Hallux valgus; An observational study on patient characteristics, surgical treatment and pre-operative HRQoL from the Swedish foot and ankle register (Swefoot).

INTRODUCTION: Hallux valgus (HV) is a common condition with impact on pain, function and HrQoL. International consensus does not exist on operative treatment of HV and population-level data regarding surgical treatment of HV is lacking. In this study we aimed to present base-line data from surgically treated HV patients reported to the Swedish register for foot and ankle surgery (Swefoot) during the period 2014-2021. MATERIAL AND METHODS: In total, 7543 feet in 6770 patients were analyzed regarding patient characteristics, grading of HV, surgical procedures and pre-operative PROMs Euroqol-5 Dimension-3 L (EQ-5D-3 L) and Self-reported Foot and Ankle Score (SEFAS). RESULTS: Median age was 55 years (range 15-91) and 87% were women. The surgeon classified 63% of the cases as moderate HV, 15% as mild and 22% as severe. The Chevron osteotomy was the preferred surgical method and was used in 74% of all cases. Out of these, 58% were fixated with a screw. The Offset-V osteotomy was the most performed shaft osteotomy. Proximal osteotomies and lateral releases were less common. The pre-operative mean EQ-5D-3 L index and SEFAS summary score were low and HV patients with overweight and rheumatoid arthritis had significantly lower scores. CONCLUSION: This is the first report from Swefoot describing surgeon- and patient reported pre-operative data in patients with surgical treated HV.

Patient-reported outcome for 17,648 patients in 5 different Swedish orthopaedic quality registers before and 1 year after surgery: an observational study.

BACKGROUND AND PURPOSE: The EQ-5D is a patientreported outcome measure (PROM). To make priorities and allocate resources between patients and surgical procedures it is necessary to evaluate outcome differences, which is why comparing PROMs between registers is important. We compared EQ-5D data and the follow-up rate for selected diagnoses reported to Swedish orthopedic registers before and 1 year after surgery. PATIENTS AND METHODS: Patients from 5 orthopedic registers (Swespine, Swedish Hip Arthroplasty Register, Swedish Knee Arthroplasty Register, Swedankle, and Swefoot) who, in 2014-2018, underwent surgery in southern Sweden were included in the study. Data on the EQ-5D index, individual questions, and the EQ-VAS at baseline and at the 1-year follow-up was compared. RESULTS: 17,648 patients had completed the EQ-5D pre- and 1-year postoperatively. The follow-up rate ranged from 32% to 88%. All registers showed a statistical and clinically relevant improvement in the EQ-5D index (mean improvement 0.29-0.39), where patients who underwent hip arthroplasties experienced the largest improvement. The EQ-5D index improvements in patients with foot and ankle surgeries were larger than for patients with knee arthroplasties and spinal surgeries. The dimensions "self-care" and "usual activities" had the largest change in patients reporting "some problems." CONCLUSION: All 5 registers showed a clinically relevant improvement 1 year postoperatively regarding the EQ-5D index, supporting continuous resource allocation to these groups of patients and surgical procedures. However, using PROM data to present register differences was challenged by the high number of non-responders.

Swefoot - The Swedish national quality register for foot and ankle surgery.

BACKGROUND: Population-based register data could be used to improve our knowledge of patients surgically treated for foot and ankle disorders. The quality register Swefoot was recently created to collect surgical and patient-reported data of foot and ankle surgery. This manuscript aims to describe the development and current use of the register. METHODS: The development of Swefoot started in 2014 and currently, data on 16 different diagnoses are collected in 49 units performing foot and ankle surgery. Registrations are performed by the surgeon and the patient. RESULTS: Between 2014 and 2020 approximately 20,000 surgical procedures have been registered. 75.1% of the registered patients were women, 9.3% were smokers, 9.3% had a concomitant rheumatoid disease, and 18.4% a BMI larger than 30 kg/m2. CONCLUSIONS: The Swefoot is a unique national register for foot and ankle surgery. It is by now possible to present demographic, surgical, and outcome parameters based on Swefoot.

Transcultural adaptation and validation of the Spanish-French versions of the Self-reported Foot and Ankle Score (SEFAS).

OBJECTIVE: The study aim was to cross-culturally adapt the Self-reported Foot and Ankle Score (SEFAS) into Spanish and French-language versions, to validate them and to evaluate their psychometric properties. METHODS: The cross-cultural translation from the original SEFAS into French and Spanish was performed in accordance with the guidelines of the ISPOR. The participants were recruited from some private healthcare institutions in France and Sapin, from June to August 2019. The following inclusion criteria were applied: aged at least 18 years, with foot and/or ankle deformity, had a history of subtalar and/or ankle and/or talonavicular or hindfoot pain, did not make daily use of walking aids, and were able to achieve the normal range of motions in the ankle, subtalar and midtarsal joints. All patients gave signed informed consent and completed the SF-36 and SEFAS questionnaires in the Spanish or French version. RESULTS: The analysis was based on 319 participants. Internal consistency was excellent (Cronbach's alpha values of 0.94 for the Spanish version and 0.88 for the French version). No floor/ceiling effect was observed in any item, in either version. CONCLUSION: The Spanish and French versions of SEFAS are valid, reliable instruments for evaluating foot and ankle pain and function.IMPLICATIONS FOR REHABILITATIONSelf-report questionnaires specific to patients with rheumatoid arthritis are needed to assess the degree of pain, disability, and disability caused by foot problems.The Spanish and French versions of SEFAS show the necessary psychometric characteristics.Each version provides a valid, reliable tool ensuring the correct evaluation of pain, function and limitation of function in the foot and/or ankle in the target population.

Foot and Ankle Problems in Patients With Rheumatoid Arthritis in 2019: Still an Important Issue.

OBJECTIVE: To study the prevalence of foot pain in patients with rheumatoid arthritis (RA) and whether including a 12-joint foot count in addition to the 28-joint count (from the Disease Activity Score 28 [DAS28]) improved detection of foot or ankle pain. In addition, the association between the self-reported foot and ankle score (SEFAS), patient-reported function, and disease-specific factors was studied. METHODS: Physician-reported data (swollen/tender 12-joint foot count, DAS28, and medication) and patient-reported data (foot/ankle pain, physical function, global health, and SEFAS) were assessed during a clinical visit. Data were analyzed with t test, χ2 tests, and regression analysis. RESULTS: A total of 320 patients with RA were included (mean age 63 years, SD 13 years; 73% women), of whom 69% reported foot or ankle pain. Patients who reported foot or ankle pain had a lower mean age and worse disease activity, general pain, function, and global health (P ≤ 0.016), and fewer were in remission (50% versus 75%; P < 0.001) compared with patients without foot pain. The 12-joint foot count identified 3.2% and 9.5% additional patients with swollen and tender joints, respectively, compared with the 28-joint count. The SEFAS was associated with walking problems (ß = -2.733; 95% confidence interval [CI] = -3.963 to -1.503) and worse function (ß = -3.634; 95% CI = -5.681 to -1.587) but not with joint inflammation severity. CONCLUSION: The prevalence of foot or ankle pain in patients with RA is high. The 12-joint foot count had minor effects on detecting patients with foot pain. However, the SEFAS contributed additional information on foot problems that was not identified by joint examinations alone.

Patient-reported outcomes of joint-preserving surgery for moderate hallux rigidus: a 1-year follow-up of 296 patients from Swefoot.

Background and purpose - Hallux rigidus (HR) may cause decreased range of motion, joint pain, and gait disturbances. There is a lack of evidence regarding the outcome of different surgical procedures for moderate HR. We report patient-reported outcomes after joint-preserving surgical procedures for moderate HR.Patients and methods - We included 296 patients registered in Swefoot (Swedish national registry of foot and ankle surgery) who underwent primary surgery for moderate HR 2014 through 2018. We extracted information on anthropometrics, grading of HR, chosen surgical procedure, and patient-reported data including the PROMs SEFAS (summary score 0-48) and EQ-5D-3L (index 0-1) preoperatively and 1 year postoperatively.Results - 115 patients underwent metatarsal decompression (i.e., Youngswick) osteotomy (YOT) and 181 underwent cheilectomy. The mean improvement in SEFAS score 1 year after surgery was 12 points (95% CI 10 - 13) for YOT and 10 points (CI 9 - 12) for cheilectomy. Also, EQ-5D improved in both groups. Patients who underwent YOT were more satisfied with the procedure (84% vs. 70% for cheilectomy, p = 0.02).Interpretation - Surgically treated patients with moderate HR improved after both YOT and cheilectomy, according to patient-reported data from Swefoot. Patients who underwent a YOT were more satisfied with their procedure. One possible explanation may be that more patients in the YOT group had a concomitant hallux valgus; however, we have no information on this.

Hallux rigidus - Osteoarthritis of the first MTP-joint. Surgical and patient-reported results from Swefoot.

BACKGROUND: Swefoot is a Swedish national registry, that covers surgery in the foot and ankle. Surgical treatment of hallux rigidus (HR) vary within and between countries. The aim of this study was to report baseline variables for patients with HR. METHODS: We extracted baseline characteristics, surgical procedures and patient-reported data for patients with HR entered in the registry during the period January 2014 to August 2019. RESULTS: By August 2019, 1818 patients were reported in the registry. 68.9% of the patients were women, the average age was 58 years, the mean BMI was 26.4kg/m2. 41.9% of the patients underwent a cheilectomy,19.8% a metatarsal osteotomy, 34.3% a fusion, 0.2% an arthroplasty, 0.3% Keller's procedure and 3.5% other methods. The preoperative summary score for SEFAS (Self-reported Foot and Ankle Score) was 26 and for EQ-5D (Euroqol-5 Dimension) 0.60. CONCLUSION: This study is the first report from Swefoot regarding HR.

Age- and Gender-Specific Normative Values for the Self-Reported Foot and Ankle Score (SEFAS).

BACKGROUND: The Self-Reported Foot and Ankle Score (SEFAS) is a foot- and ankle-specific patient-reported outcome measurement (PROM) score that has been validated with good results for a variety of foot and ankle disorders. SEFAS is sensitive detecting improvement or deterioration after surgery. However, normative values, required to put a specific patient's summary score into perspective, are lacking. METHODS: In this report, we included 396 population-based men and 383 women (43% of the invited individuals), age 20-89 years, who had completed the SEFAS questionnaire and questions regarding anthropometrics and health. We used Mann-Whitney U test to test gender differences and Spearman correlation coefficients to determine any association between SEFAS score and age. We present gender-specific median SEFAS scores with range and 5th to 95th percentiles and mean with standard deviation. RESULTS: The SEFAS normative values were median 48 in men (range 11-48), 5th to 95th percentiles 31 to 48 and mean 45 ± 6, and in women, median 47 (range 6-48), 5th to 95th percentiles 23 to 48 and mean 43 ± 8 (gender comparison P < .001). SEFAS normative values correlated inversely with age (r = -0.12, P < .001). CONCLUSION: In the general population, older age was associated with lower SEFAS value, and men had higher values than women. The population-based normative SEFAS values provided in this study can facilitate quantification of disability related to foot and ankle with and without surgery in the foot and ankle. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Minimally important change, measurement error, and responsiveness for the Self-Reported Foot and Ankle Score.

Background and purpose - Patient-reported outcome measures (PROMs) are increasingly used to evaluate results in orthopedic surgery. To enhance good responsiveness with a PROM, the minimally important change (MIC) should be established. MIC reflects the smallest measured change in score that is perceived as being relevant by the patients. We assessed MIC for the Self-reported Foot and Ankle Score (SEFAS) used in Swedish national registries. Patients and methods - Patients with forefoot disorders (n = 83) or hindfoot/ankle disorders (n = 80) completed the SEFAS before surgery and 6 months after surgery. At 6 months also, a patient global assessment (PGA) scale-as external criterion-was completed. Measurement error was expressed as the standard error of a single determination. MIC was calculated by (1) median change scores in improved patients on the PGA scale, and (2) the best cutoff point (BCP) and area under the curve (AUC) using analysis of receiver operating characteristic curves (ROCs). Results - The change in mean summary score was the same, 9 (SD 9), in patients with forefoot disorders and in patients with hindfoot/ankle disorders. MIC for SEFAS in the total sample was 5 score points (IQR: 2-8) and the measurement error was 2.4. BCP was 5 and AUC was 0.8 (95% CI: 0.7-0.9). Interpretation - As previously shown, SEFAS has good responsiveness. The score change in SEFAS 6 months after surgery should exceed 5 score points in both forefoot patients and hindfoot/ankle patients to be considered as being clinically relevant.

Comparison of the Self-reported Foot and Ankle Score (SEFAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS).

BACKGROUND: The Self-reported Foot and Ankle Score (SEFAS) is a patient-reported outcome measure, while the American Orthopedic Foot and Ankle Society Score (AOFAS) is a clinician-based score, both used for evaluation of foot and ankle disorders. The purpose of this study was to compare the psychometric properties of these 2 scoring systems. METHODS: A total of 95 patients with great toe disorders and 111 patients with ankle or hindfoot disorders completed the 2 scores before and after surgery. We evaluated time to complete the scores in seconds, correlations between scores with Spearman's correlation coefficient (r s), floor and ceiling effects by proportion of individuals who reached the minimum or maximum values, test-retest reliability and interobserver reliability by intraclass correlation coefficient (ICC), internal consistency by Cronbach's coefficient alpha (CA), and responsiveness by effect size (ES). Data are provided as correlation coefficients, means, and standard deviations. RESULTS: SEFAS was completed 3 times faster than AOFAS. The scores correlated with an r s of .49 for great toe disorders and .67 for ankle/hindfoot disorders (both P < .001). None of the scores had any floor or ceiling effect. SEFAS test-retest ICC values measured 1 week apart were .89 for great toe and .92 for ankle/hindfoot disorders, while the corresponding ICC values for AOFAS were .57 and .75. AOFAS interobserver reliability ICC values were .70 for great toe and .81 for ankle/hindfoot disorders. SEFAS CA values were .85 for great toe and .86 for ankle/hindfoot disorders, while the corresponding CA values for AOFAS were .15 and .42. SEFAS ES values were 1.15 for great toe and 1.39 for ankle/hindfoot disorders, while the corresponding ES values for AOFAS were 1.05 and 1.73. CONCLUSION: As SEFAS showed similar or better outcome in our tests and was completed 3 times faster than AOFAS, we recommend SEFAS for evaluation of patients with foot and ankle disorders. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Validity, reliability, and responsiveness of the Self-reported Foot and Ankle Score (SEFAS) in forefoot, hindfoot, and ankle disorders.

BACKGROUND AND PURPOSE: The self-reported foot and ankle score (SEFAS) is a questionnaire designed to evaluate disorders of the foot and ankle, but it is only validated for arthritis in the ankle. We validated SEFAS in patients with forefoot, midfoot, hindfoot, and ankle disorders. PATIENTS AND METHODS: 118 patients with forefoot disorders and 106 patients with hindfoot or ankle disorders completed the SEFAS, the foot and ankle outcome score (FAOS), SF-36, and EQ-5D before surgery. We evaluated construct validity for SEFAS versus FAOS, SF-36, and EQ-5D; floor and ceiling effects; test-retest reliability (ICC); internal consistency; and agreement. Responsiveness was evaluated by effect size (ES) and standardized response mean (SRM) 6 months after surgery. The analyses were done separately in patients with forefoot disorders and hindfoot/ankle disorders. RESULTS: Comparing SEFAS to the other scores, convergent validity (when correlating foot-specific questions) and divergent validity (when correlating foot-specific and general questions) were confirmed. SEFAS had no floor and ceiling effects. In patients with forefoot disorders, ICC was 0.92 (CI: 0.85-0.96), Cronbach's α was 0.84, ES was 1.29, and SRM was 1.27. In patients with hindfoot or ankle disorders, ICC was 0.93 (CI: 0.88-0.96), Cronbach's α was 0.86, ES was 1.05, and SRM was 0.99. INTERPRETATION: SEFAS has acceptable validity, reliability, and responsiveness in patients with various forefoot, hindfoot, and ankle disorders. SEFAS is therefore an appropriate patient- reported outcome measure (PROM) for these patients, even in national registries.

Patients with hip osteoarthritis have a phenotype with high bone mass and low lean body mass.

BACKGROUND: Although hip osteoarthritis (OA) is common, its etiology is poorly understood. Specifically, it is not known whether hip OA is associated with abnormal relationships among the anthropometric and musculoskeletal characteristics that are associated with OA in general. QUESTIONS: We asked whether patients with primary hip OA have a phenotype with higher bone mineral density (BMD), higher BMI, larger skeletal size, lower lean body mass, and higher fat content. MATERIAL AND METHODS: We included 30 women and 32 men (mean age, 66 years; range, 42-84 years) with primary hip OA and 96 women and 91 men as control subjects. Dual energy x-ray absorptiometry was used to measure total body BMD (g/cm(2)), femoral neck width (cm), fat and lean mass (%), and BMI (kg/m(2)). Z scores were calculated for each individual. Data are presented as means with 95% CI. RESULTS: Women with hip OA had the following Z scores: total body BMD 0.6 (0.3, 1.0); BMI 0.6 (0.2, 1.0); femoral neck width 0.2 (-0.6, 1.0); percent total body lean mass -0.9 (-1.2, -0.5); and percent total body fat mass 0.6 (0.2, 0.9). Men with hip OA had the following mean Z scores: total body BMD 0.5 (0.0, 1.0); BMI 0.8 (0.3, 1.3); femoral neck width 0.4 (0.01, 0.9); percent total body lean mass -0.8 (-1.1, -0.5); and percent total body fat mass 0.5 (0.2, 0.8). CONCLUSIONS: Women and men with idiopathic hip OA have a phenotype with higher BMD, higher BMI, proportionally higher fat mass, and proportionally lower lean body mass. Men also have a larger skeletal size. CLINICAL RELEVANCE: A higher BMD may lead to a stiffer bone and a proportionally lower lean body mass to lower joint-protective ability, both traits probably predisposing for hip OA.