Progressive collapsing foot deformity (PCFD) is a common condition with an estimated prevalence of 3.3% in women greater than 40 years. Progressive in nature, symptomatic flatfoot deformity can be a debilitating condition due to pain and limited physical function; it has been shown to have one of the poorest preoperative patient reported outcome scores in foot and ankle pathologies, second to ankle arthritis. Operative reconstruction of PCFD can be performed in a single-stage manner or through multiple stages. The purpose of this study is to compare costs for non-staged (NS) flatfoot reconstructions, which typically require longer hospital stays, with costs for staged (S) reconstructions, where patients usually do not require hospital admission. To our knowledge, the comparison between single-staged and multi-staged flatfoot reconstructions has not been previously done. This study will run in conjunction with one that compares rates of complications and reoperation, as well as patient reported outcomes on function and pain associated with S and NS flatfoot reconstruction. Overall, the goal is to optimize surgical management of PCFD, by addressing healthcare costs and patient outcomes. At our academic centre with foot and ankle specialists, we selected one surgeon who primarily performs NS flatfoot reconstruction and another who primarily performs S procedures. Retrospective chart reviews of patients who have undergone either S or NS flatfoot reconstruction were performed from November 2011 to August 2021. Length of operating time, number of primary surgeries, length of hospital admission, and number of reoperations were recorded. Cost analysis was performed using local health authority patient rates for non residents as a proxy for health system costs. Rates of operating room per hour and hospital ward stay per diem in Canadian dollars were used. The analysis is currently ongoing. 72 feet from 66 patients were analyzed in the S group while 78 feet from 70 patients were analyzed in the NS group. The average age in the S and NS group are 49.64 +/− 1.76 and 57.23 +/− 1.68 years, respectively. The percentage of female patients in the S and NS group are 63.89% and 57.69%, respectively. All NS patients stayed in hospital post-operatively and the average length of stay for NS patients is 3.65 +/− 0.37 days. Only 10 patients from S group required hospital admission. The average total operating room cost including all stages for S patients was $12,303.12 +/− $582.20. When including in-patient ward costs for patients who required admission from S group, the average cost for operating room and in-patient ward admission was $14,196.00 +/− $1,070.01 after flatfoot reconstruction. The average in-patient ward admission cost for NS patients was $14,518.83 +/− $1,476.94 after flatfoot reconstruction. The cost analysis for total operating room costs for NS patients are currently ongoing. Statistical analysis comparing S to NS flatfoot reconstruction costs are pending. Preliminary cost analysis suggests that multi-staged flatfoot reconstruction costs less than single-staged flatfoot reconstruction. Once full assessment is complete with statistical analysis, correlation with patient reported outcomes and complication rate can guide future PCFD surgical management.
Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly.
Classification systems for the reporting of surgical complications have been developed and adapted for many surgical subspecialties. The purpose of this systematic review was to examine the variability and frequency of reporting terms used to describe complications in ankle fracture fixation. We hypothesized that the terminology used would be highly variable and inconsistent, corroborating previous results that have suggested a need for standardized reporting terminology in orthopaedics. Ankle fracture outcome studies meeting predetermined inclusion and exclusion criteria were selected for analysis by two independent observers. Terms used to define adverse events were identified and recorded. If a difference occurred between the two observers, a third observer was enlisted. Results of both observers were compared. All terms were then compiled and assessed for variability and frequency of use throughout the studies involved. Reporting terminology was subsequently grouped into 10 categories. In the 48 studies analyzed, 301 unique terms were utilized to describe adverse events. Of these terms, 74.4% (224/301) were found in a single study each. Only one term, “infection”, was present in 50% of studies, and only 19 of 301 terms (6.3%) were used in at least 10% of papers. The category that was most frequently reported was infection, with 89.6% of studies reporting on this type of adverse event using 25 distinct terms. Other categories were “wound healing complications” (72.9% of papers, 38 terms), “bone/joint complications” (66.7% of papers, 35 terms), “hardware/implant complications” (56.3% of papers, 47 terms), “revision” (56.3% of papers, 35 terms), “cartilage/soft tissue injuries” (45.8% of papers, 31 terms), “reduction/alignment issues” (45.8% of papers, 29 terms),“medical complications” (43.8% of papers, 32 terms), “pain” (29.2% of papers, 16 terms) and “other complications” (20.8% of papers, 13 terms). There was a 78.6% interobserver agreement in the identification of adverse terms across the 48 studies included. The reporting terminology utilized to describe adverse events in ankle fracture fixation was found to be highly variable and inconsistent. This variability prevents accurate reporting of adverse events and makes the analysis of potential outcomes difficult. The development of standardized reporting terminology in orthopaedics would be instrumental in addressing these challenges and allow for more accurate and consistent outcomes reporting.
Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores.
Restoration of ankle alignment is thought to be critical in total ankle arthroplasty (TAA) outcomes, but previous research is primarily focused on coronal alignment. The purpose of this study was to investigate the sagittal alignment of the talar component. The talar component inclination, measured by the previously-described gamma angle, was hypothesized to be predictive of TAA outcomes. A retrospective review of the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was performed on all TAA cases at a single center over a 11-year period utilizing one of two modern implant designs. Cases without postoperative x-rays taken between 6 and 12 weeks were excluded. The gamma angle was measured by two independent orthopaedic surgeons twice each and standard descriptive statistics was done in addition to a survival analysis. The postoperative gamma angles were analyzed against several definitions of TAA failure and patient-reported outcome measures from the COFAS database by an expert biostatistician. 109 TAA cases satisfied inclusion and exclusion criteria. An elevated postoperative gamma angle higher than 22 degrees was associated with talar component subsidence, defined as a change in gamma angle of 5 degrees or more between postoperative and last available followup radiographs. This finding was true when adjusting for age, gender, body mass index (BMI), and inflammatory arthritis status. All measured angles were found to have good inter- and intraobserver reliability. Surgeons should take care to not excessively dorsiflex the talar cuts during TAA surgery. The gamma angle is a simple and reliable radiographic measurement to predict long-term outcomes of TAA and can help surgeons counsel their patients postoperatively.
Using the three responsive scores there was a significant improvement in outcome with operative intervention (p<
0.0001) with each score. Using the SRM and the ES, the AOS showed the highest level of responsiveness. It also showed an increased response rate suggesting that patients find it more useable.
