Deltoid-Spring Ligament Reconstruction in Stage IIB Adult Acquired Flatfoot Deformity with Spring Ligament Tear

Category: Hindfoot Introduction/Purpose: Spring ligament tear is often present in advanced stages of the Adult Acquired Flatfoot Deformity (AAFD). Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament to provide both medial tibiotalar and talonavicular stability. They form a large confluent ligament, the tibiocalcaneonavicular ligament, (TCNL) which is the most consistently found component of the deltoid ligament. For surgical reconstruction of advanced stage AAFD with large spring ligament tears, adding allograft TCNL reconstruction to osseous correction has suggested to augment medial peritalar stability. We aimed to investigate the clinical and radiographic outcomes of the novel TCNL reconstruction for stage IIB AAFD with spring ligament tear. Methods: Twelve feet in 11 patients (7 female, 4 male, mean age 56.1 years) who underwent osseous correction and TCNL reconstruction for stage IIB AAFD were employed. TCNL reconstruction was indicated in the presence of large spring ligament tears (1.5-3 cm) and when inadequate reduction remained after osseous corrections. All 12 feet underwent gastrocnemius recession, medializing calcaneal osteotomy, lateral column lengthening and Cotton or Lapidus procedures. Bone tunnels were made in the tibia (7 mm), sustetaculum tali (6 mm) and navicular (6 mm) for tendon allograft passage for TCNL reconstruction (Figure 1). Subjects were evaluated at mean of 24 months (range, 12-33 months) after surgery. Pre- and post-operative clinical outcomes were assessed by administrating FAAM_ADL, SF-36 PF and Pain, Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) domains using Computerized Adaptive Testing. Correction of forefoot abduction and sagittal arch were measured from weight bearing radiographs of the foot. Results: The FAAM_ADL improved from 69.3 to 90.1 (p = 0.001). SF-36 PF and Pain subscales both improved significantly (39.4 to 87.8, 44.6 to 93.1, respectively, p <0.001 for each). PROMIS PF improved from 38.2 to 46.8 (p = 0.002) and PI 62.6 to 50.1 (p = 0.003). All but one patient were satisfied with the result. Radiographic measures showed improved AP talo-first metatarsal angle of 24.7° to 11.8° (p < 0.001) and talonavicular coverage angle of 47.4° to 23.1° (p <0.01). The talar head uncoverage improved from 56.1% to 32.5% (p < 0.01). Improved Meary’s angle of 29.7° to 12.5° (P < 0.001) and calcaneal pitch angle of 11.7° to 16.9° (p = 0.14) were noted in the lateral view. Conclusion: The current study demonstrates that TCNL reconstruction is a viable surgical treatment option for augmentation of medial peritalar stability in advanced stage AAFD with spring ligament tear. This is the first short term clinical investigation to report the clinical and radiographic outcomes of the novel TCNL reconstruction. Considering the anatomic characteristic of the deltoid-spring ligament complex, the TCNL reconstruction may play a significant role in maintaining surgical correction of deformity

Surgical Trends in the Treatment of Acute Achilles Ruptures

Category: Sports Introduction/Purpose: Historically, nonoperative treatment of acute Achilles tendon ruptures was felt to have significant re-rupture rates. With improved functional rehabilitation, recent studies have shown decreased rates of tendon re-rupture. Recent randomized control trials circa 2010 have shown no difference in re-ruptures between early functional rehabilitation and surgical repair. The goal of this study was to evaluate trends in surgical treatment of Achilles ruptures, based on data obtained from the American Board of Orthopaedic Surgery (ABOS), in response to evolving level I evidence. Methods: All operative cases submitted by part II applicants from 2003 to 2015 for primary board certification by the American Board of Orthopaedic Surgery (ABOS) were retrospectively reviewed. Isolated primary Achilles tendon repairs for acute ruptures were identified by ICD-9 and CPT code. Surgeon information including fellowship training and geographic region, and patient information including age, sex, and complications were collected. Results: Out of 1,118,457 cases, there were 4792 Achilles repairs (0.43%) with 510 complications (10.6%). The rate of Achilles repairs increased from 2006 to 2010, when rates peaked at 0.57% of all collected cases (Figure 1). Since 2010, there has been a decrease in rates back to pre-2006 values. The changing rates appear to be largely driven by non-fellowship trained orthopaedic surgeons. The rates of sports and foot and ankle fellowship trained surgeons had mild increases in 2006 and decreases in 2010, but overall have slightly increased. The rate for patients greater than 65 have decreased from 2002 to 2004. Since then, there have been yearly variations, with minimal overall change. Examination of regional differences demonstrate the greatest change in the Northeast. All regions had increased rates in 2006 and decreased rates in 2010, with the exception of the Northwest and South regions, who showed little overall change. Conclusion: Surgical trends for Achilles ruptures corresponded closely to high impact level 1 publications in the literature in 2005 and 2010, suggesting evidence-based responsiveness in newly trained orthopaedic surgeons. These trends are less pronounced in the Northwest and South regions and for sports and foot and ankle specialists

Reading the Future

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a common condition of the foot with 4.4 million patients seeking care yearly for this condition. A previous study suggested specific pre-operative cut-off scores based on Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and depression (D) values could predict post-operative outcomes in foot and ankle surgery. Though hallux valgus correction, among other procedures, were identified as one of the most common surgeries in the previous study, specific conditions were not considered separately. The purpose of this study was to evaluate the validity of applying a published comprehensive pre-surgical PROMIS profile of PF, PI and D to patients undergoing bunionectomy surgery. Methods: PROMIS scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and November 2016. Using ICD-9/10 and CPT codes, a total of 65 patients with hallux valgus who underwent a bunionectomy by a single surgeon were identified. Those with less than two-month follow-up, multiple procedures during the follow-up period, and incomplete PROMIS assessment scores were excluded, resulting in 42 patients. Using pre-operative scores and scores at the last follow-up visit, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) were obtained to determine if pre-operative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve a MCID with 95% sensitivity. New cut-off values were then compared to the previous study. Results: The AUC for PF (p=0.01) and Mood (p=0.03) were significant. However, PI AUC was not significant (p=0.14). The PF cut off for 95% specificity of exceeding MCID was 39.6 and 50.2 for 95% sensitivity for failing to achieve MCID. The D cut off for 95% specificity of exceeding MCID was 39.4 and 58.1 for 95% sensitivity for failing to achieve MCID. Patients below the 50.2 threshold (n=27) had significantly greater improvements on PF (2.3 95% CI 0.5 to 4.3) and PI (-3.8 95% CI -6.9 to -0.7) but not D. Patients above the 50.2 cut off (n=15) were significantly worse on PF (-7.3 95% CI -12.0 to -2.7) at this short follow up and were statistically unchanged on PI and D. Conclusion: This data confirms that pre-surgical PROMIS PF and Depression scores are significant post-surgical predictors. However, cut-off scores for 95% sensitivity/specificity were one standard deviation higher for PROMIS PF (>50.2 versus previous study >42) and similar for Depression (50.2) experienced significantly better outcomes on all PROMIS scales and patients not meeting the cut- off (~30%) were significantly worse. Although longer term follow-up is desirable, this short term follow up suggests a significant clinical impact of using PROMIS scores for pre-surgical decisions

The Road to Recovery for Bunion Surgery

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Patient reported outcomes (PROs) can provide information on individual patient’s progress throughout a treatment course and additionally, with common surgeries, powerful numbers can be generated to provide data analytic curves to provide a recovery road map for patients and surgeons. Those who deviate negatively from the predicted path may have a complication and early intervention can be initiated. Those who deviate positively have the potential to need less physical therapy, early return to sports or work. Hallux valgus (HV) is a common condition of the foot with 4.4 million patients seeking care yearly and surgery is equally common. The purpose of this study was to determine if PROMIS PROs can be used to construct data analytic curves for HV surgery. Methods: PROMIS scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and November 2016. Using ICD-9/10 and CPT codes, a total of 65 patients with hallux valgus who underwent a bunionectomy by a single surgeon were identified. Those with less than two-month follow-up, multiple procedures during the follow-up period, as well as incomplete PROMIS assessment scores at any time point were excluded, resulting in 34 patients. Using a previously described method, bunionectomy-specific pre-operative cut-off values to achieve and fail to achieve minimally clinically important differences (MCID) in PF with 95% specificity and 95% sensitivity were determined. We then stratified patients based on their pre-operative PF T-scores as above or below the MCID cut-off. PF was evaluated using two-way ANOVA at 4 follow-up time periods and pre-operative cut-offs (above or below MCID cut-off) as factors to establish data analytic curves based on pre- operative scores. Results: Bunionectomy-specific PF cut-off for 95% specificity of exceeding MCID was 39.6 and 50.2 for 95% sensitivity for failing to achieve MCID. Patients were stratified based on PF T-scores above (n = 13) or below (n = 21) the MCID cut-off of 50.2. Data analytic curves were generated for above the PF cut off and below PF cut off. (Figure 1) Pairwise comparison demonstrated that those starting with a T-score above the bunionectomy specific cut-off had significantly better PF pre-operatively (p < 0.01) and again at 6-12 week follow-up (p = 0.02). There were no differences at 1 week or 3-4 week follow-up time points. Conclusion: This data confirms pre-operative PROMIS PF scores are significant post-operative predictors. While patients with pre-operative scores below the bunionectomy-specific cut-off met MCID changes in PF, their T-scores were significantly lower at 6-12wk follow-up than patients with high pre-operative T-scores. Although longer term follow-up is desirable, this short term follow up suggests a significant clinical impact of using PROMIS scores for pre-surgical decisions as well as provides a road map for recovery for patients and surgeons

Percentage of Articular Surface Debridement is Equivalent in Arthroscopic and Open Ankle Fusions

Category: Ankle Arthritis, Arthroscopy Introduction/Purpose: Tibiotalar arthrodesis is a reliable option in the treatment of end-stage ankle arthritis and both open and arthroscopically assisted techniques are well described. When compared head to head, multiple studies have demonstrated advantages of arthroscopic arthrodesis over open fusions including decreased morbidity, and shorter hospital stays while achieving equivalent or increased rates of fusion. It is unclear why arthroscopic fusion may be favorable to open surgery, however, it is hypothesized that patient selection and soft tissue trauma may play a role. No study, however, has evaluated the extent of articular debridement afforded by each technique. The purpose of this study was to evaluate the amount of articular cartilage denuded via open arthrodesis and via arthroscopic arthrodesis with time of procedure evaluated as a secondary measure. Methods: Six matched sets of fresh frozen cadaver lower extremities were acquired for study. One limb from each set was randomly assigned to open articular debridement while the other limb was assigned to arthroscopic debridement. The duration of each procedure was timed. The tibiotalar joints were disarticulated following debridement and the talus was dissected free of all soft tissue attachments. Photographs of the weight bearing portion of the articular surfaces were then taken and residual cartilage was mapped using ImageJ software. The percentage of the joint debrided was determined by the area of denuded bone divided by the total area of the articular surface to allow for comparison across specimens. The mapping process was blinded to the type of debridement undertaken. Repeated measurements were taken to determine intra- and inter-reliability of the measurements. Student t-tests were used to compare the percentage of joint debrided and differences in time of the procedure. Results: The average percentage of cartilage debrided in the arthroscopic procedure was 88.99+11.19% for the tibial plafond and 88.84.08+5.45% for the talar dome. For the open procedure, 82.93+6.91% of the tibial plafond was debrided and 84.08+5.45% of the talar dome was debrided. There were no significant differences of the tibia or talus between the open and arthroscopic procedures (p>0.05). Inter- and intra-reliability were calculated for all measurements with r>.8. There was a significant difference in the time of the procedure with the arthroscopic debridement taking 50.17+5.57 minutes to complete while the open debridement took 30.67+5.16 minutes to complete (p<0.01). Conclusion: There were no differences in the percentage of articular surface debrided when comparing arthroscopic versus open arthrodesis of the ankle joint in cadaver specimens. The arthroscopic debridement took significantly longer, however this difference may be offset by a decrease in time required for wound closure. Furthermore, an increased time of debridement may be warranted if it results in decreased wound complications and pain. The results of this study support previous clinical findings that arthroscopic debridement can yield fusion rates comparable to, or better, than open debridement of the ankle joint

Peritalar Kinematic Changes Associated with Increased Spring Ligament Tear in Cadaveric Flatfoot Model

Category: Hindfoot Introduction/Purpose: Adult Acquired Flatfoot Deformity (AAFD) is a complex and progressive deformity characterized by abduction of the midfoot and valgus alignment of the hindfoot. Spring ligament tear is often present in advanced stages of the AAFD. Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament to provide both medial tibiotalar and talonavicular stability aiding in coronal plane stability. Given that the spring ligament blends with the superficial deltoid ligament, we sought to investigate the kinematic effect of spring ligament tear in development of peritalar instability in cadaveric flatfoot model. We hypothesized that increased spring ligament tear size will result in increased talonavicular joint abduction (axial) and plantarflexion (sagittal), and increased valgus alignment of the tibiotalar and subtalar joints (coronal). Methods: Seven fresh-frozen cadaveric foot specimens were employed. Reflective markers were mounted on the tibia, talus, navicula, calcaneus and the first metatarsus. Kinematics of the peritalar joints were captured by multiple camera motion capture system. A flatfoot model was created by sectioning the medial and inferior talonavicular interosseous ligament, followed by cyclic axial load of 1150 N under a hydraulic loading frame with 350 N load applied to the Achilles tendon. The talo-first metatarsus (T- 1MT) abduction angle was calculated and cycles were applied until abduction of 5-10° (mild flatfoot) was achieved. Spring ligament sectioning was extended 1 cm proximally along the superomedial ligament followed by cyclic loading until 10-15° (moderate) of T- 1MT abduction was achieved. The spring ligament was sectioned for another 1 cm followed by cyclic loading until >15° (severe) abduction was noted. The relative kinematic changes were compared among the initial, mild, moderate, and severe flatfoot model using two-way ANOVA. Results: The average T-1MT abduction angles in the mild, moderate, and severe flatfoot were 7.79°+/-2.27°, 11.47°+/-2.82°, and 15.46°+4.15°. Meary’s angle increased with progression of the flatfoot (mild 6.17°+/-2.92°, moderate 9.71°+/-3.4°, severe 12.46°+/-4.13°). Hindfoot valgus angle also increased. The mild, moderate, and severe flatfoot showed 2.4°+/-3.85°, 4.13°+/-3.9°, and 4.75°+/-3.79° of tibiotalar valgus angle. The subtalar joint exhibited 2.94°+/-3.41°, 5.52°+/-4.34°, and 6.97°+/-4.83° valgus angle in the mild, moderate, and severe models. The T-1MT abduction angle and Meary’s angle were significantly different in all flatfoot models compared to the initial condition (p<0.001), and the severe vs. mild models (p<0.01). Tibiotalar valgus was significantly increased in severe compared to the initial model (p=0.02). Subtalar valgus angle significantly increased in the moderate and severe models compared to the initial (p<0.01, p<0.001). Conclusion: Serial increment in spring ligament tear size in simulated flatfoot increased relative talus adduction and plantarflexion. It also resulted in gradual increment of valgus alignment of the tibiotalar and subtalar joints in coronal plane. This finding demonstrates that a large spring ligament tear in advanced stage AAFD leads to increased strain across the medial peritalar ligaments. In addition to osseous correction and tendon transfer, medial ligament augmentation, may be a critical component in surgical correction of AAFD with a large spring ligament tear

Trends in PROMIS Scores in the Early Post-operative Period following Various Lateral Ankle Ligament Reconstructive Techniques

Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. When conservative management fails and chronic instability ensues, operative treatment is often sought. Though surgical outcomes are generally good following lateral ankle ligament reconstruction, literature suggests current scoring systems for evaluating outcomes and monitoring progression have deficiencies. Patient Reported Outcomes Measurement Information (PROMIS) scores have recently been established as a method of monitoring patient outcomes. The purpose of this study was to evaluate the trends in post-operative PROMIS physical function (PF), pain interference (PI), and depression scores in patients undergoing lateral ankle ligament reconstruction. Methods: PROMIS scores were prospectively obtained from all patients evaluated in our foot and ankle clinic between February 2015 and October 2016. Using ICD-9/10 and CPT codes, a total of 111 patients who underwent lateral ankle ligament reconstruction were identified. After meeting exclusion criteria (less than three-month follow-up, incomplete PROMIS scores or multiple surgeries), 55 patients were included. PROMIS PF, PI, and depression were evaluated at each post-operative visit. Changes in scores were calculated as compared to baseline pre-operative scores and compared at each follow-up time point using two-way ANOVA. Differences in reconstruction type in patients undergoing allograft (A), modified Broström-Gould (BG), or modified Broström-Gould augmented with fibertape (BG+FT) were also evaluated. Results: The average follow-up was 27.05 weeks (range 12-60.1 weeks). 11 patients had > 9 months follow-up. Changes in PF were significantly different from baseline at all time-points except for 8-12 week follow-up. PF was significantly worse at 2 and 4-6 week follow-up, and significantly better at >12 weeks follow-up (p12 weeks. PI scores were significantly improved from baseline beginning at 4 weeks follow-up. Depression scores also significantly improved at 8-12 weeks follow-up. BG+FT showed a trend of slower improvement in PF, though not significant. Though longer follow-up is needed, the significant improvements in PF, PI, and depression following lateral ankle ligament reconstruction in our study provides data that can be used for pre-operative counseling and monitoring progression post-operatively

Tibiocalcaneonavicular Ligament Reconstruction in Simulated Flatfoot Deformity with Medial Ligament Insufficiency

Category: Hindfoot Introduction/Purpose: Spring ligament tear is often present in advanced stages of the AAFD. Anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament to provide medial tibiotalar and talonavicular stability. Reconstruction of combined deltoid-spring ligament, or the Tibiocalcaneonvaicular ligament (TCNL) was proposed to augment medial stability in advanced AAFD with large spring ligament tears. A tendon allograft is placed to cross three peritalar (tibiotalar, talonavicular and subtalar) joints to augment medial stability. We aimed to 1) investigate the kinematic effects of TCNL reconstruction in cadaveric flatfoot model with medial ligament insufficiency, and 2) compare TCNL reconstruction with anatomic spring and anatomic deltoid ligament reconstructions (Figure 1). We hypothesized that TCNL reconstruction is effective in restoring peritalar kinematics. Methods: Five fresh-frozen cadaveric foot specimens were employed. Advanced stage flatfoot model was created by sectioning the medial and inferior talonavicular interosseous ligament and extending the release 2 cm proximally along the superomedial spring ligament. Cyclic axial load of 1150 N under a hydraulic loading frame with constant 350 N Achilles tendon load were applied until >15° talo-first metatarsal abduction was achieved. Bone tunnels were drilled for three reconstruction types, and the peroneus longus tendon was configured to reconstruct the 1) anatomic spring ligament, 2) anatomic deltoid ligament, and 3) TCNL. Reflective markers were mounted on the tibia, talus, navicula, calcaneus and first metatarsus. Each reconstruction type was loaded with 800 N ground reaction force, and kinematics of the peritalar joints were captured by 4-camera motion capture system. Forefoot abduction angle, Meary’s angle, and hindfoot valgus were calculated and compared to the severe flatfoot prior to reconstruction and to each using two-way ANOVA. Results: In creating the flatfoot deformity, both the tibiotalar and subtalar joints demonstrated an increase in valgus deformity by 5.6+3.7° and 6.1+5.3°, respectively, compared to the initial measurements. When comparing to the flatfoot deformity, the TCNL reconstruction achieved a significant improvement in percent correction of total hindfoot valgus (59.7+21.1%, p=0.017) and forefoot abduction angle (83.4+17.7%, p<0.01). The spring ligament reconstruction also demonstrated a significant improvement in forefoot abduction correction compared to the flatfoot (52+10.6%, p<0.05). No other reconstruction technique achieved a statistically significant improvement in percent correction compared to the flatfoot model in forefoot or hindfoot alignments. Additionally, no statistical differences were noted in the percent correction when comparing the three reconstructive techniques to each other. Conclusion: In advanced stage cadaveric flatfoot with spring ligament tear, we found increased valgus alignment at both the tibiotalar and subtalar joints. This kinematic changes reflects increased strain across the medial peritalar ligaments. The deltoid-spring ligament complex (TCNL) reconstruction demonstrated significantly improved alignment of hindfoot valgus and forefoot abduction compared to the severe flatfoot condition. This finding suggests that in addition to osseous correction and tendon transfer, the TCNL reconstruction may serve as an important component in augmenting medial stability in advanced AAFD with medial ligament insufficiency

Microbiome Analysis for Assessments of Treatment Response and Salvage Prognosis in Infected Diabetic Foot Ulcers

Category: Basic Sciences/Biologics, Diabetes Introduction/Purpose: Diabetic foot ulcers (DFUs) contribute to 80% of non-traumatic lower-extremity amputations. Surgeons are often forced to make surgical decision without adequate prognostic information. DFU infections are often polymicrobial, representing complex microbial communities. A microbiota is the ecological community of various microorganisms that share body space. Currently, the methods of detecting an active infection, identifying the pathogenic bacteria within the microbiome, measuring the response to therapy, and assessing prognosis are limited. Using a molecular genomic technique of 16 S rRNA sequencing, our goals are to assess the pathogenic bioburden of DFUs and to monitor the bacterial community changes in response to antibiotic treatment. Our hypothesis is that the microbiome in DFUs responding to debridement and antibiotics treatment is distinct from those that fail to respond. Methods: Patients with type I or II diabetes who presented with an infected DFU were enrolled. Infections were identified using clinical signs. The DFU size was measured and classified using the Wagner classification. Enrolled patients were initially managed with foot salvaging therapy (FST): irrigation and debridement followed by wet-to-dry dressings and 6 weeks of intravenous antibiotic treatment. Superficial and deep DFU samples were obtained and evaluated by 16 S rRNA microbiome analysis and qPCR for bacterial abundance. This was repeated at 4, 8, and 12 weeks following the initiation of FST. At 12 weeks, patients were divided into two groups, healed and non-healed, based on the change in the size of the wound and absence or presence of 12 secondary signs of infection. Alpha- and beta-diversity were measured by the Shannon index and Bray-Curtis dissimilarity index to evaluate changes in the microbiome between the healed and non-healed groups. Results: From July 2015 to August 2016, 21 patients were enrolled and 3 deceased due to medical comorbidities. Of the 18 patients available for follow-up, 10 failed FST and 8 healed. The qPCR and microbiome analysis revealed that the bacterial abundance and diversity of the bacterial community were substantially reduced following debridement and intravenous antibiotic treatment. At the initial enrollment, those group that healed versus non-healed showed significant differences in microbiome composition, with the healed group enriched with Actinomycetales and Staphylococcus, and the non-healed group enriched with Bacteroidales and Streptococcus. At week 4, such differences disappeared and bacterial abundance significantly decreased. New differences were evident at week 8: the healed group was enriched with Actinomycetales and non-healed group with Bacilli. Conclusion: Abundant presence of Bacteroidales and Streptococcus at the initial presentation of infected DFU maybe a poor prognostic sign for healing with FST. Through molecular analysis of the wound microbiome, we can identify pathogens of prognostic value at the initial cultures and assess response to therapy with significant differences at 8 weeks after. Our study provides useful information for counseling patients of treatment prognosis and determining to pursuit further foot salvage versus amputation

Pain Assessment in Foot and Ankle Patients

Category: Other Introduction/Purpose: The ability to accurately quantify a patient’s pain pre-operatively is advantageous in the preparation of post-operative expectations and pain management. The Numeric Pain Rating Scale (NPRS) is a popular method to identify patient pain level. Other patient reported outcomes are being collected, such as the Patient Reported Outcomes Measurement Information System (PROMIS) and has been suggested to be more accurate in measuring pain as well as physical function. The aim of this study was to 1) determine whether NPRS or PROMIS Pain Interference (PI) demonstrates a stronger association with physical function as determined by PROMIS Physical Function (PF) and 2) to determine which method better predicts post-surgical pain in a population of elective surgical foot and ankle patients. Methods: Prospective PROMIS PF, PI and NPRS (0-10) data was obtained for common foot and ankle elective surgical procedures (CPT codes 27698, 27870, 28285, 28289, 28300, 28705, 28730, 28750) from a multi-surgeon foot and ankle clinic between February 2015 until November 2017. Pearson correlation coefficients were used to determine the relationship between NPRS (0-10) and PROMIS domains (PI, PF) pre and post-operatively. Correlations were considered high (> 0.7), high moderate (0.6-0.69), moderate (0.4-0.6) or weak ( 6 month follow up were evaluated (74% women, mean age 54+/- SD, mean follow-up 14.4 months, range 6-34 months). Pearson correlation evaluation of NPRS and PI revealed a moderate correlation in the pre- and postoperative setting. There was a high moderate negative correlation between PI and PF t-scores pre and postoperatively suggesting more pain and less function. However, the negative correlation between NPRS and PF pre- and postoperatively was weak indicating a poor relationship between NPRS pain assessment and function. There was a moderate correlation between pre- and postoperative scores in all domains of PROMIS while the correlation between pre- and postoperative NPRS scores was weak. Conclusion: In a population of elective surgical foot and ankle patients, the use of both NPRS and PROMIS can be utilized to assess pain level, however the PROMIS PI domain demonstrated a stronger relationship with PROMIS PF than NPRS. Furthermore, only the PROMIS domains demonstrated at least a moderate correlation between pre- and post-operative scores. PROMIS PI provides superior assessment of pre- and post-operative physical function and prediction of post-operative pain. PROMIS PI can be used to gauge a patient’s pre-operative level of pain and function and aid the surgeon in guiding post-operative patient expectations and pain management