Prospective Analysis of Isolated Gastrocnemius Recession for Achilles Tendinopathy; Intermediate Follow-up

Category: Ankle Introduction/Purpose: Gastrocnemius recession (GR) has emerged as a potential alternative to traditional surgical treatments in patients with recalcitrant Achilles tendinopathy (AT). Recent retrospective studies have shown positive results. However, there is limited long-term prospective data regarding the results of this surgery. We are reporting two-year results of a prospective analysis of isolated GR for Achilles tendinopathy on pain, self reported function, and satisfaction. Methods: 8 patients (mean age 52± 10.2 years) with chronic unilateral AT (> 6 months duration) and an isolated gastrocnemius contracture participated. All subjects received a GR (Strayer) procedure. Data were collected pre- and post-operatively at 6 months and 2 years. Pain and function were assessed using the Visual Analog Scale(VAS) and the Foot and Ankle Ability Measure(FAAM). Clinical measure of calf endurance was assessed by single limb heel raises and compared to the uninvolved limb. Calf circumference was evaluated and patients were queried regarding satisfaction with the GR procedure and need for further treatment. Descriptive analysis was used to assess changes across the repeated timelines. Results: All subjects returned at 6 month follow-up and 7/8 patients participated in the final follow-up (mean 23 +/- 5.5 months). Pain was reduced by 50% at 6 months and 90% at 2 years; with 6 of 7 subjects reporting no pain. Pre-op FAAM ADL subscale was 75%, improving to 90% and 97% at 6 months and 2 years, respectively. Pre-op FAAM Sports subscale was 40%, improving to 69% and 87% at 6 months and 2 years, respectively. There were no side-to-side differences in the number of heel raises performed across time frames; involved mean 26 +/- 7, uninvolved 28 +/-6. Five (of seven) subjects reported complete satisfaction with the procedure and two were satisfied with minor reservations. Conclusion: To our knowledge, this is the first study to prospectively evaluate an isolated GR for Achilles tendinopathy and present 6 month and 2-year follow-up data. Pain relief was markedly decreased and maintained at 2 years. FAAM ADL activities were restored to normative values. However, scores for the FAAM sports subscale remained slightly below normative values and may reflect patient reported difficulties with higher-level activities such as jumping and lateral movements. High satisfaction can be expected for the majority of patients, however patients engaged in higher demand activities may have a prolonged recovery period and persistent limitations

2016 J. Leonard Goldner Award - Can Initial PROMIS Scores Predict Outcome for Foot and Ankle Patients?

Category: Other Introduction/Purpose: The use of patient reported outcomes continues to expand beyond the scope of clinical research to involve standard of care assessments across orthopaedic practices. It is currently unclear how to interpret and apply this information in the daily care of patients. We examined the relationship between patient reported outcomes (PROMIS Physical Function, Pain Interference and Depression scores) obtained at initial visit as a predictor of outcome at a minimum of 7 month follow up. Methods: Prospective collection of all consecutive patient visits to the University of Rochester Orthopaedic foot and ankle clinic was initiated on April 2015. Data through December 2015 was classified as new or follow up and operative or non-operative based on ICD-9 and CPT codes. 17,019 patient visits were collected on 7,265 patients, of which 4,213 were new patients. PROMIS physical function, pain interference, and depression scores were assessed at initial and follow up visits. Only patients with a minimum of 7 months (mean 8.2) follow up who completed all PROMIS domains were included, resulting in 262 patients (69 operative, 193 non-operative). PROMIS scores are normalized to a US population with an average score of 50 and a standard deviation of 10. Statistical analysis using student t-tests and linear regression were performed to determine if the initial PROMIS scores were predictive of patient reported outcomes at final follow up. Results: There were no differences between operative and non-operative treatment groups in initial PROMIS scores or change in scores at follow up (p>0.40). Patients with higher baseline pain were likely to experience less pain over time (r=0.63, p < 0.01). Similarly, patients with higher baseline depression were likely to experience decreased depression over time (r =0.52, p < 0.01). Patients with lower baseline physical function were likely to improve over time whereas patients with higher baseline physical function were likely to worsen over time (r=0.68, p< 0.01). Specifically, all patients with baseline physical function score less than 28 improved over time, while all patients with a score greater than 52 worsened (Figure 1). Conclusion: Physical function, pain, and depression trends did not vary between operative and non-operative patients at 8.2 month follow up. Patients with high initial pain and depression were likely to have improvements in pain and depression over time. Similarly, patients with low initial physical function were likely to have improved physical function. However, despite treatment, patients with above average initial physical function did not experience improvement in physical function, suggesting these patients are more challenging to treat. This information demonstrates that baseline patient reported outcomes are predictive of improvement in outcomes over time, and could assist in the treatment decision process

Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

Category: Other; Ankle Introduction/Purpose: Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation. This randomized, controlled trial study objectives: 1) Determine if the active use and discussion of PROMs during new patient visits are associated with patient satisfaction and experience 2) Determine if the active use and discussion of PROMs during new patient clinic visits are associated with patient activation; and 3) To determine if the objectives (1) and (2) differ based on surgeon or sociodemographic factors. Methods: This Institutional Review Board (IRB) approved singled-blinded RCT was registered prior to data collection on ClinicalTrials.gov (NCT04654910). As a standard of care, new foot and ankle patients completed PROMIS Physical Function (PF), Pain Interference (PI), and Depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). CG-CAHPS findings and PAM responses were compared between the two groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored. Results: After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses, nor PAM scores between the two groups (p>0.05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate “top box” scores for the understanding domain of the CG-CAHPS question (OR:0.51;p < 0.001) and had decreased odds of high patient activation compared to control subjects (OR:0.67;p=0.005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (p=0.09). Conclusion: Well perceived foot and ankle surgeons who show and discuss PROMs results may not improve the patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROMs discussions are most beneficial and how best to present PROMs data. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs