Prospective Surgical Cohort Analysis.

A well-conducted prospective cohort study has the potential to change the way in which surgeons practice. However, not all are equal. In this article, we provide many of the tools needed to critically appraise this powerful study design. We advocate for using a 3-step approach that centers on understanding the study's generalizability, results, and validity. We illustrate how this process is applied into practice regularly at our hospital section's journal club sessions.

A Primer on Cost-Effectiveness Analysis.

A cost-effectiveness analysis (CEA) is a type of health economics model that uses a systematic approach to simplify the complexities that exist in health-care decision-making. A CEA aids in medical decision-making by considering both the costs of a treatment and how effective that treatment is for at least 2 competing strategies. This article reviews major concepts of CEA including results interpretation, key attributes of CEA that make it differ from cost analysis, uncertainty surrounding analysis, and how/why CEA is an important contributor to the medical literature.

How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, nonmodifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the second metatarsal during second hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone second hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the second metatarsal, and joint angular measurements were obtained from the second metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6 to 10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long second metatarsal; Nilsonne values <-4 mm, multivariate hazards ratio [HR] 1.96, p = .097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, p = .028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities.

American Podiatric Surgeons' Postoperative Multimodal Analgesic-Prescribing Practice: A 2019-2020 National Survey.

BACKGROUND: Surgery is a common setting for opioid-naive patients to first be exposed to opioids. Understanding the multimodal analgesic-prescribing habits of podiatric surgeons in the United States may be helpful to refining prescribing protocols. The purpose of this benchmark study was to identify whether certain demographic characteristics of podiatric surgeons were associated with their postoperative multimodal analgesic-prescribing practices. METHODS: We administered a scenario-based, voluntary, anonymous, online questionnaire that consisted of patient scenarios with a unique podiatric surgery followed by a demographics section. We developed multiple logistic regression models to identify associations between prescriber characteristics and the odds of supplementing with a nonsteroidal anti-inflammatory drug, regional nerve block, and anticonvulsant agent for each scenario. We developed multiple linear regression models to identify the association of multimodal analgesic-prescribing habits and the opioid dosage units prescribed at the time of surgery. RESULTS: Eight hundred sixty podiatric surgeons completed the survey. Years in practice was a statistically significant variable in multiple scenarios. Compared with those in practice for more than 15 years, podiatric surgeons in practice 5 years or less had increased odds of reporting supplementation with an anticonvulsant agent in scenarios 1 (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.11-5.18; P = .03), 3 (OR, 2.97; 95% CI, 1.55-5.68; P = .001), 4 (OR, 2.54; 95% CI, 1.56-4.12; P < .001), and 5 (OR, 2.07; 95% CI, 1.29-3.32; P = .003). CONCLUSIONS: Podiatric surgeons with fewer years in practice had increased odds of supplementing with an anticonvulsant. Approximately one-third of podiatric surgeons reported using some form of a nonopioid analgesic and an opioid in every scenario. The use of multimodal analgesics was associated with a reduction in the number of opioid dosage units prescribed at the time of surgery and may be a reasonable adjunct to current protocols.

Postprocedural Opioid-Prescribing Practice in Nail Surgery.

BACKGROUND: Ingrown toenails are a common condition requiring outpatient procedures in podiatric medical clinics. To prevent recurrence, chemical matrixectomy is often recommended. Postprocedural pain management is largely based on preferences rather than on a formal guideline. This study aims to explore the postprocedural prescribing behavior among practicing podiatric physicians to foster future guideline and policy development. METHODS: We administered an open, voluntary, anonymous questionnaire via an online survey platform that included a common nail procedure scenario (chemical matrixectomy) and a prescribed demographics section. Podiatric physicians were asked what they would prescribe to manage postprocedural pain. Opioid and nonopioid options were provided. We developed two multiple logistic regression models to identify associations between prescriber characteristics and prescribing opioids after "standard" chemical matrixectomy. RESULTS: Of the 860 podiatrists who completed the survey, 8.7% opted to prescribe an opioid. Hydrocodone was most commonly chosen. A median of 18 opioid pills were prescribed. No prescriber characteristics were associated with prescribing opioids after chemical matrixectomy scenario. There is a large discrepancy and knowledge gap in the literature on the optimal postprocedural pain management for outpatient procedures, including procedures in specialties such as dentistry and dermatology. The median number of opioids prescribed by podiatrists is higher than that by dentists for management of third molar extraction. In contrast, opioid-prescribing behavior among the 8.7% of respondents is similar to dermatologic management of postprocedural pain in Mohs surgery. CONCLUSIONS: Podiatric physicians cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The presented study serves to be an initiation for procedure-specific opioid prescription benchmarking to foster future guideline and policy development. After nail procedures, opioids should not be routinely prescribed.

Initial Experience With Subchondral Stabilization for Grade II Stress Fractures of the Midfoot and Forefoot.

Stress fractures of the foot are often preceded by magnetic resonance imaging evidence of bone marrow edema. While new evidence suggests intraosseous injection of calcium phosphate ("subchondral stabilization") can alleviate symptoms associated with bone marrow edema, no data yet exist regarding its use in developing mid- and forefoot stress fractures. Fifty-four patients who underwent subchondral stabilization of various midfoot/forefoot bones in our practice were observed over a 5-year period. All patients were unresponsive to standard nonoperative measures for at least 6 weeks, and all had clinical exams and advanced imaging consistent with a Kaeding-Miller Grade II stress fracture. Forty patients were included with a mean age of 54.3 ± 14.9 years and mean follow-up of 14.1 ± 6.9 months. Patients saw a significant decrease in visual analog scale (VAS) pain as early as 1 month postoperatively (p < .05). Mean postoperative VAS at 12 months was 2.11 ± 2.50, and mean reduction in VAS pain from preoperative to 12 months postoperative was -5.00 (95% CI -3.44 to -6.56, p < .05). Fourteen patients (34%, 14/41) were entirely pain free at 12 months. Higher preoperative VAS pain scores (unadjusted odds ratio [OR] 2.13 [95% CI 1.20-3.77], p = .010) and treatment of more than 1 bone (unadjusted OR 6.23 [95% CI 1.39-27.8], p = .017) were associated with a greater likelihood of not achieving a pain free status at 12 months. Our initial experience with subchondral stabilization suggests the procedure may be safe and effective for use in many Kaeding-Miller Grade II stress fractures of the mid- and forefoot.

Validation of the Foot and Ankle Outcome Score for Use in Infracalcaneal Heel Pain.

There is growing interest in adopting validated and reliable patient-reported outcome measures following surgery. While the Foot and Ankle Outcome Score (FAOS) has previously been validated for use in multiple foot/ankle conditions, it has not yet been validated in patients with infracalcaneal heel pain. In this study we aimed to validate the FAOS by looking at 4 psychometric properties of the survey: construct validity, content validity, reliability, and responsiveness, using patients in our practice with a clinical diagnosis of plantar fasciitis. A total of 150 patients (mean age 49.7 ± 12.1 years [36 men and 114 women]) were included in one or more of the 4 components of this study. All FAOS subscales demonstrated adequate construct validity when compared with the physical health component of the 12-Item Short Form Health Survey (SF-12), and 2 out of 5 subscales demonstrated moderate correlation with the mental health component of SF-12 (all Spearman rho >0.3, and p values <0.05). Most FAOS subscales demonstrated content validity and were found to contain relevant questions from the patient's perspective. All 5 subscales demonstrated good test-retest reliability with intraclass correlation coefficients ≥ 0.827. Finally, 4 out of the 5 subscales (all but other symptoms) were responsive to change at a mean follow up of 12.2 months after surgery (p < .05). We conclude that the FAOS is a responsive, reliable, and valid instrument for use in infracalcaneal heel pain. We believe that due to its ease of use and broad applicability, the FAOS could be more widely adopted in foot/ankle practices as patient-centered healthcare delivery and research becomes increasingly prioritized in the US and abroad.

Comparison of Regenerative Injection Therapy and Conventional Therapy for Proximal Plantar Fasciitis.

Treatment of subacute and chronic heel pain often presents a unique challenge to the physician. Regenerative therapies, such as injectable amnion and connective tissue matrix, may represent a promising new approach in these patients, and have become increasingly popular in the United States. However, little literature exists evaluating these injections compared to conventional nonoperative means. As such, we designed a retrospective comparative study evaluating patients in our practice who received a standardized plantar fascial treatment protocol only (standard therapy), and those who received regenerative plantar fascial injections in addition to standard therapy. A total of 54 patients were followed over a 3-month observation period (91.7 ± 73.9 days), with numeric pain rating (NPR) serving as the primary outcome. Both groups saw an improvement in NPR at the end of the observation period, but patients in the regenerative therapy group demonstrated lower pain scores than those receiving standard therapy alone (mean NPR 2.1 ± 2.3 vs 4.4 ± 2.8, p = .004). Additionally, those in the standard therapy group were significantly more likely to proceed onto surgical intervention compared to the regenerative therapy group (unadjusted odds ratio 15.6, 95% CI 3.0-27.9). The use of regenerative injections for subacute and chronic plantar fasciitis showed promise in our study, and may help mitigate against the need for invasive surgical intervention.

Are Radiographs Associated With Patient Satisfaction After Scarf Bunionectomy?

There are over 350,000 bunion surgeries performed in the USA annually, making it one of the most common elective forefoot surgeries. Studies have suggested that as many as 10% of patients remain dissatisfied after bunion surgery. The purpose of this study is to evaluate if radiographic variables are associated with patient satisfaction at 1 year postoperatively. We performed a secondary analysis of prospectively collected data on 69 consecutive adult patients (mean age 45 ± 14 years, 91% female [63/69]) who underwent isolated hallux valgus surgery from January 2016 to January 2017. Subjects completed a standardized 4-item survey inquiring about their satisfaction with regards to pain relief, overall operative result, cosmetic appearance, and ability to wear desired shoe gear. Conventional radiographic indices for hallux valgus were examined preoperatively and 3 months postoperatively. An association model using backward stepwise logistic regression was utilized to determine which variables, if any, are most important in explaining patient satisfaction after surgery. Sixty-nine subjects completed the 4-item satisfaction survey with 53.6% (37/69) of subjects answering they were fully satisfied on all aspects of the survey at 12 months postoperatively. In the final regression model, no radiographic or demographic variables were associated with patient satisfaction including shoe gear, cosmetic appearance, pain relief, and overall operative result. Radiographic variables did not appear to be associated with patient satisfaction at one year postoperatively in our study. Factors such as quality of life, anxiety levels, fear of surgery, and/or preoperative expectations may offer more insight into satisfaction; however, further research should be performed to examine this further.

Postoperative Opioid-Prescribing Practice in Foot and Ankle Surgery.

BACKGROUND: Approximately 3,900 Americans die every month of opioid overdose. The total economic burden of the opioid epidemic is estimated to be more than $78 billion annually. We sought to determine whether postoperative opioid-prescribing practice variation exists in foot and ankle surgery. METHODS: We administered a voluntary, anonymous, online questionnaire consisting of six foot and ankle surgery scenarios followed by a demographics section. The purpose of the demographics section was to gather characteristics of podiatric foot and ankle surgeons. We invited podiatric foot and ankle surgeons practicing in the United States to complete the questionnaire via e-mail from the American Podiatric Medical Association's membership list. For each scenario, respondents selected the postoperative opioid(s) that they would prescribe at the time of surgery, as well as the dose, frequency, and number of "pills" (dosage units). We developed multiple linear regression models to identify associations between prescriber characteristics and two measures of opioid quantity: dosage units and morphine milligram equivalents. RESULTS: Eight hundred sixty podiatric foot and ankle surgeons completed the survey. The median number of dosage units never exceeded 30 regardless of the foot and ankle surgery. Years in practice correlated with reduction in dosage units at the time of surgery. Compared with the orthopedic community, podiatric foot and ankle surgeons prescribe approximately 25% less dosage units than orthopedic foot and ankle surgeons. CONCLUSIONS: Postoperative opioid-prescribing practice variation exists in foot and ankle surgery. Further research is warranted to determine whether additional education is needed for young surgeons.

Normal and Diseased Imaging: Ultrasound/MRI.

The lesser metatarsophalangeal joint plantar plate and calcaneonavicular (spring) ligament are highly specialized soft tissue structures within the foot, consisting partly of fibrocartilage and capable of withstanding high compressive and tensile loads. Preoperative advanced imaging, in the form of point-of-care ultrasound and MRI, has become indispensable for surgeons hoping to confirm, quantify, and better localize injuries to these structures before surgery. This article describes the technical considerations of ultrasound and MRI and provides examples of the normal and abnormal appearances of these structures. The pros and cons of each imaging modality are also discussed.

Diagnostic accuracy of magnetic resonance imaging (MRI) versus dynamic ultrasound for plantar plate injuries: A systematic review and meta-analysis.

BACKGROUND: Previous literature has suggested both MRI and ultrasound can accurately diagnose plantar plate tears. There is a significant cost difference between these two modalities, sparking interest for which should be the preferred method for diagnosis. PURPOSE: The purpose of this study was to examine the diagnostic accuracy of MRI and dynamic, musculoskeletal ultrasound for lesser metatarsal plantar plate injuries using a systematic review and meta-analysis. METHODS: MEDLINE, CINAHL, and Clinicaltrials.gov were searched thru May 2020. We included studies evaluating the diagnostic accuracy of MRI or ultrasound for detecting plantar plate tears, using intraoperative confirmation as the gold standard comparison. Sensitivity and specificity were obtained and pooled from included studies. Summary receiver operating curves were formed for each diagnostic test to compare accuracy. Study quality was assessed using the QUADAS-2 scoring system. RESULTS: Eleven studies met our inclusion criteria, representing 227 plantar plates for MRI and 238 plantar plates for ultrasound. MRI displayed a pooled sensitivity of 89% (95% CI 0.84, 0.93) and specificity of 83% (95% CI 0.64, 0.94). Ultrasound displayed a sensitivity and specificity of 95% (95% CI 0.91, 0.98) and 52% (95% CI 0.37, 0.68), respectively. CONCLUSION: MRI was superior to ultrasound in diagnosing plantar plate injuries overall, however, ultrasound was more sensitive than MRI, suggesting a negative ultrasound would likely rule out a plantar plate injury in the presence of an equivocal physical exam. Determining the grade of the injury is best served with MRI which can provide added insight into the joint's supporting structures (e.g. collateral ligaments) and integrity.

Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis.

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I2 statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

Do Patient Personality Traits and Self-Reported Physical and Psychosocial Symptoms Help to Predict Hallux Valgus Surgery Outcomes?

As many as 10% of patients remain unsatisfied after hallux valgus surgery. We explored the effects of patient personality traits and other preoperative patient characteristics on patient-reported outcomes following surgery. Eighty consecutive adult patients (mean age 45 ± 14 years, 91% female [73/80]) undergoing scarf bunionectomy at our practice were prospectively enrolled from January 2016 to January 2017 and followed for 12 months. Predictor variables included preoperative physical and psychosocial complaints (determined via Brief Battery for Health Improvement-2 questionnaire), patient aggression level, and personality traits (extraversion, agreeableness, conscientiousness, emotional stability and openness). Primary outcome measures included the Foot and Ankle Outcome Score (FAOS) with its 5 subscales, and patient satisfaction. Multiple multivariable regression models were used to determine preoperative patient characteristics associated with FAOS outcome and satisfaction at 12 months. Seventy subjects (70/80, 87.5%) completed the study. All patients experienced technically successful surgery. In the multivariable regression analyses, none of the combinations of potentially important predictor variables explained more than 19.8% of the variance in any of the 5 FAOS subscales at 12 months (range: 6.1%-19.8%). Furthermore, no predictor was associated with patient satisfaction in either the univariate or multivariable analyses. We conclude that patient personality traits, aggression level, and self-reported physical and psychological symptoms do very little to predict outcomes in hallux valgus surgery. As healthcare delivery in the United States has increasingly prioritized patient satisfaction, we will need to broaden the quest for predictors associated with our best (and worst) patient-reported outcomes after hallux valgus surgery.

Effects of Hallux Valgus Surgery on Balance and Gait in Middle Aged and Older Adults.

Hallux valgus is associated with balance deficits, and has been implicated as an independent risk factor for falls in older adults. However, it is unknown what effect hallux valgus surgery has on static and dynamic (i.e., while walking) balance in older adults. We enrolled 13 middle-aged and older aged adults (mean age 54.3 ± 12.7 years, range 47 to 70) who underwent isolated hallux valgus surgery and followed them for 12 months. Preoperative and postoperative gait and balance performance was assessed using non-invasive body worn sensors with standardized and validated testing protocols. Visual analog scale (VAS) for pain and radiographic angles were also assessed. All subjects reported improvements in pain (VAS mean change -38.3 ± 10.3 mm), and all subjects demonstrated improvements in their hallux valgus angles and first/second intermetatarsal angles (mean change 16.3 ± 8.8°, and 5.5 ± 3.0°, respectively). While standing in full tandem, center of mass (COM) sway was improved upon by 59% at 1 year postoperative (p < .05, paired t-test). While most gait parameters demonstrated little change postoperatively, patients tended to spend less time in double support (p = .08, paired t-test), while gait variability increased by 55% (p = .03, paired t-test) and medial-lateral sway while walking increased by 43% (p = .08, paired t-test) 12 months postoperatively. Balance improved after hallux valgus surgery in our population, particularly when subjects were forced to rely on their operative foot for support (e.g., full tandem). Patients also seemed to walk with greater variability in stride velocity and with greater medial-lateral sway postoperatively, suggesting perhaps increased ambulatory confidence after successful hallux valgus surgery.

Prevalence and Distribution of Ankle Joint Equinus in 249 Consecutive Patients Attending a Foot and Ankle Specialty Clinic.

BACKGROUND: The definition of equinus varies from less than 0° to less than 25° of dorsiflexion with the foot at 90° to the leg. Despite its pervasive nature and broad association with many lower-extremity conditions, the prevalence of ankle equinus is unclear. Furthermore, there are few data to suggest whether equinus is predominantly a bilateral finding or isolated to the affected limb only. METHODS: We conducted a prospective cohort study examining consecutive patients attending a single foot and ankle specialty practice. Participation involved an assessment of ankle joint range of motion by a single rater with more than 25 years of clinical experience. We defined ankle equinus as ankle joint dorsiflexion range of motion less than or equal to 0° and severe equinus as less than or equal to -5°. Patients who had previously experienced an Achilles tendon rupture, undergone posterior group lengthening (ie, Achilles tendon or gastrocnemius muscle lengthening), or had conservative or surgical treatment of equinus previously were excluded. RESULTS: Of 249 included patients, 61% were female and 79% nondiabetic. The prevalence of ankle equinus was 73% [183 of 249], and nearly all of these patients had bilateral restriction of ankle joint range of motion (prevalence of bilateral ankle equinus was 98.4% [180 of 183] among those with equinus). We also found that ankle equinus was more common in patients with diabetes, higher body mass indexes (BMIs), or overuse symptoms. CONCLUSIONS: The prevalence of ankle equinus in this sample was higher than previously reported, and nearly all of these patients had bilateral involvement. These data suggest that many people attending foot/ankle specialty clinics will have ankle equinus, and select groups (diabetes, increased BMI, overuse symptoms) are increasingly likely.

Association of select preventative services and hospitalization in people with diabetes.

PURPOSE: The purpose of this study was to assess the utilization rates and trends of preventative outpatient visits to providers in a population of people with diabetes, and evaluate which preventative services may offer protection against poor outcomes (i.e. all-cause hospitalization). METHODS: The National Health and Nutrition Examination Survey (NHANES) was used to examine the relationship between select outpatient services and risk of all-cause hospitalization in people with diabetes. NHANES data from 2011 to 2016 were included. We assessed five outpatient services commonly recommended to prevent future complications in patients with diabetes: (1) routine examination from a physician (2) assessment of hemoglobin A1C (3) eye exam with pupil dilation (4) foot exam and (5) assessment from a diabetes specialist. Logistic regression models were performed to assess the independent association of outpatient services used in the past 1 year, and hospitalization within that same year. RESULTS: The prevalence of diabetes within the NHANES population was 10.5% (n = 3054). Hospitalization was significantly more common among diabetics who were older, had lower income levels (i.e. under $20,000) and those who considered themselves in 'fair' or 'poor health'. After adjustment for important covariates, patients who received a preventative foot exam within the last year (i.e. 1-4 times per year) were 33% less likely to be hospitalized within that year (OR 0.67, 95%CI 0.46, 0.96). Those visiting a diabetes specialist were 44% less likely to be hospitalized that year (OR 0.56, 95%CI 0.39, 0.82) if the visit was preventative in nature (i.e. occurred more than one year before the hospitalized event). No other outpatient services displayed an independent association with hospitalization. CONCLUSION: Outpatient Services were consistently being used annually by the diabetic population. Receiving a preventative foot exam and visiting a diabetes specialist were associated with protection against hospitalization, resulting in a 33% and 44% decreased risk, respectively. RESEARCH IN CONTEXT: Evidence before this study: Current guidelines focus on preventative care measures to avert diabetes complications. In a 2018 national database study of approximately one-third of the Italian population, guidelines for prevention were not consistently being met among the diabetes population, however, patients who regularly received all the recommended preventative measures experienced a 20% risk reduction in hospitalization. The study's preventative measures included periodic lab monitoring including glycated hemoglobin and lipid profiles and dilated eye exams. Added value of this study: In our study, we used a national database representing the United States' non-institutionalized population to identify the prevalence of prevention measures being utilized in adults with diabetes and further examine their relationship with all-cause hospitalization. Logistic regression analysis identified two preventative measures with inconsistent utilization, however, when these measures were used according to guidelines, they contributed to a risk reduction in all-cause hospitalization. Implications of all the available evidence: Current preventative guidelines can contribute to a risk reduction in hospitalization among adults with diabetes. National guidelines and quality improvement initiatives should be aimed at improving the utilization of foot exams as a preventative measure and referral to a diabetes specialist before complications incur.

Comparison of Calcaneal Subchondral Injection of Calcium Phosphate and Plantar Fasciotomy vs Plantar Fasciotomy Alone for Refractory Infracalcaneal Heel Pain.

BACKGROUND: Treatment of chronic refractory heel pain has evolved to consider calcaneal structural fatigue as a component of the symptom profile. While concomitant calcium phosphate injection has become a method of addressing the accompanying calcaneal bone marrow edema (BME) frequently seen in this population, there is no literature supporting its use compared to traditional fasciotomy. METHODS: Consecutive patients with symptoms of refractory infracalcaneal heel pain and calcaneal BME were treated in our practice by either surgical fasciotomy (n = 33) or fasciotomy plus calcium phosphate injection (n = 31) between 2014 and 2019. Outcomes were retrospectively assessed via Foot and Ankle Outcome Scores (FAOS), return to activity, and complication rate. RESULTS: Sixty-four patients (64 feet) were included with a mean age of 50.3 ± 12.9 years and mean follow-up of 23.2 ± 22.3 months. No differences were observed between groups preoperatively. Significant improvements in 4 of 5 FAOS subscales were observed postoperatively in both groups (P < .05 for all, paired t test). However, patients undergoing concomitant calcium phosphate injection reported significantly better scores for both activities of daily living (ADL; mean difference +10.2; 95% confidence interval [CI] 0.07-20.2) and foot-specific QOL (mean difference +21.9, 95% CI 7.0-36.6) at final follow-up compared with those undergoing plantar fasciotomy alone. All patients returned to their desired level of activity, and the frequency of complications did not differ between groups (P > .05, Fisher exact test). CONCLUSION: In patients presenting with recalcitrant infracalcaneal heel pain accompanied by calcaneal BME, calcium phosphate injection into the calcaneus, when combined with plantar fasciotomy, was safe and more effective than traditional plantar fasciotomy alone. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND: Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES: To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS: A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS: The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS: Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE: Level II, economic and decision analysis.