◽

10.30795/jfootankle.2021.v15.1241 ◽

2021 ◽

Vol 15 (1) ◽

pp. 83-91

Author(s):

João Montechi ◽

Weslen Barros ◽

Alexandre Godoy-Santos ◽

Rafael Sposeto ◽

Rodrigo Macedo ◽

...

Keyword(s):

Quality Of Life ◽

Expert Opinion ◽

Diagnostic Methods ◽

Foot And Ankle ◽

Charcot Arthropathy ◽

Level Of Evidence ◽

Charcot Neuroarthropathy ◽

Trauma Injury ◽

Serious Disease

To critically evaluate the current literature on the etiopathogenesis of Charcot neuroarthropathy, its diagnostic methods and therapeutic management. Methods: We searched for studies that related Charcot arthropathy with a location in the foot and ankle in the PUBMED and MEDLINE databases. Results: A total of 52 studies were used for this analysis. Conclusion: Charcot neuroarthropathy is a serious disease with significant potential to impact patient quality of life. Although its pathogenesis still raises much controversy, neuropathy seems to have a central role, leading to a trauma, injury, and inflammation cycle. Level of Evidence V; Therapeutic Studies; Expert Opinion.

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Minimally invasive Chevron-Akin osteotomy

Journal of the Foot & Ankle ◽

10.30795/jfootankle.2020.v14.1208 ◽

2020 ◽

Vol 14 (3) ◽

pp. 264-268

Author(s):

Gustavo Nunes ◽

João Magalhães ◽

Tiago Baumfeld ◽

Roberto Pinto

Keyword(s):

Minimally Invasive ◽

Hallux Valgus ◽

Case Series ◽

Preoperative Assessment ◽

Foot And Ankle ◽

Level Of Evidence ◽

Intermetatarsal Angle ◽

Akin Osteotomy ◽

Severe Hallux Valgus

Objective: To present the clinical and radiographic results of surgical treatment of patients with moderate to severe hallux valgus (HV) by minimally invasive Chevron - Akin osteotomy (MICA). Methods: The case series comprises 25 patients (30 feet) with diagnoses of moderate to severe HV treated surgically with the MICA technique. All patients answered the American Orthopedic Foot and Ankle Score (AOFAS) and rated pain on visual analogue scale (VAS) at preoperative assessment and at the last follow-up consultation. Radiological assessment included measurement of the valgus angles of the hallux (HVA) and the 1st and 2nd ray intermetatarsal angle (IMA). Complications and satisfaction ratings were also documented. Results: Mean follow-up was 14.6 months. Mean AOFAS increased from 42.8 to 90 and VAS reduced from 8.6 to 1.7. Mean HVA reduced from 31.7o to 8.4o and IMA from 14o to 5o. All these improvements were statistically significant (p<0.001). The most common complication observed was discomfort caused by hardware, affecting five feet (16.6%). Two patients (6.6%) had transitory neurapraxia and one patient (3.3%) developed reflex sympathetic dystrophy. There were no cases of infection, relapse, pseudarthrosis, or malunion of osteotomies. Subjective satisfaction ratings classified 93.3% of results as good or excellent. Conclusion: Minimally invasive Chevron-Akin osteotomy is a safe and reproducible technique that achieves good clinical and radiographic results for treatment of moderate to severe hallux valgus. Level of Evidence IV; Therapeutic Studies; Case Series.

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