Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.
This month, co-author Timothy R. Daniels, MD, FRCSC summarizes the 5 most compelling findings from the >80 studies highlighted in the recently published “What’s New in Foot and Ankle Surgery.”
–With virtual foot and ankle examinations become more widespread during the COVID-19 pandemic, a recent paper on telehealth consultations offers guidance on preparing patients for the appointment as well as examination instructions that can be read by clinicians to patients and a checklist for medical record documentation1.
–Evaluating trends in foot and ankle surgery in Germany over the past decade, 1 study found that the volume of foot and ankle operations increased 39.5%, while the population increased 0.9%2. The volume of first metatarsophalangeal joint (MTPJ) arthrodesis and ankle arthrodesis rose 77% and 31%, respectively, whereas first MTPJ arthroplasty and total ankle replacement declined 48% and 39%.
Total Ankle Replacement
– In a prospective series of total ankle replacement procedures in which a standard anterior approach or an extensile anteromedial surgical approach was used in patients at higher risk for wound complications, 17 (2.6%) of 660 patients had major and 39 (5.9%) had minor wound-healing issues3. All major wound complications occurred in the anterior-approach group.
–A recent study assessed the utility of preoperative imaging and intraoperative histopathology in Morton neuroma4. Among 313 suspected neuromas operatively resected during the 10-year study period, Morton neuroma was confirmed in 309 (98.7%) on histopathologic examination. The postoperative treatment course was not altered for any patient on the basis of the pathology report, challenging the cost and utility of histopathologic evaluation of resected neuromas.
–Another recent study investigated the question of whether sociodemographic factors impact PROMIS scores meeting the Patient-Acceptable Symptom State (PASS) among foot and ankle patients. The authors found that patients ≥65 years of age accepted more functional limitation than younger patients, patients in the lowest income brackets reported more severe functional limitations as satisfactory compared with patients in the highest income brackets, and patients in the lowest income bracket sought surgical care later than those in the highest income bracket5.
- Eble SK, Hansen OB, Ellis SJ, Drakos MC. The virtual foot and ankle physical examination. Foot Ankle Int. 2020 Aug;41(8):1017-26. Epub 2020 Jul 8.
- Milstrey A, Domnick C, Garcia P, Raschke MJ, Evers J, Ochman S. Trends in arthrodeses and total joint replacements in foot and ankle surgery in Germany during the past decade-back to the fusion? Foot Ankle Surg. 2020 May 26 [Epub ahead of print].
- Halai MM, Pinsker E, Daniels TR. Effect of novel anteromedial approach on wound complications following ankle arthroplasty. Foot Ankle Int. 2020 Oct;41(10):1198-205. Epub 2020 Jul 18.
- Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of preoperative imaging and intraoperative histopathology in Morton’s neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-6. Epub 2019 May 29.
- Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients? Clin Orthop Relat Res. 2019 Nov;477(11):2555-65.
Over the last 2 decades, research into how various “preexisting conditions” affect the outcomes of orthopaedic interventions has increasingly focused on the impact of mental health (a patient’s “state of mind” and coping abilities) and psychological diagnoses such as depression. The impact of mental health, depression, and personality characteristics on patient-reported outcomes following significant skeletal trauma has been well documented in the trauma literature. In addition, previous studies in knee arthroplasty have identified depression as a major factor in suboptimal patient outcomes.
In the October 17, 2018 issue of The Journal, Halawi et al. teased out the impact of depression and mental health—independently and in combination—on patient-reported outcomes following primary total joint arthroplasty (TJA) in 469 patients at a minimum follow-up of one year.
The authors used the validated SF-12 MCS instrument to assess patient baseline mental health at the time of surgery. They also used the widely accepted WOMAC score to assess joint-specific pain, stiffness, and physical function before and after surgery. Using these tools, the authors showed that, while depression alone may diminish some patient-reported gains obtained from arthroplasty, it does not seem to affect a patient’s overall outcome as much as poor mental health prior to surgery. In this study, patients with depression but good mental health achieved patient-reported outcomes comparable to those among normal controls. Still, patients without depression and in good mental health were found to have the most robust improvements after undergoing TJA.
Orthopaedic surgeons need to better understand the interplay between these complex psychological states and patient outcomes. These authors conclude that the effect of depression on patient-reported outcomes is “less pessimistic than previously thought,” but we welcome further studies examining the link between “the mind” and orthopaedic outcomes. Finally, we should be ready to refer patients to our mental health colleagues when we detect a potential underlying nonphysical condition that might adversely affect the magnitude of benefit from the treatments we offer.
Marc Swiontkowski, MD
Many orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).
The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.
There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.
From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”