Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the ...transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing.
Methods:
This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, range of motion (ROM), return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) are evaluated post- operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up.
Results:
At time of analysis, 121 patients had undergone TMTA with at least 6 months of follow-up. Mean age was 40.6 (range:15- 58) years, and 91% of patients were female. Mean (SD) days to protected weightbearing in CAM boot, return to work, and return to full work were 8.2 (6.8), 24.0 (29.5), and 51.2 (44.0), respectively. Significant improvements (p<0.05) from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS score was -4.0 (-4.5, -3.6); Walking/Standing, Pain, and Social Interaction (MOxFQ domains) change was -38.6 (-43.6, -33.5), -41.0 (-45.8, -36.2), and -40.5 (-45.3, -35.7), respectively; and physical function (PROMIS) change was 8.7 (6.6, 10.8).
Conclusion:
These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.
Category:
Patient Care
Introduction/Purpose:
Initial impressions between physician and patient typically occur through the medium of attire and potentially gender and can significantly impact the ...comfort and trust of patients in the clinical setting. The influence that foot and ankle orthopaedic physicians have on their patient’s footwear choices is of particular importance because it potentially affects clinical outcomes. Unlike other specialties where physician appearance or gender serves as a basis for mere initial perception, the nature of foot & ankle orthopedics allows for direct influence on a component of their care. The purpose of this study was to examine whether orthopedic physicians may serve as role models for healthy behavior and to elucidate the influence of patient perception on their orthopedic-related decision making.
Methods:
In this prospective, cross-sectional study, individuals =18 years of age that had the ability to make their own footwear decisions were invited to participate. Study subjects completed a 22-question survey following their office visit with one of four foot and ankle surgeons (2 female, 2 male). Quantitative assessment included: demographic data, the level of perception and attention given to their physician’s shoe choices, and various factors that affect decision making process when purchasing orthopedic-related footwear. Chi-square analysis was used to evaluate the categorical variables.
Results:
A total of 250 patients completed the study, with a normal distribution of ages between 18-81. 62% (n=154) had seen their physician multiple times and the remaining were new patients. Female patients preferred using recommendations from same- sex surgeons (41%) much more than males (6%). However, given the option of combining male/female opinions, 45% of females chose that option whereas 72% of males preferred combing male/female physician opinions when deciding on footwear. A sizable minority of patients noticed the type of shoe their physician was wearing that day, 32% (n=81). 52% (n=130) agreed that a surgeon’s own shoe choices should reflect the desirable attributes of a shoe. Patients ranked the shoe feel (51%) and their doctor’s recommendations (28%) as the top factors when deciding shoe-wear.
Conclusion:
Our study indicates that a significant portion of patients are mindful about and do consider their physician’s gender as well as physical appearance including shoe choices. While this influence was greater for females, patient footwear choices are affected across most demographics. The impact of patients’ awareness on medical action indicates that perception of care may hold significant value. Identifying the factors that influence orthopaedic decision-making can aid in accurately targeting patient education, enhancing physician-patient interactions, and improving clinical outcomes.
Category:
Midfoot/Forefoot; Bunion
Introduction/Purpose:
Hyperpronation of the 1st metatarsal in hallux valgus (HV) is poorly understood by conventional weightbearing radiography. We aimed to ...evaluate this parameter using weightbearing computed tomography (WBCT) and understand its association with other standard measurements.
Methods:
Retrospective evaluation of WBCT and weightbearing radiographs (WBXR) was performed for 20 patients with hallux valgus (HV) feet and 20 controls with no such deformity. Axial CT images of both groups were compared for 1st metatarsal pronation angle (α angle) and tibial sesamoid subluxation (TSS) grades. The hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), 1st metatarsal-medial cuneiform angle (MMCA), Meary’s angle, and calcaneal pitch (CP) angle of the study and control groups were compared on both WBXR and the corresponding 2D images of WBCT. All the measurements were independently studied by a dedicated musculoskeletal radiology fellow.
Results:
HV group demonstrated significantly higher values for TSS grade (p < 0.001) but not for α angle (p = 0.19) compared to controls. Pearson’s correlations of the α angle, in the HV group, revealed no significant linear relationship with TSS grades, IMA and MMCA, and only a moderate positive correlation with HVA as per WBXR (r = 0.38, p = 0.014) but not by WBCT (p = 0.084). Also, α angle performed within the range of a chance (AUC 0.64, 95% CI: 0.49 to 0.66) when measured by receiver operating characteristic (ROC) curves.
Conclusion:
The α angle - a measure of abnormal hyperpronation of the 1st metatarsal - is an independent factor that may co- exist with other parameters in HV, but in isolation has limited diagnostic utility. ‘Abnormal’ α angles may even be observed in individuals without HV deformity. An increase in the HVA, IMA, MMCA or TSS grade is not necessarily associated with a similar increase in the α angle and hence, the severity of HV deformity may not be judged on this parameter alone. The WBCT is a reliable method to assess hyperpronation and guide physicians during surgical management.
Category:
Other; Bunion; Midfoot/Forefoot
Introduction/Purpose:
There is no standard guideline for prescription opioids for postoperative pain management following outpatient foot and ankle surgery. ...Multiple previous studies demonstrated that opioids were overprescribed. The purpose of this study was to prospectively investigate opioid consumption using multimodal analgesia regimen after two of the most common forefoot surgeries: isolated hallux valgus correction or 1st metatarsophalangeal (MTP) joint arthrodesis.
Methods:
We prospectively investigated opioid prescription and consumption of total 21 patients who underwent isolated hallux valgus correction with distal soft tissue procedure and proximal first metatarsal crescentic osteotomy or 1st MTP joint arthrodesis. Postoperative pain was managed using multimodal analgesia including oxycodone, ibuprofen, acetaminophen, and regional ankle block. Patients were instructed to take 5mg of oxycodone every 4 hours as needed, and 600 mg of ibuprofen as well as 1,000 mg of acetaminophen every 8 hours regularly. The number of pills patients consumed for oxycodone was recorded at postoperative follow-up at 1-week, 2-week, 4-week, 8-week, and 12-week. Subgroup analysis was performed to evaluate opioid consumption according to the prescription type: Only oxycodone was prescribed in group A while oxycodone as well as prescription strength ibuprofen and acetaminophen were prescribed in group B. Another subgroup analysis in opioid consumption was performed based on the quantity of opioid prescription and procedure type.
Results:
The overall mean opioid consumption in 12 weeks of the postoperative period was 16.2 pills per patient with an average of 37.3 pills prescribed. Lower opioid consumption was noted in group B when prescription ibuprofen and acetaminophen were prescribed compared to group A when patients took over-the-counter (OTC) ibuprofen and acetaminophen: 9.0 pills vs 24.1 pills, respectively (P = 0.036). There was a trend showing higher opioid consumption in patients prescribed greater than 30 pills of oxycodone compared to less than or equal to 30 pills: 22.0 pills vs 9.8 pills, respectively (P = 0.099). No significant difference was found in opioid consumption according to the procedure type: 15.8 pills in hallux valgus correction vs 16.5 pills in 1st MTP joint arthrodesis (P = 0.750).
Conclusion:
This study showed that on the average, patients took 16.2 pills out of 37.3 pills of the prescribed oxycodone after isolated hallux valgus correction or 1st MTP joint arthrodesis using our multimodal analgesia regimen. Patients who were prescribed prescription strength ibuprofen and acetaminophen consumed opioid significantly less than those who took the OTC strength. No significant difference was noted in opioid consumption between isolated hallux valgus correction and 1st MTP joint arthrodesis.
Category:
Midfoot/Forefoot
Introduction/Purpose:
Polyvinyl Alcohol Hydrogel (PAH) hemiarthroplasty has gained popularity in the operative management of symptomatic hallux rigidus since its ...introduction to the US in July 2016. Despite encouraging initial results, any implant has the potential for complications that may not become apparent until it is in widespread use. Also, the series of publications supporting the effectiveness of PAH have come from a limited group of institutions and surgeons which creates an opportunity for observational bias. Other complications or unsatisfactory outcomes may be under-reported, such as those experienced in community centers due to the challenges in publishing lower volume work. In order to look at a broader range of potential complications, we reviewed the United States Food and Drug Administration’s (FDA) database and compared with published literature.
Methods:
The Manufacturer and User Facility Device Experience (MAUDE) database of the US Food and Drug Administration (FDA) was retrospectively reviewed between July 2016 and October 2019 using the assigned product code: PNW for the PAH implant. All the reported adverse events, implant-related complications, and secondary procedures were analyzed.
Results:
A total of 49 events have been reported to this voluntary database over the past 3 years while over 22,000 Cartiva devices have been implanted. Implant subsidence was the most common with 16 reported instances. Fragmentation of the device was observed in nine and four reports were related to infection in which two were deep infections needing antibiotic spacers.
Bone erosion managed by grafting was documented in three reports and foreign body reaction was noted in one. Persistent pain and swelling were common presentations. Thirty-five of 49 reported events required additional operative procedures performed at a mean interval of 4.75 months following the index procedure while four more were awaiting further surgery. Conversion to fusion was the most common procedure, featured in 10 reports.
Conclusion::
The analysis of the MAUDE database disclosed certain device-related dysfunctions that have been under-reported in the published literature. Also, complications such as fragmentation, bone erosion and foreign body reaction have not been previously described. Awareness of these details will assist in decision-making and quality control. Due to the voluntary nature of reporting, the true incidence of each complication is unknown with the above data representing a baseline. Nonetheless, the MAUDE database serves as an illuminating source of information which would further be strengthened by a more robust and mandatory reporting of device-related complications.
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The majority of hallux valgus corrections are performed via a uniplanar metatarsal osteotomy approach in which the metatarsal is cut and ...shifted over in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be fully addressed with a uniplanar metatarsal osteotomy. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion has historically involved an extended period of non-weightbearing. This study evaluates the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TTA) with a biplanar plating system and protected near-immediate weightbearing.
Methods:
This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an TTA procedure using a biplanar plating system with protected near-immediate weightbearing. Outcomes (radiographic, range of motion (ROM), pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), return to weightbearing and activities) are evaluated post-operatively. Two independent musculoskeletal radiologists reviewed radiographic data. These interim results are limited to patients completing at least 6 weeks of follow-up.
Results:
At time of data cut-off, 74 patients had undergone TTA with at least 6 weeks follow-up. The majority of patients were women (95%) with mean age 41.7 years. The mean (95% confidence interval) time to protected weightbearing in CAM boot was 8.0 (6.4, 9.7) days, return to work was 19.0 (13.6, 24.4) days, and return to full work was 31.5 (22.7, 40.2) days. There was a significant change in radiographic measures pre vs. post procedure and changes were maintained over time (Table). VAS pain score decreased 4 and 6 months post-procedure by 3.9 (3.2, 4.6) and 4.2 (3.5, 5.0), respectively. The mean MOxFQ Index Score pre-procedure was 53.3 (49.5, 57.1) and at month 6 had decreased to 18.6 (12.9, 24.2).
Conclusion:
These interim findings support that TTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and demonstrated favorable clinical and patient-reported outcomes. Patients were able to return to full, unrestricted work and activities within just a few months and had meaningful pain reduction after surgery. Patients will continue to be followed for up to 60 months. Clinical/radiographic healing at 12 months and recurrence rates at 24 months, as well as complications and patient satisfaction, will be evaluated.
Background
The published outcomes of total ankle replacement (TAR) implants came from limited institutions creating observational bias. For broader perspective, we queried the Food and Drug ...Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) voluntary database to explore complications reported outside published literature.
Methods
The database was reviewed retrospectively between November 2011 and April 2019 using two product codes assigned to six TAR devices.
Results
Among 648 relevant reports available in the database, common complications were aseptic loosening (19.3%), infection (18.2%), and alignment/mechanical issues (16.5%). Others included instrument/instrumentation complications, impingement, polyethylene problems, fractures, avascular necrosis of talus (AVN), and packaging issues.
Conclusion
MAUDE database revealed various patterns of device-related malfunctions that have been under-reported in published data. Despite inconsistency in the available reports, it provided opportunities for improvements in quality control, device design, and ultimately patient safety. Database would be further strengthened by more robust reporting mechanism or mandatory reporting of device-related complications.
Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies ...helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.
Prader–Willi syndrome (PWS) is a complex genetic syndrome involving imprinted genes on chromosome 15. It is usually sporadic, and very few affected siblings have been described. Here, we report the ...clinical and molecular findings in two families with a microdeletion affecting the chromosome 15 imprinting centre (IC). Carrier males have a 50% risk of having children with an imprinting defect leading to PWS, and in one of the two families, a father has two affected daughters. In the other family, diagnostic testing was confounded by the presence of a neutral microdeletion close to the IC. The silent transmission of PWS IC deletions through the female germline and the occurrence of neutral microdeletions close to the IC can impose considerable problems on diagnostic testing and genetic counselling in affected families.
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