Immediate Weightbearing after Modified Lapidus Arthrodesis Using a Medial Plate: A Retrospective Descriptive Cohort Study.

The modified Lapidus procedure has emerged as a versatile solution for various pedal pathologies, particularly hallux abducto valgus. There have been numerous modifications over time regarding fixation techniques, joint preparation methods, graft utilization, and weightbearing protocols. However, concerns persist regarding prolonged nonweightbearing postoperatively, prompting the need for alternative approaches. This retrospective descriptive cohort analysis assessed the outcomes of 40 feet from 34 patients who underwent the modified Lapidus procedure with a medial plating system, aimed to evaluate immediate weightbearing outcomes on union rate, fixation-related complications, and functional outcomes. Among the 40 feet, findings showed a 95% (38/40) union rate within 6 months, with 2.5% (1/40) experiencing delayed union and 2.5% (1/40) facing fixation-related complications. There is a single case of malunion in the cohort. Additionally, statistically significant improvements were observed across all domains of the Manchester-Oxford Foot Questionnaire at p < .001. These findings suggest immediate weightbearing as a potential alternative to traditional nonweightbearing protocols. However, the study's retrospective nature and lack of a comparative group warrant cautious interpretation. Further research is essential to validate these findings and refine postoperative care protocols. By challenging conventional practices, this study underscores the complexity of optimizing patient outcomes in modified Lapidus procedure management. Tailored approaches and prospective investigations are imperative for establishing definitive guidelines and enhancing surgical techniques in this domain.

Cartiva interpositional arthroplasty versus arthrodesis in the treatment of Hallux rigidus: A retrospective comparative study with mean 2 year follow up.

BACKGROUND: Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief, but sacrifices ROM. The Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is limited. The aim was to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. METHODS: A retrospective cohort study was conducted, enrolling all adult patients who underwent primary first MTPJ SCI arthroplasty or arthrodesis for the treatment hallux rigidus. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included EQ-5D, complication rates, VAS Pain and FAAM (ADL). RESULTS: Between 2017 and 2020 there were 33 cases divided into two groups (17 Cartiva SCI, 16 arthrodesis, mean age 59.0 ± 9.9 years) with a mean follow up of 2.3 years. There was no statistically significant difference in any of the MOXFQ, EQ-5D, VAS Pain or FAAM (ADL) outcome scores between the Arthrodesis and SCI groups (p > 0.05). The mean MOXFQ Index score was 7.2 ± 6.4 for the SCI group and 3.9 ± 5.8 for the Arthrodesis group at final follow up (p = 0.15). Although complications were high in both groups, the overall hallux reoperation rate was 29.4 % in the SCI cohort and 0.0 % for arthrodesis. CONCLUSION: This retrospective comparative study found no significant superiority of Cartiva SCI over arthrodesis in terms of PROMs. Due to the higher rate of further surgical intervention in the SCI cohort, we recommend arthrodesis as the preferred surgical option for hallux rigidus. LEVEL OF EVIDENCE: III.

Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up.

BACKGROUND: Optimal management of displaced intraarticular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiologic outcomes of minimally invasive surgery vs nonoperative treatment in displaced intraarticular calcaneal fracture up to 2 years. METHODS: All displaced intraarticular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma center were considered for inclusion. The decision to treat was made by a multidisciplinary team consisting of fellowship-trained orthopaedic surgeons. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction and internal fixation. Nonoperative protocol involved symptomatic management with no attempt at closed reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions-5 Level (EQ-5D-5L) patient-reported outcome measures were used to assess foot and ankle and general health related quality of life outcomes, respectively, at 2-year follow-up. Radiographic assessment was performed based on preinjury and 12-week postinjury radiographs. RESULTS: A total of 101 patients were included for analysis between August 2014 and January 2019. We propensity score matched 46 patients in the surgical cohort to 46 patients in the nonsurgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (P > .05); however, the surgical cohort had a significantly higher EQ-5D-5L Index score (P < .05) and return to work (91% vs 72%, P < .05) and physical activity rate (46 vs 35%, P < .05) despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. In addition, 14% of patients in the nonoperative cohort subsequently underwent arthrodesis compared with none of the patients in the surgical cohort. CONCLUSION: In this study, we found that operative treatments were associated with low rates of surgical complication at 2 years and long-term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared with nonoperative treatment for less severe fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Anterior Talo-Fibular Ligament Reconstruction With InternalBrace™ for Chronic Lateral Ankle Instability in Pediatric Patients.

INTRODUCTION: Ankle injuries and instability in a pediatric age group are common problems and often underreported. The injuries can range from a relatively benign ankle sprain to pain-limiting ankle instability that can inhibit the child from participating in sporting activities. However, conservative management and physiotherapy are the mainstay of treatment; a small group of patients present with persistent instability and benefit from surgical intervention in lateral ligament reconstruction. Our study looked at pediatric patients who had instability following failed conservative management. METHODS: Retrospective analysis of 14 patients with Chronic lateral Ankle instability (CLAI) who underwent Modified Brostrom-Gould repair( MBG) with or without Internal brace augmentation between January 2015 and October 2020. Patients were evaluated for the visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), subjective satisfaction, and return to preinjury activity level. RESULTS: Pain score improved from 8 (average 5-9) to 1 (average 0-3) following surgery. Functional assessment was made by assessing the Manchester Oxford questionnaire pre-and postoperatively. MOxFQ scores improved from 64 (8 SD) to 7 (15 SD). Thirteen of fourteen patients returned to normal sporting activities at the final follow-up. CONCLUSION: Modified Brostrom-Gould with InternalBrace™ augmentation is an excellent procedure for chronic lateral ligament injuries in the Paediatric population. It can be safely performed if we respect the anatomy and the physeal growth plate. It allows faster rehabilitation and return to preinjury activity level.

Temporal Changes in Clinical Outcomes after Minimally Invasive Surgery for Hallux Valgus Correction in Women without Postoperative Complications.

Minimally invasive surgery (MIS) is currently used to correct hallux valgus deformities. Most studies reporting on MIS techniques to correct hallux valgus deformities included patients with postoperative complications. These reported complications, with an average rate of 23%, had significant negative effects on the clinical outcomes in this patient population. In the present study, a cohort of 63 women who underwent MIS hallux valgus correction was assessed preoperatively and at a mean follow-up of 1.0, 4.7, and 6.5 years using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the Manchester Oxford Foot Questionnaire (MOXFQ). The main criterion for inclusion in this cohort was a lack of complications during the entire follow-up period. The results showed significant improvements in both AOFAS and MOXFQ scores between the preoperative and 1-year follow-up assessments. By contrast, clinically small and nonsignificant changes were observed among postoperative follow-up values. The number of enrolled patients needs to be increased in future studies, with different surgeons and techniques included. Nevertheless, our study findings will inform patients about the outcomes they can expect over the years if no complications occur.

Fourth-Generation Minimally Invasive Hallux Valgus Surgery With Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META): 12 Month Clinical and Radiologic Results.

BACKGROUND: Fourth-generation minimally invasive surgery (MIS) includes the multiplanar rotational deformity correction achieved through manipulation of an extra-articular distal first metatarsal osteotomy that is held with rigid fixation using 2 fully threaded screws, of which one must be bicortical to provide rotational and biomechanical stability. The aim of this study is to report the clinical and radiologic outcomes of an evolved fourth-generation MIS hallux valgus technique. METHODS: A prospective single-surgeon series of consecutive patients undergoing fourth-generation MIS was performed using a distal transverse osteotomy with a minimum 12-month follow-up. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated clinical patient-reported outcome measure (PROM). Secondary outcomes included radiographic deformity correction, clinical assessment, and EuroQol-5D-5L PROMs. RESULTS: Between September 2019 and June 2021, 50 feet underwent fourth-generation MIS. The mean age was 55.8±15.3 years with a mean follow-up of 1.4 years. Preoperative and minimum 12-month primary outcome data were available for 100% of feet. There was a significant improvement in all MOXFQ domain scores, with the index domain improving from 53.4 to 13.1 (P < .001). There was a significant improvement (P < .001) in hallux valgus angle (32.7 to 7.9 degrees), intermetatarsal angle (14.0 to 4.2 degrees) and distal metatarsal articular angle (18.5 to 5.6 degrees). There was a significant improvement in general health-related quality of life EQ-5D-5L index and EQ-VAS scores (P < .05). CONCLUSION: The fourth-generation MIS technique is a safe and effective approach to hallux valgus deformity correction with significant improvement in clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level IV, prospective case series.

Higher complication rate after nail compared with plate fixation of ankle fractures in patients aged 60 years or older: a prospective, randomized controlled trial.

AIMS: The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. METHODS: In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. RESULTS: At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. CONCLUSION: The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly.Cite this article: Bone Joint J 2023;105-B(1):72-81.

Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus.

BACKGROUND: Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon. METHODS: A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain. RESULTS: Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%. CONCLUSION: Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Correlation between EFAS- and MOCART score and clinical outcome after AMIC®-procedure for osteochondral lesion of the talus.

INTRODUCTION: Even though an increased interest in the use of the EFAS Score (European Foot and Ankle Society) has been observed, no data comparing it with radiological findings has been presented in the literature. Accordingly, the aim of this study is to investigate how the post-operative integration of the AMIC® (autologous matrix-induced chondrogenesis)-membrane for osteochondral lesion of the talus using the MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) - Score is related to the clinical satisfaction of the patients. MATERIAL AND METHODS: A group of 24 patients aged between 17 and 63 (with a mean age of 35.7) were included at least 1 year post-operatively. They had all undergone an AMIC®-procedure of the talus. MRI findings using the MOCART Score were correlated to the EFAS Score at the same time point. RESULTS: Our main results showed no correlation between the MOCART-Score and the EFAS-Score (R = - 0.08). There was also no correlation between the MOCART-Score, the FFI-Score (Foot and Function Index) (R = 0.2) and the MOXFQ-Score (Manchester-Oxford Foot Questionnaire) (R = 0.12). There was no correlation between components of the MOCART-Score with the EFAS-Score (R between - 0.32 and 0.23). CONCLUSION: Our results question whether the MRI (a standard part of AMIC®-procedure-of-the-ankle post-operative follow-up) is still the most appropriate tool for post-operative control. They also offer a starting point for future discussion regarding the need for post-operative MRI and the use of other radiological diagnostics in relation to clinical satisfaction.

The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up.

BACKGROUND: Ankle fractures are a common injury and the main cause of post-traumatic ankle arthritis. The prevalence of obesity is increasing worldwide, and this population is known to have poorer short and midterm outcomes after ankle fractures. Our objective is to assess long-term patient-reported outcomes in patients with operatively treated ankle fractures, and the effect of BMI on these results using the new and validated patient-reported outcome questionnaire, the Manchester Oxford foot and ankle questionnaire (MOXFQ). METHODS: We performed a retrospective review of all ankle fractures treated operatively in a ten-year period from 2002-2012. The MOXFQ and SF-12 were sent to all patients and were obtained, on average, 11.1 years after surgery (range 5.3-16.2 years). RESULTS: Two thousand fifty-five ankle fractures were reviewed, of which 478 (34%) patients completed the questionnaires. The mean age was 48.1 ± 15.5 years, 52% were men and the mean BMI was 26.1 ± 4.5 kg/m2. Of the 478, 47% were of normal weight, 36% were overweight, and 17% were obese. Overall, 2.1% were type A, 69.9% B, and 24.9% type C fractures. There were no significant differences in the type of fracture between the BMI groups. Comparing obese and non-obese patients, there were large differences in MOXFQ pain (33 ± 29 vs. 18.7 ± 22.1, effect size 0.55), and function scores (27.3 ± 29 vs. 12.5 ± 21.1, effect size 0.58). No differences in complications and reoperations rates were observed. The BMI value at surgery correlated more strongly with the MOXFQ pain score than the BMI at follow-up (Spearman's Rho 0.283 vs. 0.185, respectively). CONCLUSION: These findings reveal that obese patients have significant worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture. Moreover, pain and function linearly declined with increasing BMI. Our findings appear to indicate that increased BMI at surgery is an important contributor to adverse outcome in the operative management of rotational ankle fractures. LEVEL OF EVIDENCE: III.

Evaluation of the new defined EFAS score (European foot and ankle society score) in relation to already established functional scores (FFI, MOXFQ) after cartilage reconstructive therapy (AMIC®) for osteochondral lesion of the talus.

BACKGROUND: In 2011, the European Foot and Ankle Society developed a Score (EFAS Score) to generate a standardized questionnaire for several European languages. The aim of this study is to analyse how the newly defined score correlates with already established function scores. METHODS: This study is a monocentric prospective study. The questionnaires were completed at least 12 months postoperatively at the same time point. All patients had undergone surgery with the Autologous Matrix-Induced Chondrogenesis® procedure for osteochondral lesions of the talus. RESULTS: A total of 69 patients (33 women, 36 men) participated in the study. The EFAS Score correlates very strongly with the Manchester-Oxford Foot Questionnaire (MOXFQ) and strongly with the Foot Function Index (FFI). CONCLUSION: This study shows that the EFAS Score correlates significantly with the FFI and the MOXFQ. The EFAS seems to be a more patient-friendly alternative due to fewer questions and response choices.

Minimally invasive surgery for severe hallux valgus in 106 feet.

BACKGROUND: There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA). METHODS: This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale). RESULTS: Between September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%. CONCLUSION: This study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery.

BACKGROUND: There is increasing evidence of positive improvement in clinical and radiological outcomes following minimally invasive hallux valgus deformity correction surgery (MIS). This study investigated the rate of improvement in clinical patient reported outcome measures (PROMs) following MIS as this is not well understood. METHODS: Between July 2014 and July 2019, data was prospectively collected from consecutive patients pre-operatively and at 6, 12, and 24 months following third-generation minimally invasive chevron and Akin osteotomies (MICA). Radiographic deformity and correction was assessed using weight-bearing radiographs pre-operatively and 6 weeks post-operatively. The primary outcome measure was the change in Manchester Oxford Foot Questionnaire (MOXFQ) score at each time point. Secondary outcomes include radiographic deformity correction, health-related quality of life PROMs and exploration of cases where PROMs did not improve. RESULTS: There were 202 feet with complete PROM data for every time point. There was a statistically significant improvement in MOXFQ Index score at each time point (p < 0.05) following MICA surgery. The majority of the improvement occurred within the first 6 months. A subgroup of 17 feet (8.4%) were identified which had worse MOXFQ Index scores 6 months following MICA. For 14 feet in this subgroup (82.4%), the MOXFQ Index score subsequently improved over time such that by two years, their score had significantly improved compared to their pre-operative score. CONCLUSION: The majority of PROM improvement with MICA is gained by 6 months post-operatively but further significant improvement can be seen up to 2 years. Those patients who have not improved at 6 months, are likely to do so with time. LEVEL OF EVIDENCE: IV.

The impact of hallux valgus on function and quality of life in females.

BACKGROUND: The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity. METHODS: Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity. RESULTS: Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. Younger females reported higher VAS-Pain scores compared to older patients with 91% of patients reporting some degree of pain symptoms. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R = -0.51, p < 0.001) and VAS-Pain scores (R = 0.54, p < 0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores although it was noted that there was a trend of increasing HVA/IMA with age. CONCLUSION: Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMsmoderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life. LEVEL OF EVIDENCE: III.

Hallux Valgus Correction Comparing Percutaneous Oblique Osteotomy and Open Chevron Osteotomy at a 2-year Follow-up.

OBJECTIVE: This study aimed to compare the percutaneous oblique osteotomy (POO) and the open chevron osteotomy technique for correction of hallux valgus deformity at a 2-year follow-up. METHODS: This is a retrospective study of consecutive patients undergoing operative correction of hallux valgus using one of two techniques (POO vs open chevron osteotomy) from 2014 to 2018. Forty eight feet (41 patients) that underwent the POO was compared with 64 feet (58 patients) that underwent open chevron osteotomy. The hallux valgus angle (HVA), intermetatarsal angle (IMA) and American Orthopedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal scores (AOFAS-HMI) were assessed preoperatively and postoperatively at the 1, 2-year follow-up. The Manchester-Oxford Foot Questionnaire (MOXFQ) were assessed preoperatively and postoperatively at the 2-year follow-up. The VAS score was collected preoperatively and on 2 weeks,1 year and 2-year follow-up. RESULTS: Both groups achieved significant correction of the hallux deformity. The HVA in the POO group during the follow-up period were 12.5 ± 2.22 and 17.9 ± 9.31, respectively, and in the open chevron group were 14.1 ± 6.78 and 14.8 ± 7.83, respectively. The IMA in the POO group during the follow-up period were 7.61 ± 1.63 and 6.94 ± 1.53, respectively, and in the open chevron group were 6.89 ± 3.06 and 6.97 ± 2.95, respectively. Postoperative MOXFQ scores in all domains were significantly improved in both groups, however there was no significant difference in the improvement of any domain between POO and open groups at a 2-year follow-up. The AOFAS HMI scores in the POO group during the follow-up period were 86.5 ± 10.7 and 85.2 ± 13.8, respectively, and in the open chevron group were 88.2 ± 10.8 and 79.5 ± 23.7, respectively. The VAS scores in the POO group during the follow-up period were 2.00 ± 0.98, 2.00 ± 0.99 and 1.55 ± 1.11, respectively, and in the open chevron group were 5.51 ± 1.45, 2.56 ± 2.88 and 2.56 ± 2.88 respectively. The 1-year and 2-year follow-up outcomes between POO and open groups showed no significant difference regarding AOFAS HMI scores and VAS scores, however the POO group showed statistically significant improvement of VAS scores in the postoperative 2 weeks (P < 0.001). There was no statistical significance between the POO and open group in terms of complications rates (8.3% vs 12.5%, P = 0.480). CONCLUSION: The POO technique is reliable and shows a comparable outcome to the open chevron osteotomy. However, the POO technique shows significantly less pain in the first 2 weeks after surgery.

Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up.

BACKGROUND: Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. METHODS: A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. RESULTS: Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. CONCLUSION: Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence. LEVEL OF EVIDENCE: Level IV, case series.

Structural validity of the Finnish Manchester-Oxford Foot Questionnaire (MOXFQ) using the Rasch model.

BACKGROUND: The 16-item patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ) with subscales of pain, social interactions, and walking/standing has been claimed for strongest scientific evidence in measuring foot and ankle complaints. This study tests the validity of the Finnish MOXFQ for orthopaedic foot and ankle population using the Rasch analysis. METHODS: We translated the MOXFQ into Finnish and used that translation in our study. MOXFQ scores were obtained from 183 patients. Response category distribution, item fit, coverage, targeting, item dependency, ability to measure latent trait (unidimensionality), internal consistency (Cronbach's alpha), and person separation index (PSI) were analyzed. RESULTS: Fifteen of the items had ordered response categories and/or sufficient fit statistics. The subscales provided coverage and targeting. Some residual correlation was noted. Removing one item in the pain subscale led to a unidimensional structure. Alphas and PSIs ranged between 0.68-0.90 and 0.67-0.92, respectively. CONCLUSIONS: Despite some infractions of the Rasch model, the instrument functioned well. The subscales of the MOXFQ are meaningful for assessing patient-reported complaints and outcomes in orthopaedic foot and ankle population.

A randomised, multi-centre trial of total ankle replacement versus ankle arthrodesis in the treatment of patients with end stage ankle osteoarthritis (TARVA): statistical analysis plan.

BACKGROUND: The total ankle replacement versus ankle arthrodesis (TARVA) trial aims to determine which surgical procedure confers the greatest improvement in pain-free function for patients with end-stage ankle osteoarthritis. Both procedures are effective but there has not yet been a direct comparison to establish which is superior. This article describes the statistical analysis plan for this trial as an update to the published protocol. It is written prior to the end of patient follow-up, while the outcome of the trial is still unknown. DESIGN AND METHODS: TARVA is a randomised, un-blinded, parallel group trial of total ankle replacement versus ankle arthrodesis. The primary outcome is the Manchester-Oxford Foot Questionnaire walking/standing domain score at 52 weeks post-surgery. Secondary outcomes include measures of pain, social interaction, physical function, quality of life, and range of motion. We describe in detail the statistical aspects of TARVA: the outcome measures, the sample size calculation, general analysis principles including treatment of missing data, the planned descriptive statistics and statistical models, and planned subgroup and sensitivity analyses. DISCUSSION: The TARVA statistical analysis will provide comprehensive and precise information on the relative effectiveness of the two treatments. The plan will be implemented in January 2020 when follow-up for the trial is completed. TRIAL REGISTRATION: ISRCTN registry number 60672307, ClinicalTrials.gov registration number NCT02128555. Registered 1 May 2014. Recruitment started in January 2015 and ended in January 2019.

Development and psychometric performance of the French language version of the Manchester-Oxford Foot Questionnaire (MOXFQ).

BACKGROUND: The Manchester-Oxford Foot Questionnaire (MOXFQ) is a 16-item patient-reported outcome measure (PROM) validated for use in patients with foot and ankle pathologies. It contains three sub-scores for pain, walking/standing and social interaction dimensions. The aim of this study was to develop a French language version of the MOXFQ and to assess its psychometric properties in patients affected by foot and ankle pathologies. METHODS: According to guidelines, forward and backward independent translations were performed. The final French version was pre-tested in 45 patients. The French MOXFQ and the Short-form 36 Health Survey (SF-36) were filled in by 149 patients. A retest was performed in 39 patients. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by factor analysis, and through correlations of MOXFQ scales with SF-36 scales. RESULTS: Internal consistency coefficients were high with Cronbach's alpha ranging from 0.79 and 0.94. Test-retest ICCs were between 0.74 and 0.93. No floor or ceiling effects were observed. The correlations between French MOXFQ and French SF-36 subscales were moderate ranging from -0.33 to -0.71. CONCLUSIONS: The French translation of the MOXFQ revealed good psychometric properties. Our French version proved to be a reliable instrument which can be used for evaluation of patients with foot and ankle disorders. LEVEL OF EVIDENCE: II.

Comparison of the Manchester-Oxford Foot Questionnaire (MOXFQ) and the Self-Reported Foot and Ankle Outcome Score (SEFAS) in patients with foot or ankle surgery.

BACKGROUND: Patient-reported outcome measures are a critical tool in evaluating the efficacy of orthopedic procedures. The intention of this study was to compare the psychometric properties of the Manchester-Oxford Foot Questionnaire (MOXFQ) and the Self-Reported Foot and Ankle Outcome Score (SEFAS) in patients with foot or ankle surgery. METHODS: 177 patients completed both scores and FAOS, Foot and Ankle Outcome Score (FAOS), Short Form 36 (SF-36) and numeric scales for pain and disability (NRS) before and after surgery. Test-Retest reliability, internal consistency, floor and ceiling effects, construct validity, responsiveness and minimal important change were analyzed. RESULTS: The MOXFQ and SEFAS demonstrated excellent test-retest reliability with interclass correlation coefficient values >0.9 Cronbach's alpha (α) values demonstrated strong internal consistency. No floor or ceiling effects were observed for both questionnaires. As hypothesized MOXFQ subscales correlated strongly with corresponding SEFAS, FAOS and SF-36 domains. MOXFQ subscales showed excellent responsiveness between preoperative assessment and postoperative follow-up, whereas SEFAS demonstrated moderate responsiveness. CONCLUSIONS: The MOXFQ and SEFAS demonstrated good psychometric properties and proofed to be valid and reliable instruments for use in foot and ankle patients. MOXFQ showed better outcomes in responsiveness.