Excess Intramyocellular Lipid Does Not Affect Muscle Fiber Biophysical Properties in Mice or People with Metabolically Abnormal Obesity.

Observational studies show correlations between intramyocellular lipid (IMCL) content and muscle strength and contractile function in people with "metabolically abnormal" obesity. However, a clear physiologic mechanism for this association is lacking and causation is debated. We combined immunofluorescent confocal imaging with force measurements on permeabilized muscle fibers from metabolically normal and metabolically abnormal mice and metabolically normal (defined as normal fasting plasma glucose and glucose tolerance) and metabolically abnormal (defined as pre-diabetes and type 2 diabetes) people with overweight/obesity to evaluate relationships among myocellular lipid droplet characteristics (droplet size and density) and biophysical (active contractile and passive viscoelastic) properties. The fiber type specificity of lipid droplet parameters varied between metabolically abnormal and normal mice and among metabolically normal and metabolically abnormal people. However, despite considerable quantities of IMCL in the metabolically abnormal groups, there were no significant differences in peak active tension or passive viscoelasticity between the metabolically abnormal groups and the control group in mice or people. Additionally, there were no significant relationships among IMCL parameters and biophysical variables. Thus, we conclude that IMCL accumulation per se does not impact muscle fiber biophysical properties or physically impede contraction.

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients.

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. Methods: A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05). Conclusion: Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level of Evidence: Level III, retrospective cohort study.

Two Orthogonal Nitinol Staples and Combined Nitinol Staple-Screw Constructs for a First Metatarsophalangeal Joint Arthrodesis: A Biomechanical Cadaver Study.

BACKGROUND: End-stage hallux metatarsophalangeal (MTP) joint arthritis is commonly treated with arthrodesis using stainless steel or titanium implants. These implants provide static compression that is maximal at the time of implant insertion. Alternatively, nitinol staples are capable of dynamic compression. They have most frequently been used for midfoot arthrodesis procedures. However, their biomechanical performance during hallux MTP arthrodesis has not been described. METHODS: 8 matched pairs of cadaveric feet (4 female, 4 male) were prepared for hallux MTP arthrodesis using cup and cone reamers. Cadaveric pairs were then instrumented with either (1) a transarticular lag screw and dorsal nitinol staple or (2) orthogonal nitinol staples placed dorsally and medially. Walking in a short leg cast for 6 weeks was simulated by applying 90-N forces at 3 Hz to the plantar proximal phalanx for up to 250 000 cycles. Failure was defined as catastrophic implant failure or plantar gapping beyond 7 mm. RESULTS: 15 of 16 specimens failed cyclic loading. All 8 specimens fixed with orthogonal staples failed at an average of 37 ± 81 cycles. 7 of 8 specimens fixed with a dorsal staple and crossed screw failed at 14 900 ± 39 000 cycles. Collectively, 5 specimens failed because of bone fracture (1 in orthogonal staples, 4 in staple-screw group) and 10 failed because of excessive gap formation (7 in orthogonal staples, 3 in staple-screw group). The number of cycles to failure was significantly lower (P = .0469) in the orthogonal staple constructs compared with the dorsal staple and crossed screw constructs. CONCLUSION: The tested constructs permit significant motion at the first MTP fusion surface during simulated protected weightbearing. Although multiple in vivo factors should be considered when extrapolating results from this cadaveric study, this motion may result in clinical failure with early postoperative weightbearing protocols. CLINICAL RELEVANCE: We report the first biomechanical evaluation of hallux MTP arthrodesis using modern nitinol staples in 2 separate constructs.

Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective.

OBJECTIVES: Although the body of literature on syndesmosis injuries is growing with regard to both the biomechanics and clinical outcomes for various fixation constructs, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavoured to assess the current approaches to managing syndesmotic injuries through a Research Electronic Data Capture survey. METHODS: The survey consisted of 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment and technique, and postoperative management. Responses were generated through six different athlete scenarios: moderate impact, high impact, and very high impact athletes with/without complete deltoid injury. Frequencies and percentages were calculated for all categorical responses. RESULTS: A total of 742 providers responded to the survey, including 457 American surgeons and 285 members of various international societies. Flexible devices were the preferred fixation construct (47.1%), followed by screws (29.6%), hybrid fixation (e.g. combination of flexible device and screw, 18%), and other (5.3%). Sixty-four percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated return to full participation, largely dependent on the presence or absence of a deltoid ligament injury. CONCLUSION: The most common elements used as surgical indications were syndesmosis widening > 2 mm on x-ray, an anterior inferior talofibular ligament injury in combination with a posterior inferior talofinular ligament or deltoid ligament involvement on magnetic resonance imaging, and widening of the distal tibiofibular joint during arthroscopic evaluation. Overall, flexible fixation (e.g. suture button) was the preferred device choice for the repair of an injured syndesmosis. Most respondents did not alter their rehab protocol or anticipated return to play timeline based on the injury severity. However, there was considerable variability between respondents on the time to weight-bearing, running, and full participation. Further pragmatic outcomes data are necessary to guide safe return to play protocols for syndesmotic injuries. LEVEL OF EVIDENCE: Level IV.

Outcomes Following Repeat Ankle Arthroscopy and Microfracture for Osteochondral Lesions of the Talus.

BACKGROUND: The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs. METHODS: Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts. RESULTS: We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5). CONCLUSION: At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations.Level of Evidence: Level IV Case Series.

Does the Canadian Orthopaedic Foot and Ankle Society Postoperative COFAS End-Stage Ankle Arthritis Classification System Correlate With Pre- and Postoperative PROMIS Scores for Total Ankle Arthroplasty?

Background: Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores. Methods: From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed. Results: Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function. Conclusion: The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes.Level of Evidence: Level IV, retrospective analysis of prospectively collected data.

Forefoot Success.

The goal of this chapter is to familiarize orthopaedic surgeons with the latest information pertaining to typical problems of the forefoot. Painful and deforming problems of the forefoot are surprisingly common. The understanding of forefoot deformity and pathology has evolved considerably over the past decade. A more precise understanding of the mechanics of deformity and resulting pathology has resulted in significant improvements in nonsurgical and surgical managements. This chapter provides an up-to-date examination of the literature regarding the management of forefoot pathology. First, a review of recent advances in the understanding of the pathology and mechanics of these problems and then a thorough review of specific diseases are presented. These include management of the bunion deformity, hallux rigidus, metatarsalgia and plantar plate disruption, hammer toe deformities, and interdigital neuritis. Nonsurgical and surgical options are described. This chapter provides information that will lead to thoughtful treatment options for surgeons.

Skeletal Muscle Regeneration in Advanced Diabetic Peripheral Neuropathy.

BACKGROUND: Decreased lean muscle mass in the lower extremity in diabetic peripheral neuropathy (DPN) is thought to contribute to altered joint loading, immobility, and disability. However, the mechanism behind this loss is unknown and could derive from a reduction in size of myofibers (atrophy), destruction of myofibers (degeneration), or both. Degenerative changes require participation of muscle stem (satellite) cells to regenerate lost myofibers and restore lean mass. Determining the degenerative state and residual regenerative capacity of DPN muscle will inform the utility of regeneration-targeted therapeutic strategies. METHODS: Biopsies were acquired from 2 muscles in 12 individuals with and without diabetic neuropathy undergoing below-knee amputation surgery. Biopsies were subdivided for histological analysis, transcriptional profiling, and satellite cell isolation and culture. RESULTS: Histological analysis revealed evidence of ongoing degeneration and regeneration in DPN muscles. Transcriptional profiling supports these findings, indicating significant upregulation of regeneration-related pathways. However, regeneration appeared to be limited in samples exhibiting the most severe structural pathology as only extremely small, immature regenerated myofibers were found. Immunostaining for satellite cells revealed a significant decrease in their relative frequency only in the subset with severe pathology. Similarly, a reduction in fusion in cultured satellite cells in this group suggests impairment in regenerative capacity in severe DPN pathology. CONCLUSION: DPN muscle exhibited features of degeneration with attempted regeneration. In the most severely pathological muscle samples, regeneration appeared to be stymied and our data suggest that this may be partly due to intrinsic dysfunction of the satellite cell pool in addition to extrinsic structural pathology (eg, nerve damage). CLINICAL RELEVANCE: Restoration of DPN muscle function for improved mobility and physical activity is a goal of surgical and rehabilitation clinicians. Identifying myofiber degeneration and compromised regeneration as contributors to dysfunction suggests that adjuvant cell-based therapies may improve clinical outcomes.

Outcome of Lesser Metatarsophalangeal Joint Interpositional Arthroplasty With Tendon Allograft.

BACKGROUND: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. In the setting of global metatarsal head collapse, there are limited operative options. The purpose of our study was to evaluate clinical and radiographic outcomes after lesser toe metatarsophalangeal (MTP) joint interpositional arthroplasty with a tendon allograft and to describe the operative technique. METHODS: We retrospectively reviewed a consecutive series of patients treated by 3 fellowship-trained foot and ankle surgeons at one institution. We created a phone survey to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed before and after surgery. Preoperative and postoperative radiographs were evaluated for preservation of metatarsal length. The procedure was performed through a dorsal midline approach. The metatarsal head was reamed to a concave shape. A tendon allograft was fashioned into a ball and secured to the metatarsal with an anchor. Fifteen feet in 14 patients underwent lesser MTP joint interposition arthroplasty, with the average age of 49 years (range, 24-69), and an average follow-up of 4.2 years. RESULTS: Eighty percent (12/15) reported they would have the procedure again. Visual analog scale pain scores showed a decrease in pain from 7 to 1. FAAM sports subscale improved from 56% to 85%. Radiographically, the ratio of the affected metatarsal length to the adjacent metatarsal remained constant before and after surgery, suggesting preservation of the metatarsal cascade. CONCLUSION: Interpositional arthroplasty of the lesser MTP joints with a rolled tendon allograft provided a unique solution, as it allows the surgeon to fill a large void without harvesting an autograft. This study showed improved patient-reported outcomes, high patient satisfaction, and good radiographic outcomes. Lesser metatarsophalangeal joint allograft interposition arthroplasty was a viable solution as a salvage procedure in the setting of global metatarsal head collapse. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series.

Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.

Preoperative Anxiety Effect on Patient-Reported Outcomes Following Foot and Ankle Surgery.

BACKGROUND: Preoperative emotional distress has been shown to negatively influence joint arthroplasty and spine surgery, but limited data exist for foot and ankle outcomes. Emotional distress can be captured through modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) anxiety domain. We hypothesized that patients with greater preoperative PROMIS anxiety scores would report greater pain and less function after foot and ankle surgery than patients with lower preoperative anxiety levels. METHODS: Elective foot and ankle surgeries from May 2016 to December 2017 were retrospectively identified. PROMIS anxiety, pain interference (PI), and physical function (PF) scores were collected before and after surgery. Patients were grouped based on preoperative PROMIS scores greater or less than 59.4. A cutoff of PROMIS anxiety above 59.4 was selected as the threshold that corresponds to traditional measures of anxiety. RESULTS: Compared to patients with less preoperative anxiety (average: 47.2, n=146), patients with higher preoperative anxiety (average: 63.9, n=59) had greater preoperative pain (PROMIS PI: 63.5 vs 59.1, P < .001) and lower physical function (PROMIS PF: 37.9 vs 42.0, P = .001). Postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability as compared to patients with less preoperative emotional distress (PROMIS PI: 58.6 vs 52.9, P < .001; PROMIS PF: 39.8 vs 44.4, P < .001; respectively). CONCLUSION: Our evidence showed that preoperative emotional anxiety predicted worse pain and function at early operative follow-up. Measures of preoperative anxiety could be useful in identifying patients at risk for poorer operative outcomes, but continued study is necessary. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Avascular Necrosis of the Sesamoids.

Avascular necrosis (AVN) of the sesamoid is pathology of the medial or lateral hallucal sesamoid resulting in pain under the first metatarsophalangeal joint often presenting in young female athletes. There is overlap of stress fracture, nonunion, and AVN that makes defining the diagnosis difficult but the treatment and outcomes are similar. The most reliable operative treatment used for AVN of the sesamoid is an accumulation of anatomic and mechanical factors with repetitive microtrauma. Nonoperative modalities are designed to offload the sesamoid. The only operative treatment used for AVN of the sesamoid is excision of the involved bone, which results most commonly in complete patient satisfaction.

The Arterial Anatomy of the Lateral Ligament Complex of the Ankle: A Cadaveric Study.

BACKGROUND: Ankle sprains are the most common musculoskeletal injury in the United States. Chronic lateral ankle instability can ultimately require operative intervention to decrease pain and restore stability to the ankle joint. There are no anatomic studies investigating the vascular supply to the lateral ankle ligamentous complex. PURPOSE: To define the vascular anatomy of the lateral ligament complex of the ankle. STUDY DESIGN: Descriptive laboratory study. METHODS: Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded. RESULTS: The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%). CONCLUSION: There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries. CLINICAL RELEVANCE: Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability.

Patient-Reported Allergies Do Not Predict Poorer PROMIS Function, Pain, and Depression Scores Following Foot and Ankle Surgery.

BACKGROUND: Identifying preoperative risk factors that may portend poorer operative outcomes remains a topic of current interest. In hip and knee arthroplasty patients, the presence of patient-reported allergies (PRAs) has been associated with worse pain and function after joint replacement. However, these results have not been replicated across studies, including in shoulder arthroplasty cases. The impact of PRAs on foot and ankle outcomes has yet to be studied. The purpose of our study was to evaluate whether PRAs influence patient-reported outcome in foot and ankle surgery. METHODS: To determine if PRAs are linked to poorer operative outcomes, we retrospectively identified 159 patients who underwent elective foot and ankle surgery. PRA data were obtained via chart review, and patient-reported outcomes were assessed preoperatively and postoperatively via multiple domains, including Patient Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, and depression measures. Consistent with prior methodology, we compared outcome measures (preoperative, postoperative, and the change in outcome scores) between patients without self-reported allergies to patients with at least 1 PRA. RESULTS: There were 159 patients studied; 79 patients had no allergies listed, and 80 patients had at least 1 PRA. Of the 80 patients with at least 1 PRA, there were a total of 170 possible allergies. There were no differences in preoperative, postoperative, or the change in outcome scores for all PROMIS measures (physical function, pain interference, and depression; P > .05) between patients with at least 1 PRA and those patients without any listed PRAs. CONCLUSIONS: We were unable to prove our hypothesis that PRAs were linked to poorer patient-reported outcomes following foot and ankle surgery. Closer review of the published reports linking PRAs to worse total joint arthroplasty outcomes revealed data that, while statistically significant, are likely not clinically relevant. Our negative findings, then, may in fact parallel prior studies on hip, knee, and shoulder arthroplasty patients. The presence of PRAs does not appear to be a risk factor for suboptimal outcomes in foot and ankle surgery. LEVEL OF EVIDENCE: Level III, comparative series.

Surgical Management of Charcot Arthropathy.

The historic management of Charcot foot arthropathy has consisted of immobilization until the active phase of the disease resolves, followed by longitudinal accomodative bracing of the acquired deformity. This historic management of Charcot foot arthropathy has not resulted in improved quality of life and has fostered interest in the surgical correction of the acquired deformity. Orthopaedic surgeons should understand the current indications for the surgical management of and the specific surgical techniques to correct acquired deformities in patients with Charcot foot and ankle disorders.

Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score.

INTRODUCTION: Classification systems for hallux rigidus imply that, as radiographic changes progress, symptoms will concurrently increase in severity. However, symptom intensity and radiographic severity can be discordant for many patients. We studied the correlation between hallux rigidus grades and the Foot and Ankle Ability Measure (FAAM) scores to better understand this relationship. METHODS: We retrospectively reviewed weight-bearing radiographs of the foot and FAAM Activities of Daily Living (ADL) questionnaires for 84 patients with hallux rigidus. The Spearman rank coefficient was used to correlate clinical-radiographic hallux rigidus grade with FAAM ADL scores. RESULTS: In 84 patients, the clinical-radiographic grade for hallux rigidus showed no relationship with FAAM ADL score (r = -0.10; P = 0.36) but did show moderate correlation with patient age (r = 0.63; P < 0.001). DISCUSSION: Advancing radiographic changes in hallux rigidus did not correspond with patient symptoms as measured via FAAM ADL scores. CONCLUSION: The reliability and validity of current grading criteria for hallux rigidus may require further exploration. LEVEL OF EVIDENCE: Level III.

PROMIS Pain Interference and Physical Function Scores Correlate With the Foot and Ankle Ability Measure (FAAM) in Patients With Hallux Valgus.

BACKGROUND: Traditional patient-reported outcome instruments like the Foot and Ankle Ability Measure (FAAM) quantify patient disability but often are limited by responder burden and incomplete questionnaires. The Patient-Reported Outcome Measurement Information System (PROMIS) overcomes such obstacles through computer-adaptive technology and can capture outcome data from various domains including physical and psychosocial function. Prior work has compared the FAAM with PROMIS physical function; however, there is little evidence comparing the association between foot and ankle-specific tools like the FAAM with more general outcomes measures of PROMIS pain interference and depression in foot and ankle conditions. QUESTIONS/PURPOSES: (1) We asked whether there was a relationship between FAAM Activities of Daily Living (ADL) scores with PROMIS physical function, pain interference, and depression in patients with hallux valgus. (2) Additionally, we asked if we could identify specific factors that are associated with variance in FAAM and PROMIS physical function scores in patients with hallux valgus. METHODS: Eighty-five new patients with either a primary or secondary diagnosis of hallux valgus based on clinic billing codes from July 2015 to February 2016 were retrospectively identified. Patients completed FAAM ADL paper-based surveys and electronic PROMIS questionnaires for physical function, pain interference, and depression from new patient visits at a single time. Spearman rho correlations were performed between FAAM ADL and PROMIS scores. Analyses then were used to identify differences in FAAM ADL and PROMIS physical function measures based on demographic variables. Stepwise linear regressions then determined which demographic and/or outcome variable(s) accounted for the variance in FAAM ADL and PROMIS physical function scores. RESULTS: FAAM scores correlated strongly with PROMIS physical function (r = 0.70, p < 0.001), moderately with PROMIS pain interference (r = -0.65, p < 0.001), and weakly with PROMIS depression (r = -0.35, p < 0.001) scores. Regression analyses showed that PROMIS pain interference scores alone were associated with sizeable portions of the variance in FAAM ADL (R2 = 0.44, p < 0.001) and PROMIS physical function (R2 = 0.57, p < 0.001) measures. CONCLUSIONS: PROMIS function and pain measures correlated with FAAM ADL scores, highlighting the interrelationship of pain and function when assessing outcomes in patients with hallux valgus. PROMIS tools allow for more-efficient data collection across multiple domains and, moving forward, may be better poised to monitor changes in pain and function with time compared with traditional outcome measures like the FAAM. CLINICAL RELEVANCE: The relationships shown here between PROMIS and FAAM scores further support the use of PROMIS tools in outcomes-based research. In patients with hallux valgus, pain-related disability appears to be a central feature of the patient-experience. Future studies should assess the association of various outcome domains on other common foot and ankle diagnoses.

Rheumatoid Forefoot Reconstruction in the Nonrheumatoid Patient.

BACKGROUND: Recurrent pain and deformity following forefoot surgery can cause significant patient disability. In patients with rheumatoid arthritis, first metatarsophalangeal (MTP) joint arthrodesis with lesser metatarsal head resections-termed the rheumatoid forefoot reconstruction-has been shown to be a reliable operation for pain relief and deformity correction. Limited data, however, have been published on outcomes of the same forefoot reconstruction operation in the nonrheumatoid patient. Here, we describe our experience with this procedure in patients without rheumatoid disease, hypothesizing improved clinical and radiographic outcomes following surgery. METHODS: Following chart review and reviewing billing codes, we retrospectively identified patients without a diagnosis of rheumatoid arthritis who underwent first MTP arthrodesis with lesser metatarsal head resections. Phone surveys were conducted to assess clinical outcomes including pain and patient satisfaction. Preoperative and postoperative radiographs were reviewed for 1, 2 intermetatarsal angle (IMA), hallux valgus angle (HVA), second MTP angle (MTP-2), and lesser MTP alignment (in both sagittal and axial planes). Postoperative radiographs were assessed for radiographic union. We identified 14 nonrheumatoid patients (16 feet) who underwent forefoot reconstruction. Of those, 13 patients (15 feet) were successfully contacted via follow-up phone survey at an average of 44.3 months postoperatively (range: 20-76 months). RESULTS: Mean postoperative satisfaction scores were 9.0 (out of 10). No patients required reoperation at final phone follow-up. Pain scores significantly decreased from 6.2 preoperatively to 1.9 postoperatively ( P <.001). Radiographic parameters (1,2 IMA, HVA, MTP-2, and lesser MTP alignment in the sagittal plane) improved with surgery ( P <.05), and all 16 feet achieved union of the first MTP arthrodesis. CONCLUSION: With decreased pain, high satisfaction rates, and improved radiographic parameters, first MTP arthrodesis coupled with lesser metatarsal head resection was a viable option for nonrheumatoid patients who failed prior attempts at forefoot reconstruction or have chronic forefoot pain with deformity. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Arterial Anatomy of the Posterior Tibial Nerve in the Tarsal Tunnel.

BACKGROUND: Both vascular and compression etiologies have been proposed as the source of neurologic symptoms in tarsal tunnel syndrome. Advancing the understanding of the arterial anatomy supplying the posterior tibial nerve (PTN) and its branches may provide insight into the cause of tarsal tunnel symptoms. The purpose of this study was to describe the arterial anatomy of the PTN and its branches. METHODS: Sixty adult cadaveric lower extremities (thirty previously frozen and thirty fresh specimens) were amputated distal to the knee. The vascular supply to the PTN and its branches was identified, measured, and described macroscopically (the thirty previously frozen specimens, prepared using a formerly described debridement technique) and microscopically (the thirty fresh specimens, processed using the Spälteholz technique). RESULTS: On both macroscopic and microscopic evaluation, the PTN and the medial and lateral plantar nerves were observed to have multiple entering vessels within the tarsal tunnel. On microscopic evaluation, a vessel was observed to enter the nerve at the bifurcation of the PTN into the medial and lateral plantar nerves in twenty-two (73%) of the thirty specimens. There was a significant difference (p < 0.05) in vascular density between the PTN and each of its branches. CONCLUSIONS: The abundant blood supply to the PTN and its branches identified in this study is consistent with observations of other peripheral nerves. This rich vascular network may render the PTN and its branches susceptible to nerve compression related to vascular congestion. The combination of vascular and structural compression may also elicit neurologic symptoms. CLINICAL RELEVANCE: Advancing the understanding of the arterial anatomy supplying the PTN and its branches may provide insight into the cause and treatment of tarsal tunnel syndrome.

Correlation of Clinical, Operative, and Histopathologic Diagnosis of Interdigital Neuroma and the Cost of Routine Diagnosis.

BACKGROUND: Diagnosis of an interdigital neuroma (IDN) is clinically based on patient symptoms. During operative excision, it is common to send the excised specimen for routine histopathologic examination. The purpose of this study was to evaluate the accuracy of the clinical and intraoperative diagnosis of IDN and correlate these with the histopathologic results of IDN. METHODS: Case logs of 3 fellowship-trained foot and ankle surgeons were reviewed to identify all neuroma excisions completed between 1997 and 2014. Charts were reviewed to identify the preoperative clinical diagnosis and intraoperative diagnosis as well as concern for pathology besides a neuroma. All results were compared to final histopathology to identify instances of discordance between diagnoses. A total of 123 patients with 133 neuromas were identified. RESULTS: Of the total 133 neuromas, 5 cases included a clinical or intraoperative concern for a diagnosis other than neuroma. In these 5 instances surgeons accurately identified cysts and rheumatoid nodules. 132 of 133 histopathology reports indicated the presence of nerve tissue in their report. There were no reports of malignancy or abnormal nerve tissue. There were no changes to the postoperative protocol based on histopathology. CONCLUSION: The clinical, intraoperative, and histopathologic diagnosis of neuroma was in concordance 100% of the time. With a high level of clinical and intraoperative acumen in identifying a neuroma, we believe it is reasonable not to submit the specimen for histopathologic evaluation. In addition, limiting the amount of routine histopathologic evaluation could have saved approximately $480 per case. LEVEL OF EVIDENCE: Level IV, case series.