Journal of Foot & Ankle Surgery最新文献

Background: Ankle fractures are common injuries encountered in emergency and orthopedic trauma care. Although routine follow-up radiography is widely used, its clinical utility has been increasingly questioned. In response, structured care models such as Virtual Fracture Care (VFC) have been developed to optimize efficiency by minimizing unnecessary follow-up.

Purpose: To assess whether clinically and non-clinically indicated follow-up radiographs meaningfully impact treatment decisions in patients with ankle fractures managed within the VFC model.

Study design: Retrospective cohort study.

Methods: A retrospective cohort study was conducted at a Dutch level 2 trauma center. Patients with non-Weber A ankle fractures treated in the VFC model between January 2022 and January 2024 were included. The primary outcome was the proportion of radiographs that led to a modification of follow-up care, stratified by indication category.

Results: In 193 included patients, 312 follow-up radiographs were obtained, of which 230 (73.7%) were non-clinically indicated. 10 radiographs (3.2%) led to modifications in follow-up care, more often among clinically indicated images (4.9% vs. 2.6%) and non-operatively treated patients (5.1% vs. 2.6%). 3 radiographs (1.0%) led to therapeutic intervention rather than additional follow-up.

Conclusions: Even within a largely symptom-guided care model such as VFC, follow-up radiographs are often obtained despite lacking a documented clinical indication. Their therapeutic yield remains limited. These findings underscore the importance of consistent implementation of the model's symptom-based principles to avoid unnecessary routine imaging.

Background: Over the past decade, there has been a notable increase in the incidence of total ankle arthroplasty (TAA). The primary purpose of the study was to evaluate regional differences in TAA volume, reimbursement, and patient demographics within the Medicare population from 2013 to 2022.

Methods: The Medicare Physician and Other Practitioners database was used to identify all instances of primary TAA (CPT 27702). Procedure volume, inflation-adjusted reimbursement, and patient demographics were collected for analysis. Data were regionally sorted based on US Census guidelines. Continuous variables were analyzed using two sample t-tests, and regional differences were evaluated using Kruskal-Wallis tests.

Results: From 2013 to 2022, TAA volume increased by 202.9% nationally. The largest increase was in the Northeast (+439.6%) while the smallest increase was in the Midwest (+74.7%). Inflation-adjusted TAA reimbursement declined by 13% nationally, with the Midwest experiencing the greatest decline (-24%), and the Northeast seeing a slight increase (+4%). In 2022, the TAA volume of services per 10,000 beneficiaries was greatest in the South (3.22/10,000) and lowest in the Midwest (1.21/10,000). Reimbursements varied per region, with lowest in the South ($625) and highest in the West ($782). The number of Medicare beneficiaries per TAA surgeon increased by 24% nationally and the average number of billable services per beneficiary increased by 25%. Surgeons in the Northeast performed the most billable services per beneficiary in 2022 (5.4). The average comorbidity burden of patients decreased by 3% during the study period.

Conclusion: The rising volume of TAA services has been accompanied by declining reimbursement rates in recent years. Surgeons are treating healthier patients overall and performing more services per beneficiary, reflecting potential pressures of billing practices and raising concerns about access for more complex patients. These patterns highlight potential challenges in maintaining long-term equitable access to TAA for Medicare beneficiaries.

Background: Plantar fasciitis (PF) is one of the most common causes of heel pain, and multiple injection-based treatments are used in practice; however, short-term comparative data remain limited.

Purpose: To compare the short-term clinical outcomes of four injection methods for PF-peppering alone, peppering combined with corticosteroid, corticosteroid alone, and autologous blood injection-using pain reduction measured by the Visual Analog Scale (VAS).

Study design: Comparative cohort study.

Methods: A total of 123 patients diagnosed with PF were screened, and 83 met the inclusion criteria (available VAS scores, completed third-week and third-month follow-ups, no prior foot surgery or fracture). Patients were allocated into four groups: peppering (n = 21), peppering with corticosteroid (n = 20), corticosteroid alone (n = 22), and autologous blood injection (n = 20). Pain severity was assessed using VAS at baseline, third week, and third month. Nonparametric tests were applied, including Mann-Whitney U and Kruskal-Wallis for independent comparisons and Wilcoxon or Friedman tests for repeated measures.

Results: Significant differences in VAS scores were observed among groups at both follow-ups. The peppering with corticosteroid and corticosteroid-alone groups demonstrated greater pain reduction than the peppering or autologous blood groups. Improvement in the peppering group appeared only at the third month, while the autologous blood group showed no significant short-term change. The combination of peppering and corticosteroid produced a more sustained reduction in pain than corticosteroid alone.

Conclusion: Corticosteroid combined with the peppering technique was the most effective short-term option for reducing PF-related pain. Peppering alone may require longer follow-up to show meaningful benefit, whereas autologous blood injection demonstrated limited short-term efficacy.

Background: Medial malleolus fractures are common injuries. Although various fixation methods are used, the optimal technique remains a subject of debate.

Purpose: This study aimed to compare complication rates associated with different fixation techniques for medial malleolar fractures and to evaluate whether fracture classification, implant size or number of screws influence outcomes.

Study design: Retrospective cohort study.

Methods: A retrospective cohort study was conducted, analyzing clinical and radiographic data of 80 patients (82 ankles) treated surgically for medial malleolar fractures at a level 1 trauma center. The median follow-up time was 40 weeks (9 to 187 weeks). Fixation methods included plate fixation, screw fixation, screw fixation with K-wire, and tension band wiring. Complication rates (nonunion, infection, secondary dislocation, wound dehiscence) were compared across groups.

Results: The overall complication rate was 12.2% (10 of 82 ankles). Plate fixation demonstrated the highest complication rate (27.3%), with deep infection in 18.2% of cases, significantly higher compared to other fixation techniques (p = .012). No significant differences in complication rates were observed regarding the Herscovici classification for fracture types, implant size, or single versus double screw fixation.

Conclusion: In conclusion, plate fixation was associated with a significantly higher risk of complications, particularly deep infection, compared to other fixation methods. These findings suggest that less invasive fixation techniques should be considered when feasible to minimize postoperative morbidity.

Background: Workforce analysis and access to care investigations are relatively lacking in podiatric medicine and surgery. This might be of concern when considering fragility within the medical workforce infrastructure, rising diabetes mellitus prevalence rates, and the aging US population.

Purpose: The objective of this investigation was to provide a broad description of podiatric physician practice location distribution as it relates to population, economic factors, and diabetes prevalence.

Study design: Epidemiologic descriptive analysis.

Methods: The CMS National Downloadable File, US census data, and American Diabetes Association state statistics were utilized to provide correlation data and ratios of relative podiatric work force distribution.

Results: We identified 6603 US zip codes in the CMS National Downloadable File with at least one DPM billing address. Statistically significant positive Pearson correlation coefficients were observed between the number of DPM billing addresses in a zip code with zip code population (0.281; p<0.001), median income (0.083; p<0.001), and mean income (0.099; p<0.001). We further observed a mean±standard deviation (range) of 2582.1±1593.8 (824-10148) state residents with diabetes mellitus per DPM in the US. The southeastern US tended to demonstrate higher ratios potentially indicating the potential for more challenging diabetes patient access to care, whereas the northeast corridor tended to demonstrate lower ratios.

Discussion: The results of this investigation provide unique information on podiatric physician distribution of practice location, and might be utilized as an introductory starting point to improve the efficacy of podiatric care offered to patients in the US.

Background: Treatment strategies for talar avascular necrosis range from nonsurgical management to surgical interventions, including joint-sparing and joint-sacrificing procedures. However, no consensus exists on the optimal treatment approach, particularly in cases requiring ankle arthrodesis.

Purpose: This study evaluated whether open ankle arthrodesis and arthroscopic ankle arthrodesis differ in complication rates when used for the treatment of talar avascular necrosis.

Study design: Patient outcomes following ankle arthrodesis procedures were analyzed retrospectively using a national healthcare database containing diagnosis and procedure codes.

Methods: Utilizing data from the TriNetX database, we identified patients with talar avascular necrosis who underwent open or arthroscopic ankle arthrodesis between January 29, 2004, and January 29, 2024. Propensity score matching controlled for age, sex, long-term steroid use, and comorbidities. Primary outcomes included one-year rates of nonunion and hardware removal. Risk differences were calculated, and significance was assessed with Z-tests.

Results: No significant differences in orthopaedic complications between the open-ankle and arthroscopic cohorts, including rates of nonunion (30.6% vs. 31.1%, p = 0.936) and hardware removal (19.0% vs. 12.1%, p = 0.147) were found.

Conclusion: This study found no significant differences in complication rates between open and arthroscopic ankle arthrodesis for talar avascular necrosis, including nonunion and hardware removal. These findings suggest that both open and arthroscopic approaches offer comparable complication profiles.

Background: With an aging U.S. population, demand for foot and ankle surgical services continues to increase. The purpose of this study was to evaluate 25-year trends in Medicare reimbursement for foot and ankle surgical procedures. We hypothesized that inflation-adjusted reimbursement has declined.

Methods: Medicare reimbursement data (facility pricing, locality 0431200 Oklahoma) for 81 commonly performed foot and ankle surgical CPT codes was extracted from the CMS Physician Fee Schedule Look-Up Tool for 2000-2024. Reimbursement was adjusted to 2000 dollars using both the Consumer Price Index (CPI) and Medicare Economic Index (MEI). Compound annual growth rates (CAGR) were calculated.

Results: From 2000 to 2024, inflation-adjusted reimbursement for foot and ankle surgical procedures declined 45.9% (CPI-adjusted) and 36.9% (MEI-adjusted), corresponding to CAGR values of -2.5% and -1.9%, respectively. This represents an average decline of $221 per procedure (CPI-adjusted) or $178 per procedure (MEI-adjusted) in 2000 dollars.

Conclusion: Medicare reimbursement for foot and ankle surgical procedures has declined substantially over the past 25 years when adjusted for inflation. These findings should alert surgeons, hospital administrators, and policymakers to the widening gap between operative costs and reimbursement, with potential downstream effects on access to care.

Purpose: To evaluate the clinical and functional outcomes of percutaneous correction of lesser toe deformities using extra-articular osteotomies, with a focus on patient-reported outcomes and postoperative complications.

Methods: A retrospective review was conducted on 98 percutaneous hammertoe correction procedures performed on 41 patients between April 2019 and April 2024. Inclusion criteria included age >18, minimum 12-month clinical follow-up, and pre- and post-operative radiographs. Procedures involving interphalangeal arthrodesis or isolated fifth toe corrections were excluded. Functional outcomes were assessed using the Foot Function Index (FFI) pre-operatively and at least one year post-operatively. Statistical analysis was performed using paired t-tests. Complications and concomitant procedures were also recorded.

Results: Patients had a significant improvement in overall FFI scores, from a pre-operative average of 86.3 to a post-operative average of 34.9 (p < 0.0001). Subscale improvements were also statistically significant for pain (p < 0.0001) and disability (p < 0.0001), but not for activity limitation (p = 0.06). Common concomitant procedures included percutaneous hallux valgus correction (46%) and distal metatarsal metaphyseal osteotomies (39%). The most frequent complications were recurrence requiring revision arthrodesis (7%) or capsular release (5%). No infections or wound complications were reported.

Conclusion: Percutaneous correction of lesser toe deformities using extra-articular osteotomies offers a safe and effective alternative to traditional open techniques. The procedure significantly improves patient-reported outcomes with a low complication rate and high patient satisfaction. Further research, including long-term follow-up and comparison with open techniques, is warranted.

Background: The Foot and Ankle Outcome Score (FAOS) assesses pain, function, sports activity, and quality of life in patients with foot and ankle disorders. Its use in Arabic-speaking populations is limited by the absence of a validated Arabic version.

Purpose: To translate, culturally adapt, and validate an Arabic version of the FAOS (FAOS-AR).

Study design: Prospective validation study.

Methods: The FAOS was translated and culturally adapted into Arabic using cross-cultural methodology, including forward translation, reconciliation, back-translation, review, and pilot testing. Adults aged ≥18 years with foot or ankle pain were recruited from two outpatient clinics and completed the FAOS-AR and the Arabic American Orthopaedic Foot and Ankle Society score (AOFAS-AR). A clinically stable subgroup repeated the FAOS-AR after 5-10 days. Psychometric evaluation included internal consistency, test-retest reliability, measurement error, and content, structural, and convergent validity.

Results: Score distributions showed acceptable floor and ceiling effects. Internal consistency was excellent for Function/Activities of Daily Living (α=0.97), Sports/Recreation (α=0.90), and Pain (α=0.89); acceptable for Quality of Life (α=0.73); satisfactory for Stiffness (α=0.75); and low for Symptoms (α=0.34). Test-retest reliability was excellent for the total score (ICC=0.978) and all subscales except Symptoms (ICC=0.778). The standard error of measurement was 3.16, yielding a minimal detectable change of 8.76 points. Principal component analysis supported unidimensionality for most subscales, whereas Symptoms demonstrated multidimensionality. Convergent validity was shown by correlations with AOFAS-AR domains (ρ=0.516-0.673).

Conclusion: The FAOS-AR is valid for assessing outcomes in patients with foot and ankle conditions.

Background: Clinical standards for diagnosing Charcot neuroarthropathy (CN) rely on two-dimensional (2D) radiographs, despite the complex three-dimensional (3D) deformities. This study utilized a 3D measurement method, previously applied to nonweightbearing imaging, for weightbearing imaging to quantify deformities in CN patients and compared these to 2D weightbearing radiographs (WBR).

Methods: This retrospective study included seven CN patients who underwent both 2D WBR and 3D weightbearing CT scans (WBCT). Five observers manually annotated 2D radiographs, and placed 3D fiducial markers on anatomic landmarks that were processed using a patient-specific coordinate system. Paired t-tests and Bonferroni adjustment (p_adj) compared 2D and 3D values.

Results: The 3D WBCT measurements revealed significantly greater anteroposterior talocalcaneal angles (153.59 degrees ± 2.49 vs. 19.98 degrees ± 1.74, p < 0.0001, p_adj< 0.0001) and talonavicular angles (10.61 degrees ± 2.16 vs. 1.75 degrees ± 0.25, p < 0.0001, p_adj<0.0001). Unadjusted medial and lateral column heights were significantly higher on WBCT (25.31 mm ± 3.70 vs. 14.09 mm ± 2.39, p = 0.001, p_adj=0.009; 15.60 mm ± 2.39 vs. 8.17 mm ± 2.29, p = 0.027, p_adj=0.243, respectively). Tibiotalar angles were significantly lower on WBCT (91.72 degrees ± 1.27 vs. 124.05 degrees ± 2.04, p < 0.0001, p_adj< 0.0001).

Discussion: Comparisons between the novel method of analyzing 3D WBCT and standard analysis of 2D WBR revealed significant differences in several angular and distance measurements of pathological deformities in CN. Measurements related to forefoot abduction, midfoot arch height, and hindfoot valgus alignment differ from 2D WBR compared to 3D WBCT.