Prospective Assessment of Dorsal Cheilectomy for Hallux Rigidus Using a Patient-reported Outcome Score

Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.     

Minimal important change for Foot and Ankle Outcome Score (FAOS)

BackgroundAlthough Foot and Ankle Outcome Score (FAOS) is a widely used patient-reported outcome measure (PROM) for foot and ankle conditions, research on its longitudinal validity is still needed. Minimal important change (MIC) values for the FAOS were determined using predictive modeling.MethodsOverall, 134 patients that underwent operative treatment for foot and ankle conditions were included. An anchor based predictive logistic modeling method was used for estimating the MIC values for the FAOS subscales after surgery.ResultsMean score changes in the improved and the unimproved groups were 17.7 and 0.43 points for Pain, 3.9 and ?3.3 points for Symptoms, 21.3 and 1.8 points for Activities and daily living (ADL), 8.7 and ?2.8 points for Sport, and 12.5 and ?3.3 points for quality of life subscale, respectively. MIC was successfully determined to four out of five subgroups as follows: Pain 9.5 (94% CI ?6.4 to 24.6); ADL 11.7 (95% CI ?19.6 to 46.6); Sport (95% CI ?10.4 to 15.4); QoL 5.0 (95% CI ?2.6 to 12.9). The Symptoms subgroup presented with low MIC of 0.3 (95% CI ?11.7 to 13.4) fitting to the measurement error.ConclusionADL, Sports, Pain, and QoL subscales of the FAOS presented logical MIC values. The MIC can be further evaluated for specific conditions.     

Prevalence of Hallux Rigidus in Patients With End-Stage Ankle Arthritis

Arthritis of the foot is a significant cause of pain and disability. The prevalence of foot arthritis in adults aged ≥50 has been reported to be 17%. Of those, 25% are estimated to be radiographic arthritis of the first metatarsophalangeal joint. The purposes of this study were to (1) identify the prevalence of radiographic hallux rigidus (HR) in a population of patients with end-stage ankle arthritis relative to that reported in the general population and (2) identify associations between the presence of HR and demographic and clinical factors. A total of 870 feet in 809 subjects with end-stage ankle arthritis who underwent primary total ankle arthroplasty between November 2006 and November 2017 were included. Feet were stratified by patient age: <40, 40 to 59, 60 to 79, and ≥80 years. Etiology of ankle arthritis was classified as inflammatory, post-traumatic, primary, and other. The prevalence of HR in the study group was 72.9%. The prevalence of HR was slightly higher in patients with inflammatory arthritis (odds ratio 1.31, 95% confidence interval 0.73 to 2.32) and primary arthritis (odds ratio 1.18, 95% confidence interval 0.86 to 1.63). The prevalence of HR increased with age (p = .01). In conclusion, the prevalence of radiographic HR in a population with end-stage ankle arthritis was significantly higher relative to patients without documented comorbidities in the foot and ankle. Increasing age was associated with a higher prevalence of the disease.     

Evaluation and Validation of the Dutch European Foot and Ankle Society (EFAS) Score

The European Foot and Ankle Society (EFAS) score is a recently developed foot and ankle patient-reported outcome measure. It has been developed and partly validated in seven languages. This study's aim was to investigate the measurement properties of the Dutch version of the EFAS score. Subscales of the Dutch EFAS score were evaluated in 547 patients with a variety of foot and ankle diagnoses. Floor and ceiling effect, reliability, and construct validity were assessed. The internal consistency of the EFAS score was acceptable (Cronbach's alpha 0.79-0.94). Repeatability was considered poor, with intraclass correlation coefficients between 0.32 and 0.39. Construct validity was inadequate with confirmation of 67% of the hypothesized correlations. In conclusion, the Dutch version of the EFAS score does not have adequate measurement properties for use in patient with patients with varying foot and ankle problems.     

EFAS Score - Validation of Portuguese Version by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in ten languages (English, German, French, Italian, Polish, Dutch, Swedish, Finnish, Turkish, Portuguese). From other languages under validation, the Portuguese version completed data acquisition and underwent further validation.MethodsThe Portuguese version of the EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Portuguese version (completed during initial validation study in nine other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.ResultsThe internal consistency was confirmed in the Portuguese version (Cronbach’s Alpha 0.84). The Standard Error of Measurement (SEM) was 0.27 and is similar to other language versions. Between baseline and follow-up, 69.4% of patients showed an improvement on their EFAS score, with adequate responsiveness (effect size 0.64).ConclusionsThe Portuguese EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.     

Validity and Reliability of the European Foot and Ankle Society (EFAS) Score in Patients With Hallux Valgus in Singapore

The European Foot and Ankle Society score is a popular tool for monitoring treatment outcomes of foot or ankle conditions. However, few studies have assessed its psychometric properties in patients with hallux valgus. We aimed to validate the European Foot and Ankle Society score in patients with hallux valgus in Singapore. This is a cohort study of 121 patients with operatively managed hallux valgus from a tertiary referral hospital, evaluated preoperatively and at 6 months postoperatively with the primary endpoint of restoring patients to premorbid status. Internal consistency was assessed via Cronbach's alpha. Construct validity was assessed through 7 a priori hypotheses by correlating the European Foot and Ankle Society score with other patient‐reported outcomes measures. Structural validity was assessed via Confirmatory Factor Analysis, whereby a good fit was indicated when Comparative Fit Index >0.95, Tucker‐Lewis Index >0.95, Root Mean Square Error of Approximation <0.06, and Standardized Root Mean Residuals <0.08. Among our subjects, the European Foot and Ankle Society score demonstrated reliability, reflected by a good internal consistency (Cronbach's alpha = 0.773). Six out of the 7 a priori hypotheses were fulfilled, indicating both convergent and divergent construct validity. Structural validity was confirmed with our European Foot and Ankle Society score model which showed good fit for a 1‐factor structure (Confirmatory Factor Analysis = 0.998, Tucker‐Lewis Index = 0.996, Root Mean Square Error of Approximation = 0.025 [90% CI: 0-0.111], Standardized Root Mean Residuals = 0.027). In conclusion, the European Foot and Ankle Society score was validated for monitoring treatment outcomes of patients with hallux valgus in Singapore.     

Nonimplant Arthroplasty for the Treatment of End-Stage Hallux Rigidus

Surgical management of end-stage hallux rigidus involves joint-sparing techniques, including cheilectomy and decompression osteotomies, and joint-destructive procedures, including arthroplasty (resection, interpositional, implant, Valenti) and arthrodesis. Joint-destructive procedures have traditionally been reserved for the end stages of hallux rigidus involving grade 3 and 4. We present a modification of the previously reported Valenti arthroplasty with short-term patient outcomes. We performed a retrospective review of the medical records of 96 patients who had undergone the nonimplant arthroplasty procedure for treatment of end-stage hallux rigidus with a minimum follow-up period of 6 months. The preoperative and postoperative dorsiflexion of the first metatarsophalangeal joints and visual analog scale (VAS) scores were compared. Of the 96 medical records, 27 (28%) met the inclusion criteria. The mean patient age was 60.2 (range 48 to 73) years, and the mean follow-up period was 12 (range 6 to 23) months. The mean preoperative range of motion for first metatarsophalangeal joint dorsiflexion was 4.69° (range ?3° to 10°), and the mean postoperative dorsiflexion was 48.23° (range 30° to 65°), with a mean difference of 43.54° (range 25° to 60°). The preoperative VAS score averaged 6.46° (range 4° to 10°), and the postoperative VAS score averaged 0.69° (range 0° to 3°). Nonimplant arthroplasty was found to increase first metatarsophalangeal joint dorsiflexion and significantly decrease patient pain. Thus, it is a viable option for the treatment of end-stage hallux rigidus.     

EFAS Score—Validation of Spanish and Estonian Versions by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in 11 languages (Dutch, English, German, Finnish, French, Italian, Polish, Portuguese, Persian, Swedish, Turkish). From other languages under validation, the Spanish and Estonian versions completed data acquisition and underwent further validation.MethodsThe EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during the initial validation study), 2) item reduction and scale exploration (completed during the initial validation study), 3) confirmatory analyses and responsiveness of the Spanish and Estonian versions (completed during the initial validation study in seven other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.ResultsThe internal consistency of the scale was confirmed in the Spanish and Estonian versions (Cronbach’s Alpha>0.8). Responsiveness was good, with moderate to large effect sizes in both languages, and evidence of a statistically significant positive association between the EFAS Score and patient-reported improvement.ConclusionsThe Spanish and Estonian EFAS Score versions were successfully validated in orthopaedic ankle and foot surgery patients, with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.