A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs.

PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians. METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted. RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and (3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care. CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

Health Considerations for Female Orthopaedic Surgeons.

The number of female orthopaedic surgeons is increasing. They face unique health concerns, which include cancer risk, pregnancy and fertility problems, musculoskeletal issues, and mental health disorders. In 2010, a survey study showed a 2.9-fold increased prevalence of breast cancer in female orthopaedic surgeons, compared with women in the general US population. A follow-up study 13 years later showed a 3.97-fold higher prevalence of breast cancer in female orthopaedic surgeons compared with matched women in the US general population. Surveys on fertility have also reported that orthopaedic surgery is one of three surgical subspecialty fields with the highest rates of fertility difficulty. In addition, the rate of pregnancy loss in female surgeons was twice the rate compared with that of the general population. There is an increased risk of preterm delivery in female orthopaedic surgeons. Awareness, education, and preventive measures may help reduce these issues and thereby promote the recruitment, retainment, and success of female surgeons in orthopaedic surgery.

Locked versus nonlocked plate fixation for first metatarsophalangeal arthrodesis: a biomechanical investigation.

BACKGROUND: First metatarsophalangeal (MTP) arthrodesis using dorsal plate fixation is a common procedure for painful conditions of the great toe. Locked plates have become increasingly common for arthrodesis procedures in the foot, including the hallux MTP joint. The biomechanical advantages and disadvantages of these plates are currently unknown. The purpose of this study was to compare locked and nonlocked plates used for first MTP fusion for strength and stiffness. MATERIALS AND METHODS: The first ray of nine matched pairs of fresh-frozen cadaveric feet underwent dissection, preparation with cup-and-cone reamers, and fixation of the MTP joint with a compression screw and either a nonlocked or locked stainless steel dorsal plate. Each specimen was loaded in a cantilever fashion to 90 N at a rate of 3 Hz for a total of 250,000 cycles. The amount of plantar MTP gap was recorded using a calibrated extensometer. Load-to-failure testing was performed for all specimens that endured the entire cyclical loading. Stiffness was calculated from the final load-to-failure test. RESULTS: The locked plate group demonstrated significantly less plantar gapping during fatigue endurance testing from cycle 10,000 through 250,000 (p < .05). Mean stiffness was significantly greater in the locked plate group compared with the nonlocked plate group (p = .02). There was no significant difference in load to failure between the two groups (p = .27). CONCLUSION: Compared with nonlocked plates, locked hallux MTP arthrodesis plates exhibited significantly less plantar gapping after 10,000 cycles of fatigue endurance testing and significantly greater stiffness in load-to-failure testing. CLINICAL RELEVANCE: As the use of locked plate technology is becoming increasingly common for applications in the foot, a thorough understanding of the biomechanical characteristics of these implants may help optimize their indications and clinical use.

Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons.

INTRODUCTION: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population. METHODS: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey. RESULTS: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003). DISCUSSION: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.

Influence of stretching and warm-up on Achilles tendon material properties.

BACKGROUND: Controversy exists on stretching and warm-up in injury prevention. We hypothesized that warm up has a greater effect on Achilles tendon biomechanics than static stretching. This study investigated static stretching and warm-up on Achilles tendon biomechanics in recreational athletes, in vivo. MATERIALS AND METHODS: Ten active, healthy subjects, 5 males, 5 females, With a mean age of 22.9 years with no previous Achilles tendon injuries were recruited. Typical stretching and warm-up routines were created. Testing was performed in a randomized cross-over design. A custom-built dynamometer was utilized to perform controlled isometric plantarflexion. A low profile ultrasound probe was utilized to visualize the musculotendinous junction of the medial gastrocnemius. An eight-camera motion capture system was used to capture ankle motion. Custom software calculated Achilles tendon biomechanics. RESULTS: Achilles tendon force production was consistent. No statistically significant differences were detected in stretch, stiffness, and strain between pre-, post-stretching, and post-warm-up interventions. CONCLUSION: Stretching or warm-up alone, and combined did not demonstrate statistically significant differences. Stretching and warm-up may have an equivalent effect on Achilles tendon biomechanics. Prolonged and more intense protocols may be required for changes to occur. CLINICAL RELEVANCE: Stretching and warm-up of the Achilles before exercise are commonly practiced. Investigating the effect of stretching and warm-up may shed light on potential injury prevention.

Biomechanical comparison of blade plate and intramedullary nail fixation for tibiocalcaneal arthrodesis.

BACKGROUND: Tibiocalcaneal arthrodesis is an uncommon salvage procedure used for complex problems of the ankle and hindfoot. A biomechanical evaluation of the fixation constructs of this procedure has not been studied previously. The purpose of this study was to compare intramedullary nail to blade plate fixation in a deformity model in fatigue endurance testing and load to failure. MATERIALS AND METHODS: Nine matched pairs of fresh frozen cadaveric legs underwent talectomy followed by fixation with a blade plate and 6.5-mm fully threaded cancellous screw or an ankle arthrodesis intramedullary nail. The specimens were loaded to 270 N at a rate of 3 Hz for a total of 250,000 cycles, followed by loading to failure. RESULTS: Intramedullary nail fixation demonstrated greater mean stiffness throughout the fatigue endurance testing, from cycles 10 through 250,000 (blade plate versus intramedullary nail; cycle 10, 93 +/- 34 N/mm versus 117 +/- 40 N/mm (t = 2.33, p = 0.04); cycle 100, 89 +/- 34 N/mm versus 118 +/- 42 N/mm (t = 3.16, p = 0.01); cycle 1000, 86 +/- 32 N/mm versus 120 +/- 45 N/mm (t = 3.52, p = 0.01); cycle 10,000, 83 +/- 36 N/mm versus 128 +/- 50 N/mm (t = 3.80, p = 0.01); cycle 100,000, 82 +/- 34 N/mm versus 126 +/- 52 N/mm (t = 3.70, p = 0.01); cycle 250,000, 80 +/- 31 N/mm versus 125 +/- 49 N/mm (t = 4.2, p = 0.003). There was no statistically significant difference between the intramedullary nail and blade plate fixation in cycle one or in load to failure; cycle 10, blade plate 70 +/- 38 N/mm and intramedullary nail 67 +/- 20 N/mm (t = 0.60, p = 0.56); load to failure, blade plate 808 +/- 193 N, IMN 1074 +/- 290 N) (p = 0.15). CONCLUSION: Intramedullary nail fixation was biomechanically superior to blade plate and screw fixation in a tibiocalcaneal arthrodesis construct. CLINICAL RELEVANCE: The ankle arthrodesis intramedullary nail provides greater stiffness for fixation in tibiocalcaneal arthrodesis, which may improve healing.

Radiation Exposure and Case Characteristics in National Sample of Female Orthopaedic Trauma and Arthroplasty Surgeons.

Background: The risks of radiation exposure in orthopaedic surgery have become a topic of increasing interest in the setting of widespread fluoroscopy use and concern for an increased prevalence of breast cancer among female orthopaedic surgeons. The aim of this national study of 31 female orthopaedic surgeons was to achieve a deeper understanding of fluoroscopic use in the OR and its associated exposure to radiation, by comparing female orthopaedic trauma and arthroplasty surgeons. Methods: A total of 31 surgeons wore dosimeters for 10 operating days each to track cumulative radiation exposure. Surgeons were not asked to modify their practice in any way, with no requirement that the operating days had to be chosen with the knowledge that fluoroscopy would be used. Participants were also asked to fill out a form at the end of each day, detailing the number of cases that day, the number of hours spent in the OR, and the total amount of time using fluoroscopy. Results: Trauma surgeons received significantly higher radiation doses in the OR (p=0.01) and reported longer use of fluoroscopy (p<0.001). Trauma surgeons also spent more time per day in the OR and had more cases per day compared to arthroplasty surgeons, but this difference was not significant. Radiation dose penetrating through protective equipment remained minimal. Conclusion: Although the female trauma surgeons in the study operated longer and performed more procedures per day, the higher radiation exposure was best explained by the amount of time fluoroscopy is used in the OR. The fluoroscopic times in this study therefore may be a useful self-assessment tool for attending trauma and arthroplasty surgeons. Awareness of these differences will hopefully increase an individual surgeon's mindfulness toward the length of fluoroscopy use in each case, regardless of orthopaedic subspecialty.Level of Evidence: IV.

Tumors of the foot and ankle: experience with 153 cases.

BACKGROUND: Both primary and metastatic tumors in the foot and ankle have been reported as rare. The purpose of this study was to describe 153 cases of foot and ankle tumors from a 20-year experience in a tertiary referral center specializing in orthopaedic oncology. It is the largest reported series of both bone and soft tissue tumors in the foot and ankle. MATERIALS AND METHODS: Between 1986 and 2006, a retrospective chart review was performed of a total of 2,660 tumors surgically treated in all anatomic sites by a single surgeon at a musculoskeletal tumor referral center. RESULTS: One hundred fifty-three patients (5.75%) with bone and/or soft tissue tumors of the foot and ankle were treated. There were 84 women and 69 men. The patients' ages ranged from 1 to 84, with a median age of 30 and mean of 33.2. The tissue types included 80 soft tissue and 73 bone tumors. Overall, 60 (39.2%) were malignant, and 93 (60.8%) were benign. The most common diagnosis was giant cell tumor. In addition, giant cell tumor was the most common bone tumor, while pigmented villonodular synovitis and giant cell tumor of the tendon sheath were the most common soft tissue tumors. CONCLUSION: The incidence of tumors of the foot and ankle in this series of a single surgeon over a 20-year practice was 5.75%. The results of this study reaffirm that awareness, correctly diagnosing, and appropriately treating or referring to an orthopaedic oncologist may help with an improved outcome for patients.

Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results.

BACKGROUND: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. MATERIALS AND METHODS: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. RESULTS: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. CONCLUSION: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion.

Osteoarthritis of the ankle: the role of arthroplasty.

Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis. The ankle joint has unique, complex anatomic and biomechanical characteristics that must be considered in a successful total ankle arthroplasty prosthesis. Initial designs from the 1960s to the 1970s had many failures. Current designs use two or three components, and recent reports on total ankle arthroplasty show consistent good to excellent intermediate clinical results, with up to 90% decreased pain and high patient satisfaction. The follow-up time of these studies is limited, however, and long-term studies with 10- to 15-year follow-ups are needed. Also, a wide variety of complications has been reported, including osteomyelitis and osteolysis. To limit the number of complications and improve clinical outcome of total ankle arthroplasty, careful patient selection and surgeon experience are important.

Secretan's disease of the foot: a case report and review.

Secretan's disease is a rare disorder that has, to date, only been reported in the hand. After minor trauma, edema and hyperplasia of the hand may result, and pathological evaluation demonstrates thick fibrous tissue. We present the first report of Secretan's disease involving the foot in a 15-year-old athletic teenage girl with a remote history of blunt trauma, and review the relevant literature.

Biomechanical comparison of the simple running and cross-stitch epitenon sutures in achilles tendon repairs.

BACKGROUND: Augmenting the strength of Achilles tendon repairs may allow for earlier active rehabilitation with less risk of adhesion formation and re-ruptures, leading to quicker and stronger healing. Building upon previous research that has (1) demonstrated strength gains in Achilles repairs upon addition of simple running epitenon sutures, and (2) shown the cross-stitch epitenon suture to be stronger than the simple running stitch in flexor tendons of the hand, this study compares use of these epitenon sutures in the Achilles tendon. MATERIALS AND METHODS: Ruptures were simulated in 7 matched pairs of fresh frozen human Achilles tendons and repaired with the two-tailed Krakow locking loop core technique using No. 2 nonabsorbable, braided, polyester suture. From each pair, one specimen was randomly selected to also receive the epitenon cross-stitch, the other receiving the simple running stitch. All epitenon repairs employed 4-0 nylon suture. Repaired tendons were loaded in tension to the point of failure on a Materials Testing Machine (MTS). RESULTS: Tendon repair augmented with the cross-stitch displayed a significant, 53% greater failure strength than those repaired with the simple running stitch. Increases in initial stiffness and resistance to 2-mm gap formation in the cross-stitch specimens were 3.1% and 3.6%, respectively. CONCLUSION: Gapping resistance and initial stiffness in Achilles tendon repairs were comparable between the cross-stitch and simple running stitch, but the cross-stitch significantly improved failure strength. CLINICAL RELEVANCE: Greater failure strength may translate clinically to lower rates of re-rupture and earlier mobilization following Achilles tendon repair.

Variation of nerve to flexor hallucis brevis.

BACKGROUND: Hallopeau's nerve is a branch of the lateral plantar nerve that supplies the flexor hallucis brevis muscle while also forming an anastomosis with the medial plantar nerve. In this study, the presence of this neural anastomosis was determined through dissection of cadaveric specimens. MATERIALS AND METHODS: Twenty-six fresh-frozen adult feet (13 matched pairs) were dissected to assess the presence or absence of Hallopeau's nerve. RESULTS: Dissections revealed four out of 26 specimens had this anastomosis. CONCLUSION: This study confirms this anatomic variation. CLINICAL RELEVANCE: The clinical significance of these anastomoses remains unknown. These anastomoses are analogous to some in the hand and forearm.

Postoperative pain following foot and ankle surgery: a prospective study.

BACKGROUND: Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain. MATERIALS AND METHODS: A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively. RESULTS: The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain. CONCLUSION: The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.

Postoperative Pain After Surgical Treatment of Ankle Fractures: A Prospective Study.

BACKGROUND: Postoperative pain after fixation of ankle fractures has a substantial effect on surgical outcome and patient satisfaction. Patients requiring large amounts of narcotics are at higher risk of long-term use of pain medications. Few prospective studies investigate patient pain experience in the management of ankle fractures. METHODS: We prospectively evaluated the pain experience in 63 patients undergoing open reduction and internal fixation of ankle. The Short-Form McGill Pain Questionnaire was administered preoperatively and postoperatively (PP) at 3 days (3dPP) and 6 weeks (6wPP). Anticipated postoperative pain (APP) was recorded. RESULTS: No significant differences were found between PP, APP, and 3dPP; however, 6wPP was markedly lower. Significant correlations were found between PP and APP and between preoperative and postoperative Short-Form McGill Pain Questionnaire scores. PP and APP were independent predictors of 3dPP; however, only APP was predictive of 6wPP. Sex, age, and inpatient versus outpatient status were not notable factors. No statistically significant differences were found in pain scores between fracture types. CONCLUSIONS: Both preoperative pain severity and anticipated postoperative pain are predictive of postoperative pain levels. Orthopaedic surgeons should place a greater focus on the postoperative management of patient pain and expectations after surgical procedures.

Treatment of severe, painful pes planovalgus deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft.

BACKGROUND: This study tested the hypothesis that modification of the standard technique of hindfoot arthrodesis with the use of a wedge-shaped tricortical allograft would improve the amount of correction of pes planovalgus deformity. The results were compared to previous reports. METHODS: Between 1998 and 2005, the senior author (LBC) performed 13 hindfoot arthrodeses on 12 patients using an allograft to improve correction of the deformity for severe, painful pes planovalgus deformity. The average patient age was 55 (range 27 to 77) years. There were seven women and five men. The indications were posterior tibial tendon dysfunction (seven feet), rheumatoid arthritis (three feet), post-traumatic arthritis and deformity (one foot), congenital pes planovalgus (one foot), and tarsal coalition (one foot). RESULTS: Twelve of 13 feet achieved union by 12 weeks postoperatively. There was one nonunion. The average time to fusion was 12 weeks. All 12 patients were satisfied with the results of the operation. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 87 points, and the AOFAS Midfoot score was 85 points. Preoperative and postoperative radiographs were compared to evaluate correction of deformity. On lateral weightbearing views, the talo-first metatarsal angle improved from 15 to 6 degrees, and the lateral talocalcaneal angle improved from 48 to 35 degrees. On anteroposterior views, the talo-first metatarsal angle improved from 17 to 7 degrees, the talonavicular coverage decreased from 28 to 13 degrees, and the talocalcaneal angle improved from 23 to 13 degrees. CONCLUSIONS: A simple modification of the addition of allograft to a common procedure of hindfoot arthrodesis to treat severe, painful pes planovalgus results is reliable and offers satisfactory correction.

Biomechanical testing of epitenon suture strength in Achilles tendon repairs.

BACKGROUND: Recent evidence that early, active mobilization protocols after Achilles tendon repairs increase recovery speed and strength make operative repair strength critical to positive outcomes after Achilles tendon ruptures. While previous research has focused on core (tendon proper) repair techniques, no previous literature has reported testing of core repairs augmented with epitenon sutures, which have been shown to increase the strength of repairs of flexor tendons of the hand. METHODS: Five matched pairs of fresh frozen human Achilles tendons were tested with and without the addition of an epitenon suture to the core repair suture. All specimens were repaired using a No. 2 Ethibond Krakow locking loop core suture. The epitenon suture was added to one tendon randomly chosen from each pair, using a 4-0 nylon suture. All specimens were mounted on an MTS testing machine (MTS Systems Corp., Eden Prairie, MN) and loaded to failure, which was defined as a 1-cm gap formation. RESULTS: The addition of epitenon sutures significantly increased the force necessary to produce a 2-mm gap as compared to core sutures alone by 74%, and it increased the average load to failure by 119%. Also, initial tendon stiffness was 173% greater in tendons reinforced with epitenon sutures. CONCLUSIONS: This study demonstrates that greater resistance to gap formation, approximation of tissue ends, and tensile strength were achieved by the addition of an epitenon suture. Clinical relevance may improve healing by decreased gap formation at the repair site and a lower risk of adhesion formation.

Stress fracture as a complication of autogenous bone graft harvest from the distal tibia.

BACKGROUND: Autogenous bone graft from the distal tibia provides cancellous bone graft for foot and ankle operations, and it has osteogenic and osteoconductive properties. The site is in close proximity to the foot and ankle, and published retrospective studies show low morbidity from the procedure. METHODS: One-hundred autografts were obtained from the distal tibia between 2000 and 2003. In four cases the distal tibial bone graft harvest resulted in a stress fracture. There were three women and one man. RESULTS: The average time of diagnosis of the stress fracture from the operation was 1.8 months. All stress fractures healed with a short course (average 2.4 months) of cast immobilization. CONCLUSIONS: This study demonstrated that a stress fracture from the donor site of autogenous bone graft of the distal tibia occurs and can be successfully treated nonoperatively.

Surgical treatment of severe hallux valgus: the state of practice among academic foot and ankle surgeons.

BACKGROUND: The purpose of this study was to evaluate the operative procedures used for treatment of severe hallux valgus by academic foot and ankle surgeons practicing in the United States. METHODS: A patient with severe hallux valgus deformity was developed as a hypothetical case: a 50-year-old woman with a severe deformity (intermetatarsal angle = 20 degrees; hallux valgus angle = 42 degrees). The patient was symptomatic with pain, did not improve with conservative measures, and wanted the deformity corrected. This case was sent to academic foot and ankle surgeons in a survey to determine their preferred operative treatment for this case. The overall response rate was 84% (128 of 153). To be included in the study group each surgeon had to have 1) foot and ankle patients comprising 50% or more of his clinical practice and 2) direct responsibility for teaching orthopaedic residents. One hundred and five respondents met the inclusion criteria and formed the study group; however, three surveys with invalid responses were deleted. RESULTS: Fifty-two percent (54 of 102) of the respondents chose a metatarsal osteotomy, 26% (26 of 102) a first metatarsophalangeal (MTP) joint arthrodesis, and 24% (24 of 102) a Lapidus procedure. Two respondents chose both an arthrodesis and a metatarsal osteotomy. Among the 54 respondents who chose metatarsal osteotomies, 24 used a Ludloff, 16 a proximal crescentic, eight a proximal chevron, two a scarf, two a distal chevron, and two other. In addition, secondary procedures to enhance the correction included a Weil osteotomy in 46% (47 of 102) and an Akin osteotomy in 30% (31 of 102). CONCLUSIONS: There was a wide variation in the type of procedure used to correct this severe hallux valgus deformity; approximately 50% of the respondents chose a metatarsal osteotomy, 25% chose a first MTP joint arthrodesis, and 25% a Lapidus procedure.